Healthy States Progressive India Report

Ministry of Health
& Family Welfare
Healthy States, Progressive India

R e p o r t o n t h e R a n k s o f S t a t e s a n d U n i o n Te r r i t o r i e s
Visit http://social.niti.gov.in/ to download this report, state-wise data and other content
Foreword
NITI Aayog has been mandated with transforming India by exercising thought leadership and by invoking
the instruments of co-operative and competitive federalism, focussing the attention of the State
Governments and Union Ministries on achieving outcomes. As the nodal agency responsible for charting
India’s quest for attaining the commitments under the Sustainable Development Goals (SDGs), it was
necessary to devise a mechanism for measuring outcomes particularly in the critical social sectors – such as
Health and Education, where India’s record has been less than stellar. This was intended to provide
feedback to all stakeholders as to whether we are on course to what we have set out to achieve, and
deviations, if any, to be pointed out in time to ensure necessary mid-course correction.
It is important to realize that implementation of social sector programs is squarely in the domain of the
State Governments and India’s achievement of SDGs is therefore critically dependent on the action in the
States. Nudging States towards improving their social outcomes therefore requires developing indices that
would capture annual increments in performance through an independent third party process and publish
these. It is true that summarizing the complexities of a given sector and condensing it in an Index has its own
limitations. However, in an environment where the focus is on budget spends and outputs with limited
attention on outcomes, there is a need to increase competition among States to encourage them to strive
evermore for increasing the pace of change.
The Health of its population is central to a nation’s well-being and productivity. While India has made some
significant gains in improving life expectancy and reducing infant and maternal mortality, our rates of
improvement have been inadequate as a nation.
Further, there are large variations in health system performance and outcomes achieved across States. The
“Performance in Health Outcomes” Index seeks to capture the annual progress of States and Union
Territories (UTs) on a variety of indicators – Outcomes, Governance and Processes. While we have also
reported the overall levels of performance of States, the focus of the NITI Index is to propel change,
highlighting those States that have shown most improvement. The exercise has been spearheaded by NITI
Aayog in collaboration with the Ministry of Health and Family Welfare, with technical assistance from the
World Bank, the authors of this report on the ranks and their interpretation.
The exercise, which is the first of its kind attempted by the Union Government was conducted over a period
of eighteen months. In addition to the technical expertise of the World Bank, experts in public health,
economics, statistics and health systems were consulted in the development of the Index. It involved
extensive engagement with the States for finalization of the indicators, sensitization workshops for sharing
the methodology, process of data submission and addressing concerns; mentoring of States for the data
submission process on an online portal and independent data validation.
The process of Index development and implementation highlighted the large gaps in data availability on
health outcomes.The need for making outcome data available for smaller states, more frequent and updated
outcomes for non-communicable diseases and financial protection, and the need for robust programmatic
data that can be used for continuous monitoring, were important issues that despite our efforts, could not be
addressed optimally in this first round. Despite these challenges and limitations, it was decided to launch the
Index in the first year as a model to measuring performance and ranking States on change. We thereby hope
to spur action on several fronts in bringing about national level transformation. We will strive to address the
lessons learned in this first round and refine the Index in the successive years of its implementation. The
linking of the Health Index with incentives under the National Health Mission by the Ministry of Health
and Family Welfare underlines the importance of such an exercise. It re-emphasizes the move towards
performance based financing for better outcomes.
I would like to acknowledge here the large number of individuals who contributed to the initiative being
brought to completion of its first round. The Ministry of Health and Family Welfare under the guidance of
Mr. C.K. Mishra, former Secretary, Department of Health & Family Welfare; Ms. Preeti Sudan, Secretary,
i
Department of Health & Family Welfare; Mr. Manoj Jhalani, Additional Secretary and Mission Director,
National Health Mission, as well as the Joint Secretaries and their teams from the programme divisions
provided their complete support to the initiative and worked in close co-ordination with NITI Aayog during
its entire course.
Technical Assistance to NITI Aayog was provided through the entire duration by The World Bank, along
with authorship of this report. We are grateful to Mr. Junaid Kamal Ahmad, Country Director and the
technical team led by Ms. Sheena Chhabra, Senior Health Specialist along with Dr. Rattan Chand, Senior
Consultant; Dr. Nikhil Utture, Consultant; and Dr. Iryna Postolovska, Young Professional with support from
Ms. Manveen Kohli, Consultant. Peer review of the final report by Dr. Rekha Menon, Practice Manager;
Dr. Ajay Tandon, Lead Economist; Dr. Mickey Chopra, Global Lead on Service Delivery; and Dr. Owen
K. Smith, Senior Economist is gratefully acknowledged.
Inputs from statistical, economics and sector experts including Prof. Pulak Ghosh, IIM-Bangalore; Prof.
Karthik Muralidharan, University of California, San Diego; Prof. Ladu Singh, International Institute of
Population Sciences; Prof. Arvind Pandey, ICMR; Prof. Mudit Kapoor, Indian Statistical Institute; Dr.
Shamika Ravi, Brookings India (and currently a Member of the Economic Advisory Council to the Prime
Minister), were obtained at various stages of the project. Support provided by the Registrar General and
Census Commissioner of India and the officials from the Office of Registrar General and Census
