Kerala has a lot to be proud of being ranked a second time as the best performing State in India with an overall score of 74.01 in the annual Health Index released by the NITI Ayog on June 25.
But there is widespread scepticism about the conclusions regarding some key health outcomes flagged in the report as needing immediate attention and the data used to arrive at such results.
The Health Index June 2019 prepared in collaboration with the World Bank and the Ministry of Health and Family Welfare examined the “overall performance” and “incremental improvement” in health outcomes in the States and Union Territories during the years 2015-16 (base year) and 2017-18 (reference year).
The report reveals large disparities in performance of the States and highlights Kerala’s excellent overall record regarding (a) important health outcomes such as Neonatal Mortality Rate (NMR), Under-Five Mortality Rate (U5MR), Total Fertility Rate (TFR), Low Sex Ratio at Birth (SRB) and Full Immunisation Coverage; (b) outcomes in the domain of health governance and information, including on institutional deliveries and average occupancy of senior officers in particular posts; and (c) key inputs and processes in the health care system, including information on posts of health care providers lying vacant.
The State was ranked first in the Health Index released last year, too, but had a higher score of 76.55. Moreover, while considering the “progress” achieved by various States and Union Territories specifically in the two years, the index says Kerala has had setbacks with regard to some of the outcomes—a reason why its overall Health Index score has gone down by 2.55 points. Kerala has been given an “incremental rank” of 16 among States and its “incremental performance” has been categorised as “not improved” despite its excellent overall rating.
Among the setbacks mentioned were rather surprising findings that between the base and reference years, Kerala’s Sex Ratio at Birth (SRB) went down from 967 to 959 (considered a sign that gender discrimination and sex selective abortions may be taking place, though other factors too could contribute to it); the proportion of institutional (hospital) child deliveries went down from 92.6 per cent to 90.9 per cent; total case notification rate of tuberculosis (TB)—one of the critical indicators of TB management and control—went down dramatically from 139 to 67; the treatment success rate of new microbiologically confirmed TB cases went down from 87.5 per cent to 83.7 per cent; and birth registration declined from 100 to 97.1 per cent.
Kerala is a State whose health outcomes on many counts are on a par with upper or middle income countries and further incremental improvement would come only slowly. The State has achieved much more, much ahead of many other States that are now categorised as “most improved” or have been given higher incremental ranks. For instance, Kerala has already reached the U.N.’s 2030 Sustainable Development Goal (SDG) targets for Neonatal Mortality rate (which is 12 neonatal deaths per 1,000 live births) and Under Five Mortality (which is 25 deaths per 1,000 live births). In those respects, therefore, Kerala’s further progress will understandably be slow and difficult, unlike States that still have a lot more ground to cover, Minister for Health and Social Justice K.K. Shailaja Teacher told Frontline .
High performer but “most deteriorated”
Most health experts and officials that Frontline spoke to were sceptical if not dismissive about many of these critical results on Kerala. For instance, even though its SRB is shown as going down in the last two years, only Kerala and Chhattisgarh, out of 21 larger States, had an SRB of more than 950 girls for every 1,000 boys. But the Index puts Kerala in the “most deteriorated” category with respect to the fall in SRB (from 967 to 959).
The State with its well-known health and educational attainments has long been considered to be above the trend elsewhere in the country of bias against the girl child. But there have been occasions when such notions have been challenged. For instance, some scholars argued in the late 1990s (quoting the 1991 Census figures) that the ratio of female children per 1,000 males in the under-six population was falling in Kerala, too, suggesting that there may be gender bias at work. They sought to tie it to several changes in Kerala society noticed then, among them the unbridled growth of private hospitals and diagnostic services targeting women, the “unjustified” (as per WHO norms) rise in the number of caesareans and hysterectomies performed in many hospitals, and the increase in the number of abortions.
