Tamil Nadu’s letter to Union Health Minister Harsh Vardhan objecting to the ranking given to the State in the NITI Aayog’s Healthy States Progressive India report, provides stout reasons for its remonstrance and faults the flawed methodology used to evaluate the health outcomes.
In the letter, a copy of which is available with The Hindu , the State’s Health Minister C. Vijayabaskar points to the inherent inconsistencies and contradictions in the NITI Aayog’s own position on Tamil Nadu.
“The recent SDG India Index report 2018, published by Niti Aayog, puts Tamil Nadu in the second position among States in health SDG ranking, with an index score of 77, at least 25 points higher than the national average,” he wrote to his counterpart in Delhi.
“It is surprising then, that the same NITI Aayog in the Healthy States Progressive India report published on June 25 has ranked Tamil Nadu ninth overall at the national level… Such rankings, based on disputed methodologies that have not been accepted universally, only serve to cause unnecessary alarm.”
“I believe that the strength of any health system is captured by its objective achievements, and a State like Tamil Nadu, which has already achieved most of the SDG targets, should not be pulled down to a lower ranking due to methodical flaws that can lead to loss of faith in the health systems among the people,” Dr. Vijayabaskar noted.
The letter further goes on to list what the State government reasons as flaws in methodology. In many of the high weightage outcome indicators, such as ‘institutional deliveries’, and ‘full immunisation coverage’, NITI Aayog has taken the estimated number of live births, instead of actual live births as the denominator. This has resulted in misleading interpretations. For instance, it has fixed an expected live birth target of 11.8 lakh for Tamil Nadu, even though the real time data captured by the State indicates there are only 9.4 lakh live births. This also coincides with the total number of birth certificates issued in the State.
Notably, when the NITI Aayog report stated that the ‘level of birth registration in the civil registration system’ of Tamil Nadu is 100 %, it fails to register 9.4 lakh live births as the right figure. If this figure is taken as the denominator, then the institutional delivery will be 99.8 %, instead of the 80.5 % mentioned in the report, in tune with the NFHS 4 data of institutional deliveries in the State — 99 %.
MMR and IMR
The same logic applies to the category ‘immunisation coverage’. The State has already achieved a Maternal Mortality Rate (MMR) of 66 (third best among big States) and an Infant Mortality Rate (IMR) of 16 (second best for big States) under the SRS, achievements that will be impossible, if the State had the low rate of institutional deliveries and immunisation coverage as claimed by the NITI Aayog report.
“Attributing the decline in the health index score of Tamil Nadu to the decline in several health outcomes in the report is in complete contradiction to the reduction achieved by the State in MMR, IMR and Neonatal Mortality Rate,” the letter stated. He also charged the NITI Aayog with completely overlooking the Tamil Nadu Public Cadre, unique to the State, while using ‘average occupancy of the District Chief Medical Officer (DCMO)’ as an indicator. In Tamil Nadu, it is the Deputy Director of Health Services, a public health expert, who leads the response to public health challenges, a role which the DCMO plays in other States.
Dr. Vijayabaskar contends it is erroneous to measure the ‘proportion of facilities functional as 24x7 PHCs’ by the efficacy of deliveries happening there. He goes on to explain that while all the PHCs in the State are 24x7, Tamil Nadu also uses 126 Comprehensive Emergency Obstetric and Newborn Care centres to provide quality maternal and child care, as evidenced by the falling MMR.
While pledging that the State would work closely with the Centre to provide equitable, affordable and quality health care to the public, Dr. Vijayabaskar points out that these points had been raised at the consultation stage itself, with the Chief Secretary of the State writing to the CEO of NITI Aayog. However, these were not factored in to the final report.