Commissioner, India is gratefully acknowledged. Inputs received from Technical Organizations including
UNICEF and DFID are also acknowledged.
NITI Aayog is most grateful to senior officials of the Health departments, nodal officers and their teams in
all the States and UTs for their extensive co-operation throughout the project, including providing inputs
and feedback during the development of the index, participation in regional sensitization workshops,
submission of data on the online portal and provision of required supporting documentation/evidence for
validation of data.
The mentor organizations, USAID (led by Mr. Xerxes Sidhwa and Mr. Gautam Chakraborty, and the team
led by Ms. Alia Kauser and Dr. Rashmi Kukreja), Regional Resource Centre for the North Eastern States,
branch of National Health Systems Resource Centre, MoHFW (led by Dr. Bamin Tada and Mr. Bhaswat
Das), Centre for Innovations in Public Systems (led by Dr. Nivedita Haran) and TERI (led by Ms. Meena
Sehgal) provided their valuable support to the States during the data submission phase of the project.
Extended mentor support provided by Mr. Pankaj Gupta, USAID is also gratefully acknowledged. The data
validation was conducted by the team at IPE Global led by Mr. Soumitro Ghosh and Ms. Daljeet Kaur. The
online portal was developed by Silvertouch Technologies, led by Ms. Surbhi Singhal and Mr. Rushiraj Yadav.
The project was designed and executed under the guidance of the senior leadership of NITI Aayog,
Dr. Arvind Panagariya, former Vice Chairman, NITI Aayog; Dr. Rajiv Kumar, Vice Chairman, NITI
Aayog; Dr. Bibek Debroy, Member and Dr. Vinod Paul, Member, NITI Aayog. The Health Division team
led by Mr. Alok Kumar, Adviser; Mr. Sumant Narain, former Director; Dr. Dinesh Arora, Director, and Dr.
Kheya Furtado, Research Assistant, with support from Ms. Jyoti Khattar, Senior Research Officer planned,
implemented and co-ordinated the entire project.
Amitabh Kant
Chief Executive Officer, NITI Aayog
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Abbreviations
AHPI Association of Healthcare Providers (India)
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
ART Antiretroviral Therapy
BCG Bacillus Calmette–Guérin
BY Base Year
CCU Cardiac Care Unit
CHC Community Health Centre
CIPS Centre for Innovation in Public Systems
CMO Chief Medical Officer
CRS Civil Registration System
C-Section Caesarean Section
DH District Hospital
DPT Diphtheria, Pertussis, and Tetanus
EAG Empowered Action Group
ENT Ear-Nose-Throat
GBD Global Burden of Disease
FLV First Level Verification
FRU First Referral Unit
Hb Hemoglobin
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HRMIS Human Resources Management Information System
IDSP Integrated Disease Surveillance Programme
IMR Infant Mortality Rate
INR Indian Rupees
IVA Independent Validation Agency
ISO International Organization for Standardization
IT Information Technology
JSSK Janani Shishu Suraksha Karyakram
JSY Janani Suraksha Yojana
LBW Low Birth Weight
L Form IDSP Reporting Format for Laboratory Surveillance
MCTS Mother and Child Tracking System
MCTFC Mother and Child Tracking Facilitation Centre
MIS Management Information System
MMR Maternal Mortality Ratio
MO Medical Officer
MoHFW Ministry of Health and Family Welfare
NA Not Applicable
NABH National Accreditation Board for Hospitals and Healthcare Providers
NACO National AIDS Control Organization
NCDs Non-communicable Diseases
NE North-Eastern
NFHS National Family Health Survey
NHM National Health Mission
NHP National Health Policy
NITI National Institution for Transforming India
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NMR Neonatal Mortality Rate
NQAS National Quality Assurance Standards
OPV Oral Polio Vaccine
ORGI Office of the Registrar General and Census Commissioner, India
OOP Out-of-Pocket
PCPNDT Pre-Conception and Pre-Natal Diagnostic Techniques
P Form IDSP Reporting Format for Presumptive Surveillance
PHC Primary Health Centre
PLHIV People Living with HIV
RRC-NE Regional Resource Centre for North Eastern States
RNTCP Revised National Tuberculosis Control Programme
RU Reporting Unit
RY Reference Year
SBR Still Birth Rate
SC Sub-Centre
SDGs Sustainable Development Goals
SDH Sub-District Hospital
SLV Second Level Verification
SRB Sex Ratio at Birth
SRS Sample Registration System
SN Staff Nurse
SNO State Nodal Officer
TA Technical Assistance
TB Tuberculosis
TERI The Energy Research Institute
TFR Total Fertility Rate
U5MR Under-Five Mortality Rate
USAID United States Agency for International Development
UTs Union Territories
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Contents
FOREWORD i
ABBREVIATIONS iii
LIST OF TABLES vii
LIST OF FIGURES viii
EXECUTIVE SUMMARY 1
BACKGROUND 8
1. OVERVIEW – EVOLUTION AND RATIONALE 9
2. ABOUT THE INDEX – DEFINING AND MEASURING 10
2.1 Aim 10
2.2 Objectives 10
2.3 Salient Features 10
2.4 Methodology 10
2.4.1 Computation of Index scores and ranks 10
2.4.2 Categorization of States for ranking 11
2.4.3 The Health Index - List of indicators and weightage 12
2.5 Limitations of the Index 15
3. PROCESSES – FROM IDEA TO PRACTICE 17
3.1 Key stakeholders - Roles and responsibilities 17
3.2 Process flow 17
3.2.1 Development of Index 18
3.2.2 Regional workshops with States 18
3.2.3 Submission of data on the portal 18
3.2.4 Independent validation of data 19
3.2.5 Index and rank generation 19
RESULTS AND FINDINGS 20
4. UNVEILING PERFORMANCE – ENCOURAGING ACTIONS 21
4.1 Performance of Larger States 21
4.1.1 Overall performance 21
4.1.2 Incremental performance 23
4.1.3 Domain-specific performance 25
4.1.4 Incremental performance on indicators 27
4.2 Performance of Smaller States 29
4.3. Performance of Union Territories 35
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4.4 States and Union Territories: Performance on indicators 40
WAY FORWARD 69
5. INSTITUTIONALIZATION – TAKING THE INDEX AHEAD 70
ANNEXURES 71
Annexure 1: Discrepancies in data and resolution 72
Annexure 2: Original Health Index 73
Annexure 3: Reference Year Index (with and without the indicator on out-of-pocket expenditure) 77
Annexure 4: Snapshot: State-wise performance on indicators 79
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List of Tables
Table E.1 - Categorization of Larger States on incremental performance
and overall performance 5
Table E.2 - Categorization of Smaller States on incremental performance
Table E.3 - Categorization of Union Territories on incremental performance
Table 2.1 - Categorization of States and UTs 12