An inconclusive study, Child Sex Ratio in Kerala, commissioned by the State Social Welfare Department in 2003, also argued that an inter-district analysis of available data does not offer a promising picture of the view that gender equality is comparatively better in Kerala ( Daughter deficit? ). But suggestions that all this meant that sex-selective abortions were on the rise and discrimination of daughters were a reality in Kerala have always been met with strong scepticism ( ‘Is the bias so severe as to cause death? )
“So far there is nothing to show that intentional female foeticide is taking place. But it may be taking place among some sections, we cannot be sure. When you compare with other States, we do not also see a preference for sons in general here. In truth, Kerala is a State where couples with a son are known to pray for a girl child too. I have asked around. But experts have no satisfactory explanation as to why then the sex ratio at birth or child sex ratio (those in the 0 to 6 age group) or other such data are perhaps indicating a bias against the girl child. Some have said it is a result of natural process. But we need to ensure that it is not a result of deliberate sex selection . Kerala will launch a special investigation to find out whether sex selective abortions are at all taking place in the State, as a result of discrimination against the girl child in any section of society, even though there is no hard evidence so far to support such an assumption,” the Minister told Frontline .
Director of Health Services Dr Saritha R.L. said the State has been very vigilant about violations to the provisions of the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act (PNDT) Act, 1994 (which, among other things, banned prenatal sex determination and made registration of all diagnostic laboratories and facilities compulsory). “We have not found any proof that violations are taking place.”
According to State Planning Board Member Dr. B. Eqbal, who is also a health expert, there is no way that the NITI Ayog’s conclusions on some counts, such as a reduction in the proportion of institutional deliveries in the State, TB patients not getting proper follow-up care, and reduction in the SRB, could be right. There is no evidence that sex selective abortions are taking place in Kerala. Moreover, the change in ratio as mentioned in the Index does not seem to be statistically relevant.
Keshvendra Kumar, State Mission Director, National Health Mission (NHM), said the data that were provided on TB cases had some mistakes and this had led to some wrong inferences in the Health Index. Officials at the State TB Centre said the total case notification rate of TB was wrongly shown as going down in the Index because of a duplication error in the data supplied in the previous year (2016-2017), when private sector cases too began to be reported. The number of public sector TB cases was reported twice, suggesting that there was a fall in cases notified in the reference year. Similarly, the introduction of a new software for registration, which took a long time to stabilise, resulted in a delay in the reporting of details of patients who had completed or came for follow-up treatment. All this had led to the conclusion, in the NITI Ayog’s Health Index, that the treatment success rate of new microbiologically confirmed TB cases had gone down in Kerala, when in fact Kerala was moving towards elimination of TB and its model was being followed by other States.
“A drop in sex ratio at birth as suggested by the Index, if true, must be a cause for worry. But first we must make sure that the data used is correct because there is no other evidence. It is also well known that Kerala is moving towards elimination of TB and the risk of TB infection is very low in the State. And, unlike what the Index suggests, in Kerala, all births are registered and almost all deliveries take place in hospitals,” said Rajeev Sadanandan, former Additional Chief Secretary (Health).
Professor S. Irudaya Rajan of the Centre for Development Studies told Frontline that it is important to remember also that Kerala has for some time been showing a trend of negative population growth rate and most couples increasingly prefer only one child. The number of births too are coming down ( ‘Pointers to a negative growth rate’ ). The finding in the Health Index that the SRB went down from 967 to 959, I believe, is because they used the wrong data base. They have based it on the Sample Registration System (SRS) data. We have said earlier, too, that the sample size used by the SRS is very low for a State like Kerala. Instead, in a State where everybody knows there is 100 per cent registration of births, they should have relied on the data from the Civil Registration System (CRS).”
The Minister said that it was regarding another aspect—“the proportion of low birth weight (less than 2,500 grams) among new-born children”’, where the Index marks a slight improvement for Kerala from 11.7 to 11.4 per cent (Jammu and Kashmir, in comparison, had the lowest proportion of 5.5 per cent)—that the government was more concerned about. “It is an important problem Kerala has been trying to tackle with concerted effort, targeting pregnant mothers and newborns with low weights. Often the physical environment of the pregnant mother and her mental status, etc., are important factors that result in children being born with low birth weight. Despite all that the government has been doing, it remains a worrying issue and needs special study,” she said.