Table 2.2 - Health Index: Summary 12
Table 2.3 - Health Index: Indicators, definitions, data sources, base and reference years 13
Table 3.1 - Key stakeholders: Roles and responsibilities 17
Table 3.2 - Timeline for development of Health Index 17
Table 3.3 - Health Index regional workshops 18
Table 3.4 - List of mentor agencies 19
Table 4.1 - Larger States: Overall performance in reference year - Categorization 22

Table 4.2 - Larger States: Incremental performance from
base to reference year - Categorization 24
Table 4.3 - Smaller States: Overall performance in reference year - Categorization 30
Table 4.4 - Smaller States: Incremental performance from
Table 4.5 - Union Territories: Overall performance in reference year - Categorization 36
Table 4.6 - Union Territories: Incremental performance from
Table A.2.1 - Original Health Index indicators: A snapshot 73

Table A.2.2 - Original Health Index: Indicators, definitions and data sources 73
Table A.4.1 - Larger States: Health Outcomes domain indicators, base and reference years 80
Table A.4.2 - Larger States: Governance and information domain
indicators, base and reference years 82
Table A.4.3 - Larger States: Key Inputs/Processes domain indicators, base and reference years 83
Table A.4.4 - Smaller States: Health outcomes domain indicators, base and reference years 86
Table A.4.5 - Smaller States: Governance and information domain indicators,
base and reference years 86
Table A.4.6 - Smaller States: Key Inputs/Processes domain indicators, base and reference years 87
Table A.4.7 - Union Territories: Health outcomes domain indicators, base and reference years 88
Table A.4.8 - Union Territories: Governance and information domain indicators,
Table A.4.9 - Union Territories: Key Inputs/Processes domain indicators,
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List of Figures
Figure E.1 - Larger States: Incremental scores and ranks, with overall performance
from base year to reference year and ranks 3
Figure E.2 - Smaller States: Incremental scores and ranks, with overall performance
Figure E.3 - Union Territories: Incremental scores and ranks, with overall performance
Figure 3.1 - Steps for validating data 19
Figure 4.1 - Larger States: Overall performance - Composite Index score and rank,
Figure 4.2 - Larger States: Overall and incremental performance,
base and reference years and incremental rank 23
Figure 4.3 - Larger States: Overall and domain-specific performance, reference year 25
Figure 4.4 - Larger States: Performance in the Health Outcomes domain,
Figure 4.5 - Larger States: Performance in the Key Inputs/Processes domain,
Figure 4.6 - Larger States: Number of indicators/sub-indicators,
by category of incremental performance 28
Figure 4.7 - Smaller States: Overall performance - Composite Index score and rank,
Figure 4.8 - Smaller States: Overall and incremental performance,
Figure 4.9 - Smaller States: Overall and domain-specific performance, reference year 32
Figure 4.10 - Smaller States: Performance in the Health Outcomes domain,
Figure 4.11 - Smaller States: Performance in the Key Inputs/Processes domain,
Figure 4.12 - Smaller States: Number of indicators/sub-indicators,
Figure 4.13 - Union Territories: Overall performance - Composite Index score and rank,
Figure 4.14 - Union Territories: Overall and incremental performance,
Figure 4.15 - Union Territories: Overall and domain-specific performance, reference year 38
Figure 4.16 - Union Territories: Performance in the Health Outcomes domain,
Figure 4.17 - Union Territories: Performance in the Key Inputs/Processes domain,
Figure 4.18 - Union Territories: Number of indicators/sub-indicators,
Figure 4.19 - Indicator 1.1.1: Neonatal Mortality Rate - Larger States 40
Figure 4.20 - Indicator 1.1.2: Under-five Mortality Rate - Larger States 41
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Figure 4.21 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Larger States 42
Figure 4.22 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns -
Smaller States and UTs 42
Figure 4.23 - Indicator 1.1.5: Sex Ratio at Birth - Larger States 43
Figure 4.24 - Indicator 1.2.1: Full immunization coverage - Larger States 44
Figure 4.25 - Indicator 1.2.1: Full immunization coverage - Smaller States and UTs 44
Figure 4.26 - Indicator 1.2.2: Proportion of institutional deliveries - Larger States 45
Figure 4.27 - Indicator 1.2.2: Proportion of institutional deliveries - Smaller States and UTs 46
Figure 4.28 - Indicator 1.2.3: Total case notification rate of TB - Larger States 46
Figure 4.29 - Indicator 1.2.3: Total case notification rate of TB - Smaller States and UTs 47
Figure 4.30 - Indicator 1.2.4: Treatment success rate of new microbiologically
confirmed TB cases - Larger States 47
Figure 4.31 - Indicator 1.2.4: Treatment success rate of new microbiologically
confirmed TB cases - Smaller States and UTs 48
Figure 4.32 - Indicator 1.2.5: Proportion of people living with HIV on
antiretroviral therapy - Larger States 48
Figure 4.33 - Indicator 1.2.5: Proportion of people living with HIV on
antiretroviral therapy - Smaller States 49
Figure 4.34 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in
public health facility (in INR) - Larger States 49
Figure 4.35 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in
public health facility (in INR) - Smaller States and UTs 50
Figure 4.36 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Larger States 50
Figure 4.37 - Indicator 2.1.1: Data Integrity Measure - ANC registered within
first trimester - Larger States 51
Figure 4.38 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries -
Figure 4.39 - Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester -
Figure 4.40 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for
three key posts at State-level for last three years - Larger States 52
Figure 4.41 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for
three key posts at State-level for last three years - Smaller States and UTs 53
Figure 4.42 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for
all the districts in last three years - CMOs or equivalent post - Larger States 54
Figure 4.43 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all
the districts in last three years - CMOs or equivalent post - Smaller States and UTs 54
Figure 4.44 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions -
ANMs at sub-centres - Larger States 55
Figure 4.45 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions -
ANMs at sub-centres - Smaller States 56
Figure 4.46 - Indicator 3.1.1b: Proportion of vacant healthcare provider positions -
Staff nurses at PHCs and CHCs - Larger States 56
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Figure 4.47 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions -
Medical officers at PHCs - Larger States 57
Figure 4.48 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions -
Medical officers at PHCs - Smaller States 57
Figure 4.49 - Indicator 3.1.1.d: Proportion of vacant healthcare provider positions -
Specialists at district hospitals - Larger States 58
Figure 4.50 - Indicator 3.1.1d: Proportion of vacant healthcare provider positions -
Specialists at district hospitals - Smaller States and UTs 58
Figure 4.51 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as
First Referral Units - Larger States 59
Figure 4.52 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as
First Referral Units - Smaller States 60
Figure 4.53 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Larger States 61
Figure 4.54 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Smaller States 61
Figure 4.55 - Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units -
Larger States 62
Figure 4.56 - Indicator 3.1.5: Proportion of ANC registered within first trimester against
total registrations - Larger States 63
Figure 4.57 - Indicator 3.1.5: Proportion of ANC registered within first trimester against
total registrations - Smaller States and UTs 63
Figure 4.58 - Indicator 3.1.6: Level of registration of births - Larger States 64
Figure 4.59 - Indicator 3.1.6: Level of registration of births - Smaller States and UTs 65
Figure 4.60 - Indicator 3.1.7: Completeness of IDSP reporting of P form - Larger States 66
Figure 4.61 - Indicator 3.1.7: Completeness of IDSP reporting of P and L forms - Smaller States 66
Figure 4.62 - Indicator 3.1.8: Proportion of CHCs with grading above 3 points - Larger States 67
Figure 4.63 - Indicator 3.1.10: Average number of days for transfer of Central National
Health Mission fund from State Treasury to implementation agency
(Department/Society) based on all tranches of the last financial year - Larger States 68
Figure 4.64 - Indicator 3.1.10: Average number of days for transfer of Central NHM
fund from State Treasury to implementation agency (Department/Society)
based on all tranches of the last financial year - Smaller States and UTs 68
Figure A.3.1 - Larger States: Ranking for reference year (2015-16) with and without the OOP
expenditure indicator 77
Figure A.3.2 - Smaller States: Ranking for reference year (2015-16) with and without OOP
Figure A.3.3 - Union Territories: Ranking for reference year (2015-16) with and without OOP
x
Executive
Summary
Background and Methodology

Key Results
Conclusions and Way Forward
1
Background and Methodology
1. The National Institution for Transforming India (NITI) Aayog is spearheading the Health Index
initiative to bring about transformational change in achieving desirable health outcomes: India
has achieved significant economic growth over the past decades, but the progress in health has not been
commensurate. Despite notable gains in improving life expectancy, reducing fertility, maternal and child
mortality, and addressing other health priorities, the rates of improvement have been insufficient, falling
short on several national and global targets. Furthermore, there are wide variations across States in their
health outcomes and systems performance. In order to bring about transformational change in
population health through a spirit of co-operative and competitive federalism, NITI Aayog has
spearheaded the Health Index initiative, to measure the annual performance of States and Union
Territories (UTs), and rank States on the basis of incremental change, while also providing an overall
status of States’ performance and helping identify specific areas of improvement. It is envisaged that
this tool will propel States towards undertaking multi-pronged interventions that will bring about the
much-desired optimal population health outcomes.
2. Multiple stakeholders contributed to the Index development: The Index was developed by NITI
Aayog with technical assistance from the World Bank through an iterative process in consultation with
the Ministry of Health and Family Welfare (MoHFW), States and UTs, domestic and international
sector experts and other development partners (Table 2.3 provides Health Index-indicator details and
data sources).
3. States and UTs have been ranked on a composite Health Index in three categories (Larger States,
Smaller States and UTs) to ensure comparison among similar entities: With a focus on outcomes,
outputs and critical inputs, the main criteria for inclusion of indicators was the availability of reliable
data for States and UTs, with at least an annual frequency. The Index is a weighted composite Index
based on indicators in three domains: (a) Health Outcomes; (b) Governance and Information; and (c)
Key Inputs/Processes, with each domain assigned a weight based on its importance. The indicator
values are standardized (scaled 0 to 100) and used in generating composite Index scores and overall
performance rankings for base year (2014-15) and reference year (2015-16). The annual incremental
progress made by the States and UTs from base year to reference year is used to generate incremental
ranks (Section 2 provides methodological details of constructing the Index). States and UTs have been
ranked in three categories (Larger States, Smaller States and UTs) to ensure comparison among similar
entities (Table 2.1 deals with categorization of States and UTs).
4. For generation of Index values and ranks, data was submitted online and validated by an
Independent Validation Agency (IVA): The States were sensitized about the Health Index including
indicator definitions, data sources and process for data submission through a series of regional
workshops and mentor support was provided to most States (Table 3.4). Data was submitted by States
on the online portal hosted by NITI Aayog and data from sources in the public domain was pre-entered.
This data was then validated by an IVA and was used as an input into automated generation of Index
values and ranks on the portal (Sections 3.2.4 and 3.2.5).
2
Key Results
5. There is a large gap in overall performance between the best and the least performing States and
UTs; besides, all States and UTs have substantial scope for improvement: In the reference year
(2015-16) among Larger States, the Index score for overall performance ranged widely between 33.69
in Uttar Pradesh to 76.55 in Kerala. Similarly, among Smaller States, the Index score for overall
performance varied between 37.38 in Nagaland to 73.70 in Mizoram, and among UTs this varied
between 34.64 in Dadra & Nagar Haveli to 65.79 in Lakshadweep. Among Larger States, the variation
between the best and least performing States and UTs was the widest around 43 points as compared
with 36 points in Smaller States and 31 points in UTs. However, based on the highest observed overall
Index scores in each category of States and UTs, clearly there is room for improvement in all States and
UTs.
6. The States and UTs rank differently on overall performance and annual incremental
performance: States and UTs that start at lower levels of the Health Index (lower levels of development
of their health systems) are generally at an advantage in notching up incremental progress over States
with high Health Index score due to diminishing marginal returns in outcomes for similar effort levels.
It is a challenge for States at high levels of the Index score even to maintain their performance levels.
For example, Kerala ranks on top in terms of overall performance and at the bottom in terms of
incremental progress mainly as it had already achieved a low level of Neonatal Mortality Rate (NMR)
and Under-five Mortality Rate (U5MR) and replacement level fertility, leaving limited space for any
further improvements.
Figure E.1 - Larger States: Incremental scores and ranks, with overall performance from base year to reference year and ranks
Kerala 76.55 80.00 -3.45 1 21
Punjab 62.02 65.21 3.19 2 6
Tamil Nadu 63.28 63.38 0.10 3 15

Gujarat 61.99 63.28 -1.29 4 19
Himachal Pradesh 61.20 62.12 -0.92 5 17
Maharashtra 60.09 61.07 0.98 6 10
Jammu & Kashmir 53.52 60.35 6.83 7 2
Andhra Pradesh 57.75 60.16 2.41 8 7
Karnataka 58.70 59.73 -1.03 9 18
West Bengal 57.87 58.25 0.38 10 13
Telangana 54.94 55.39 0.45 11 12
Chhattisgarh 48.63 52.02 3.39 12 5
Haryana 46.97 49.87 -2.90 13 20
Jharkhand 38.46 45.33 6.87 14 1
Uttarakhand 45.22 45.32 -0.10 15 16
Assam 43.53 44.13 0.60 16 11
Madhya Pradesh 38.99 40.09 1.10 17 9
Odisha 39.23 39.43 0.20 18 14
Bihar 34.70 38.46 3.76 19 4
Rajasthan 34.55 36.79 2.24 20 8
Uttar Pradesh 28.14 33.69 5.55 21 3
20 30 40 50 60 70 80 -4 0 4 8
Overall Reference Incremental
Overall Performance Index Score Incremental Change Year Rank Rank
Base Year (2014-15)
Reference Year (2015-16)
3
7. Among the Larger States, Jharkhand, Jammu & Kashmir, and Uttar Pradesh are the top three
ranking States in terms of annual incremental performance, while Kerala, Punjab, and Tamil
Nadu ranked on top in terms of overall performance: In terms of annual incremental performance
in Index scores from the base to the reference year, the top three ranked States in the group of Larger
States are Jharkhand (up 6.87 points), Jammu & Kashmir (up 6.83 points) and Uttar Pradesh
(up 5.55 points). However, in terms of overall levels of performance, these States are in the bottom
two-third of the range of Index scores, with Kerala (76.55), Punjab (65.21) and Tamil Nadu (63.38)
showing the highest scores. Jharkhand, Jammu & Kashmir, and Uttar Pradesh showed the maximum
gains in improvement of health outcomes from base to reference year in indicators such as NMR,
U5MR, full immunization coverage, institutional deliveries, and people living with HIV (PLHIV) on
antiretroviral therapy (ART).
8. Among Smaller States, Manipur ranked first in terms of annual incremental performance and
second in terms of overall performance, while Goa ranked second in terms of annual incremental
performance: Among Smaller States, Mizoram (73.70) followed by Manipur (57.78) are the best
overall performers. In annual incremental performance, Manipur (up 7.18 points) and Goa (up 6.67
points) ranked the highest. For Smaller States, among the top performers, the indicators that
contributed to higher incremental performance varied. Manipur, ranked at the top and registered
maximum incremental progress on indicators such as PLHIV on ART, first trimester antenatal care
(ANC) registration, grading of Community Health Centres (CHCs) on quality parameters, average
occupancy of three key State-level officers, and good reporting on the Integrated Disease Surveillance
Programme (IDSP).
Figure E.2 - Smaller States: Incremental scores and ranks, with overall performance from base year to reference year and ranks
Mizoram 71.27 73.70 2.43 1 4

Manipur 50.60 57.78 7.18 2 1
Meghalaya 51.40 56.83 5.43 3 3
Sikkim 53.20 53.39 -0.19 4 5
Goa 46.46 53.13 6.67 5 2
Arunachal
Pradesh 49.51 50.60 -1.09 6 6
Tripura 43.51 48.35 -4.84 7 7
Nagaland 37.38 45.26 -7.88 8 8
30 40 50 60 70 80 -10 0 10
Overall
Reference Incremental
Base Year (2014-15)
9. Among UTs, Lakshadweep showed both the highest annual incremental performance as well as
the best overall performance: In annual incremental performance, Lakshadweep ranked at the top
(up 9.56 points) followed by Andaman & Nicobar Islands (up 3.82 points). In terms of overall
performance, Lakshadweep (65.79) ranked at the top, followed by Chandigarh (52.27). Lakshadweep
showed the highest improvement in indicators such as institutional deliveries, tuberculosis (TB)
treatment success rate and transfer of Central National Health Mission (NHM) funds from State
Treasury to implementation agency.
4
Figure E.3 - Union Territories: Incremental scores and ranks, with overall performance from base year to reference year and ranks
Lakshadweep 56.23 65.79 9.56 1 1
Chandigarh 52.27 57.49 -5.22 2 6
Delhi 48.05 50.02 1.97 3 4

Andaman & Nicobar 46.18 50.00 3.82 4 2
Islands
Puducherry 46.54 47.48 0.94 5 5
Daman & Diu 36.10 44.77 -8.67 6 7
Dadra & Nagar Haveli 31.34 34.64 3.30 7 3

30 40 50 60 70 -10 -5 0 5 10 Overall
Reference Incremental
Base Year (2014-15)
10. The incremental measurement shows that about one-third of the States have registered a decline
in their Health Indices in the reference year as compared to the base year: This is a matter of
concern and should nudge the States into reviewing and revitalizing their programmatic efforts. Among
the Larger States, six States, namely Uttarakhand, Himachal Pradesh, Karnataka, Gujarat, Haryana
and Kerala have shown a decline in performance from base year to reference year, despite some of them
being among the top ten in overall performance. Among the Smaller States, Sikkim, Arunachal
Pradesh, Tripura and Nagaland have shown a decline; and among the UTs, Chandigarh and Daman
& Diu have shown a decline. Tables E.1, E.2 and E.3 provide a categorization of States and UTs based
on the level of annual incremental performance and the overall performance.
Table E.1 - Categorization of Larger States on incremental performance and overall performance
Incremental Performance Overall Performance
Aspirants Achievers Front-runners

Not Improved Uttarakhand Himachal Pradesh Kerala
Haryana Karnataka
Gujarat
Least Improved Madhya Pradesh Maharashtra Tamil Nadu
Assam Telangana
Odisha West Bengal
Moderately Improved Bihar Chhattisgarh Punjab

Rajasthan Andhra Pradesh
Most Improved Jharkhand Jammu & Kashmir
Uttar Pradesh
Note: Overall Performance: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>62); Achievers:
middle one-third (Index score between 48 and 62), Aspirants: lowest one-third (Index score<48).
Incremental Performance: The States are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’
(incremental Index score between 0.01 and 2), ‘Moderately Improved’ (incremental Index score between 2.01 and 4), ‘Most Improved’ (incremental Index score>4.0).
5
Table E.2 - Categorization of Smaller States on incremental performance and overall performance
Not Improved Tripura Sikkim -

Nagaland Arunachal Pradesh
Least Improved - - -
Moderately Improved - - Mizoram
Most Improved - Manipur -

Meghalaya
Goa
Note: Overall Performance: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>61.60), Achievers:
middle one-third (Index score between 49.49 and 61.60), Aspirants: lowest one-third (Index score <49.49).
Incremental Performance: The States are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’
Table E.3 - Categorization of Union Territories based on incremental performance and overall performance
Not Improved Daman & Diu Chandigarh -
Least Improved - Delhi
Puducherry -
Moderately Improved Dadra & Nagar Haveli Andaman &

Nicobar Islands -
Most Improved - Lakshadweep
Note: Overall Performance: The UTs are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>55), Achievers: middle
one-third (Index score between 45 and 55), Aspirants: lowest one-third (Index score<45).
For Incremental Performance: The UTs are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’
In terms of numbers of indicators, Chhattisgarh, Goa and Delhi showed improvement in the highest
number of parameters, within the three categories of States respectively (Figures 4.6, 4.12, 4.18). The
specific indicators for which the States’ performance has dipped or improved and actual values for these
are provided in Annexure 4. The indicators where most States and UTs need to focus include
addressing vacancies in key staff, establishment of functional district Cardiac Care Units (CCUs),
quality accreditation of public health facilities, and institutionalization of Human Resources
Management Information System (HRMIS). Additionally, almost all Larger States need to focus on
improving the Sex Ratio at Birth (SRB).
11. The overall performance of States is not always consistent with the domain-specific performance:
Some States fare significantly better in one domain than others, suggesting that there is scope to
improve their performance in lagging domains with specific targeted interventions. For example, while
most States showed a better performance in Health Outcomes, Tamil Nadu, West Bengal, Assam,
Madhya Pradesh, Odisha, Rajasthan, Daman & Diu, and Dadra & Nagar Haveli performed better in
terms of Key Inputs/Processes. Domain-wise incremental performance among the three categories of
States showed the highest improvement in outcomes, respectively for Jammu & Kashmir, Uttar Pradesh
and Jharkhand; Goa and Manipur; Andaman & Nicobar Islands and Lakshadweep.
6
Conclusions and Way Forward
12. The Health Index is a useful tool for systematic measurement of annual performance across
States and UTs: Rich learnings have emerged that will guide improvement of both the methods and
the data to make the Index better. The Health Index is an important aid in understanding the
heterogeneity and complexity of the nation’s performance in health. It is the first attempt at establishing
an annual systematic tool for measurement of performance across States and UTs on a variety of health
parameters within a composite measure. In its first year, it may not have achieved perfection; however,
it does set the foundation for a systematic output and outcome based performance measurement. In
linking this Index to incentives under the NHM, the MoHFW has underlined the importance of such
an exercise. The results and analysis in this report provide an important insight into the areas in which
States have improved, stagnated or declined and this will help in better targeting of interventions.
Owing to the multiplicity of determinants that impact health outcomes, some of these actions may lie
outside the ambit of health departments and, in fact, depend on the actions of the private sector and
sectors other than health. The learnings that have emerged during the process of development of the
Health Index, will guide in refining the Index for the coming year and also address some of the
limitations. The exercise also calls for urgently improving the data systems in health, in terms of
representativeness of the priority areas, periodic availability for all States and UTs, and completeness
for private sector service delivery.
7
Background
Overview – evolution and rationale

About the Index – defining and measuring
Processes – from idea to practice
8
1. Overview – evolution and rationale
India has achieved significant economic growth over the past decades, but the progress in health has not
been commensurate. The inability to rapidly improve the human capital also places a binding
constraint on economic growth. Between 1991 and 2015, India made major improvements, for
instance, life expectancy at birth increased by approximately 10 years; Infant Mortality Rate (IMR)
more than halved; Total Fertility Rate (TFR) dropped to near replacement level; and Maternal
Mortality Ratio (MMR) declined by more than 60 percent1. At the same time, non-communicable
diseases (NCDs) have emerged as the leading cause of morbidity and death for adults, contributing to
55 percent of all disease burden and more than 62 percent of deaths in the country2. When compared
with India’s economic progress and achievements, the rates of improvement in health outcomes have
remained slower than that of developing countries with comparable levels of spending on health3.
Furthermore, there is large variation in terms of health outcomes and health systems across States.
The National Development Agenda unanimously agreed to by all State Chief Ministers and Lieutenant
Governors of Union Territories in 2015 had inter alia identified education, health, nutrition, women
and children as priority sectors. To fulfil the National Development Agenda, it is imperative to make
rapid improvement in these sectors. While the responsibility in this regard is shared between the Center
and the States, given that health is a State subject, implementation is largely done by the States. The
Center’s role is limited primarily to financing, setting policy principles and program guidelines.
India, along with other countries, has committed itself to adopting the Sustainable Development Goals
(SDGs) to end poverty, protect the planet, and ensure prosperity for all as part of a new global
sustainable development agenda to be fulfilled by 2030. There is renewed commitment in India to
accelerate the pace of achievement of the SDGs, including Goal 3 related to ensuring healthy lives and
promoting the well-being for all.
In order to bring about rapid transformative action in achieving the desired outcomes, a priority for
NITI Aayog is to nudge the States towards improvement in outcomes in the coming years. The broader
goal is to develop a spirit of co-operative and competitive federalism whereby the Center and States can
jointly determine the route to progress and prosperity. It is in this context that NITI Aayog has
spearheaded the Health Index initiative with the MoHFW, and has an explicit focus on the outcomes of
health systems. Technical assistance for the Health Index initiative was provided by the World Bank.
Various stakeholders, including the States, domestic and international sector experts and development
partners, were consulted throughout the process and given the opportunity to provide feedback. An
interactive web portal hosted by NITI Aayog, provided a pre-designed format for the States to submit
data concerning identified indicators for the Health Index. The data was verified by IPE Global, an
independent validation agency prior to computing the Index and ranks for all States and UTs.
The Health Index consists of 24 indicators grouped in the domains of Health Outcomes, Governance
and Information, and Key Inputs/Processes. The States and UTs have been ranked in three categories
to ensure comparison among similar entities - Larger States, Smaller States, and UTs. The Health Index
will be calculated and disseminated annually, with a focus on measuring and highlighting annual
incremental improvement in the States and UTs. The composite Health Index and ranking of States
and UTs will assist in monitoring the States’ performance, also serving as an input for
performance-based incentives, leading ultimately to improvements in the state of health in each State.
1
World Bank. 2017. World Development Indicators 2017. Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/26447 License: CC BY 3.0 IGO.
2
Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation. India: Health of the Nation's States — The India State-Level Disease Burden
Initiative. New Delhi, India: ICMR, PHFI, and IHME; 2017.
3
Paper no I/2015, Working Paper Series I, Health Division, NITI Aayog.
9
2. About the Index – defining and measuring
2.1 AIM
To promote a co-operative and competitive spirit amongst the States and UTs to rapidly bring about
transformative action in achieving the desired health outcomes.
2.2 OBJECTIVES
1. To develop a composite Health Index based on key health outcomes and other health systems and
service delivery indicators.
2. To ensure States’ participation and ownership through Health Index data submission on a
web-based portal with requested mentor support.
3. To build transparency through independent validation of data by an independent agency.
4. To generate Health Index scores and rankings for different categories of the States and UTs based
on year-to-year progress (annual incremental performance) and overall performance.
2.3 SALIENT FEATURES
• The Health Index consists of a limited set of relevant indicators categorized in the domains of
Health Outcomes, Governance and Information, and Key Inputs/Processes.
• Health Outcomes are assigned the highest weight, as these remain the focus of performance.
• Indicators have been selected on the basis of their importance and availability of reliable data at
least annually from existing data sources such as the Sample Registration System (SRS), Civil
Registration System (CRS) and Health Management Information Systems (HMIS).
• Data on indicators is included for Index calculations after validation by the IVA.
• A composite Index is calculated as a weighted average of various indicators, focused on measuring

the state of health in each State and UT for a base year (BY) and a reference year (RY).
• The change in the Index score of each State from the base year to a reference year measures the
annual incremental progress of each State.
• States and UTs have been grouped in three categories to ensure comparison among similar
entities, namely 21 Larger States, 8 Smaller States, and 7 UTs.
2.4 METHODOLOGY
2.4.1 Computation of Index scores and ranks
After validation of data by the IVA, data submitted by the States and pre-entered from established
sources was used for the Health Index score calculations. Each indicator value was scaled, based on the
nature of the indicator. For positive indicators, where higher the value, better the performance (e.g. service
coverage indicators), the scaled value (Si) for the ith indicator, with data value as Xi. was calculated as
follows:
10
(Xi – Minimum value) x 100
Scaled value (Si) for positive indicator =
(Maximum value – Minimum value)
Similarly, for negative indicators where lower the value, better the performance (e.g. NMR, U5MR, human
resource vacancies), the scaled value was calculated as follows:
(Maximum value – Xi) x 100

Scaled value (Si) for negative indicator =
(Maximum value – Minimum value)
The minimum and maximum values of each indicator were ascertained based on the values for that
indicator across States within the grouping of States (Larger States, Smaller States, and UTs) for that
year.
The scaled value for each indicator lies between the range of 0 to 100. Thus, for a positive indicator
such as institutional deliveries, the State with the lowest institutional deliveries will get a scaled value of
0, while the State with the highest institutional deliveries will get a scaled value of 100. Similarly, for a
negative indicator such as NMR, the State with the highest NMR will get a scaled value of 0, while the
one with the lowest NMR will get a scaled value of 100. Accordingly, the scaled value of other States
will lie between 0 and 100 in both cases.
Based on the above scaled values (Si), a composite Index score was then calculated for the base year and
reference year after application of the weights using the following formula:
(∑ Wi*Si )
Composite Index =
(∑ Wi)
where Wi is the weight for ith indicator.
The composite Index score provides the overall performance and domain-wise performance for each
State and UT, and has been used for generating overall performance ranks.
The difference between the composite Index score of reference and base years was used to compute the
annual incremental performance. Ranks were also generated to ascertain the relative position of the
States in terms of annual incremental performance.
The ranking is primarily based on the incremental progress made by the States and UTs from the base
year to the reference year. However, rankings based on Index scores for the base year and the reference
year performance have also been presented to provide the overall performance of the States and UTs.
A comparison of the change in ranks between the base and reference years has also been undertaken.
2.4.2 Categorization of States for ranking
Based on the availability of data and the fact that similar States should be compared, it was decided to
rank the States in three categories, namely Larger States, Smaller States and UTs (Table 2.1).
11
Table 2.1 - Categorization of States and UTs
Category Number of States and UTs

States and
UTs
Larger States 21 Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jammu &
Kashmir, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan,
Tamil Nadu,Telangana, Uttar Pradesh, Uttarakhand, West Bengal
Smaller States 8 Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura
Union Territories 7 Andaman & Nicobar, Chandigarh, Dadra & Nagar Haveli, Daman & Diu, Delhi, Lakshadweep, Puducherry
This categorization was adopted due to the following reasons:
• The SRS data on health outcomes (NMR, U5MR, TFR and SRB) are not available for 8 Smaller
States and 7 UTs, and though options were explored by the Office of the Registrar General and
Census Commissioner of India (ORGI) to generate these estimates, no reliable option was
available.
• Experts consulted4 by NITI Aayog also reported that reliable estimates for these outcome
indicators based on raw data obtained from SRS for the Smaller States and UTs could not be
derived due to small sample size and insufficient number of events.
2.4.3 The Health Index - List of indicators and weightage
As the Index is a weighted composite Index based on indicators in three domains, each domain has been
assigned weights based on its importance. Within a domain or sub–domain, the weight has been equally
distributed among the indicators in that domain or sub-domain. Table 2.2 provides a snapshot of the
number of indicators in each domain and sub-domain along with weights, while Table 2.3 provides the
detailed Health Index with indicators, their definitions, data sources, and specifics of base and reference
years.
Table 2.2 - Health Index: Summary
Larger States Smaller States Union Territories

Domain Sub-domain Number Number Number
of Weight of Weight of Weight
Indicators Indicators Indicators
Health Key Outcomes 5 500 1 100 1 100

Outcomes Intermediate
Outcomes 6* 300* 6* 300* 5* 250*
Governance Health
and Monitoring and 1 70 1 70 1 70
Information Data Integrity
Governance 2 60 2 60 2 60
Key Inputs/ Health
Processes Systems/Service 10 200 10 200 10 200
Delivery
TOTAL 24 1130 20 730 19 680
* The data for indicator no. 1.2.6 related to out of pocket expenditure was available only for 2015-16 and hence was used to calculate independently the
reference year Index and rank (as provided in Annexure 3). This was not included for analyzing improvements between the base and reference
years/annual incremental performance as data between the two years needed to be comparable for that purpose.
4
Experts included Pulak Ghosh, Professor, Indian Institute of Management, Bangalore; Arvind Pandey, Advisor, Indian Council for Medical Research/ National Institute of Medical Statistics
(ICMR-NIMS); Laishram Ladusingh, Director, International Institute of Population Studies; Mudit Kapoor, Associate Professor of Economics, the Indian Statistical Institute (ISI).
12
Table 2.3 - Health Index: Indicators, definitions, data sources, base and reference years
S. No. Indicator Definition Data Source Base Year (BY) Remarks

& Reference
Year (RY)
DOMAIN 1 – HEALTH OUTCOMES
Sub-domain 1.1 - Key Outcomes (Weight: Larger States – 500, Smaller States & UTs – 100)
1.1.1 Neonatal Mortality Number of infant deaths SRS BY: 2014 Indicators 1.1.1,
Rate (NMR) of less than 29 days per thousand live [pre-entered] RY: 2015 1.1.2, 1.1.3,
births during a specific year. and 1.1.5 are not
applicable for
category of
Smaller
States and UTs
1.1.2 Under-five Mortality Number of child deaths of less than 5 years SRS BY: 2014
Rate (U5MR) per thousand live births during a specific year. [pre-entered] RY: 2015
1.1.3 Total Fertility Average number of children that would be born SRS BY: 2014
Rate (TFR) to a woman if she experiences the current [pre-entered] RY: 2015
fertility pattern throughout her reproductive
span (15-49 years), during a specific year.
1.1.4 Proportion of Low Proportion of low birth weight (<=2.5 kg) HMIS BY: 2014-15
Birth Weight (LBW) newborns out of the total number of RY:2015-16
among newborns newborns weighed during a specific year
born in a public health facility.
1.1.5 Sex Ratio at Birth The number of girls born for every 1,000 SRS BY: 2012-14
(SRB) boys born during a specific year. [pre-entered] RY: 2013-15
Sub-domain 1.2 - Intermediate Outcomes (Weight: Larger & Smaller States – 300, UTs – 250)
1.2.1 Full immunization Proportion of infants 9-11 months old who HMIS BY: 2014-15
coverage have received BCG, 3 doses of DPT, 3 doses RY: 2015-16
of OPV and one dose of measles against
estimated number of infants during a
specific year.
1.2.2 Proportion of Proportion of deliveries conducted in public HMIS BY: 2014-15

institutional and private health facilities against the RY: 2015-16
deliveries number of estimated deliveries
during a specific year.
1.2.3 Total case Number of new and relapsed TB cases Revised National BY: 2015
notification rate notified (public + private) per 100,000 Tuberculosis Control RY: 2016
of tuberculosis population during a specific year. Programme (RNTCP)
(TB) MIS, MoHFW
[pre-entered]
1.2.4 Treatment success Proportion of new cured and their treatment RNTCP MIS, MoHFW BY: 2014
rate of new completed against the total number of new [pre-entered] RY: 2015
microbiologically microbiologically confirmed TB cases
confirmed TB cases registered during a specific year.
1.2.5 Proportion of people Proportion of PLHIVs receiving ART Central MoHFW Data BY: 2014-15 Indicator not
living with HIV treatment against the number of [pre-entered] RY:2015-16 applicable for
(PLHIV) on antiretroviral estimated PLHIVs who needed ART category of UTs.
therapy (ART) treatment for the specific year.
1.2.6 Average out-of-pocket Average out-of-pocket expenditure per National Family Health RY: 2015-16 Indicator applicable
expenditure per delivery delivery in public health facility (in INR). Survey (NFHS)-4 only for reference
in public health facility [pre-entered] year ranking. Not
(in INR) considered for
generating
incremental
performance
scores/ranks or
drawing
comparison
between base and
reference years
scores/ranks.
13
& Reference
Year (RY)
DOMAIN 2 – GOVERNANCE AND INFORMATION
Sub-domain 2.1 – Health Monitoring and Data Integrity (Weight: 70)
2.1.1 Data Integrity Measure: Percentage deviation of reported data from HMIS and NFHS-4 BY & RY: The NFHS data was
standard survey data to assess the quality/ 2015-16 (NFHS) available only for
a. Institutional deliveries integrity of reported data for a specific period. reference year and
BY & RY: the data for this was
b. ANC registered within 2011-12 to repeated for the
first trimester 2015-16 base year and
(HMIS) reference year.
Sub-domain 2.2 – Governance (Weight – 60)
2.2.1 Average occupancy of Average occupancy of an officer (in months), State Report BY: April 1,
an officer (in months), combined for following posts in last three years: 2012-March
combined for following 1. Principal Secretary 31, 2015
three posts at State level 2. Mission Director (NHM)
for last three years 3. Director (Health Services) RY: April 1,
1. Principal Secretary 2013-March
2. Mission Director (NHM) 31, 2016
3. Director (Health
Services)
2.2.2 Average occupancy of Average occupancy of a CMO (in months) for all State Report BY: April 1,
a full-time officer (in the districts in last three years. 2012- March
months) for all the 31, 2015
districts in last three
years - District Chief RY: April 1,
Medical Officers (CMOs) 2013-March
or equivalent post 31, 2016
(heading District Health
Services)
DOMAIN 3 – KEY INPUTS/PROCESSES
Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 200)
3.1.1 Proportion of vacant Vacant healthcare provider positions in public State Report BY: As on
healthcare provider health facilities against total sanctioned healthcare March 31, 2015
positions (regular + provider positions for following cadres
contractual) in public (separately for each cadre) during a specific year: RY: As on
health facilities a. Auxiliary Nurse Mid-wife (ANM) at sub-centers March 31, 2016
(SCs)
b. Staff nurse (SN) at Primary Health Centers
(PHCs) and Community Health Centers (CHCs)
c. Medical officers (MOs) at PHCs
d. Specialists at District Hospitals (Medicine,
Surgery, Obstetrics and Gynaecology,
Pediatrics, Anesthesia, Ophthalmology,
Radiology, Pathology, Ear-Nose-Throat (ENT),
Dental, Psychiatry)
3.1.2 Proportion of total staff Availability of a functional IT-enabled HRMIS State Report BY: As on
(regular + contractual) measured by the proportion of staff (regular + March 31, 2015
for whom an e-payslip contractual) for whom an e-payslip can be
can be generated in the generated in the IT-enabled HRMIS against total RY: As on
IT-enabled Human number of staff (regular + contractual) during a March 31, 2016
Resources Management specific year.
Information System
(HRMIS).
3.1.3 a. Proportion of specified Proportion of public sector facilities conducting State Report on BY: 2014-15 Indicator definition
type of facilities specified number of C-sections* per year (FRUs) number of functional modified
functioning as First against the norm of one FRU per 500,000 FRUs, MoHFW data on RY: 2015-16
Referral Units (FRUs) population during a specific year. required number of
(FRUs
b. Proportion of Proportion of PHCs providing all stipulated State Report on number BY: 2014-15
functional 24x7 PHCs healthcare services** round the clock against of functional 24x7
the norm of one 24x7 PHC per 100,000 PHCs, MoHFW data on RY: 2015-16
population during a specific year. required number of
PHCs
14
& Reference
Year (RY)
3.1.4 Proportion of districts Proportion of districts with functional CCUs [with State Report BY: As on
with functional Cardiac desired equipment (ventilator, monitor, March 31, 2015
Care Units (CCUs) defibrillator, CCU beds, portable ECG machine,
pulse oxymeter etc.), drugs, diagnostics and RY: As on
desired staff as per programme guidelines] March 31, 2016
against total number of districts.
3.1.5 Proportion of ANC Proportion of pregnant women registered for ANC HMIS BY:2014-15
registered within first within 12 weeks of pregnancy during a
trimester against total specific year. RY: 2015-16
registrations
3.1.6 Level of registration Proportion of births registered under Civil Civil Registration BY: 2013
of births Registration System (CRS) against the estimated System (CRS)
number of births during a specific year. [pre-entered] RY: 2014
3.1.7 Completeness of IDSP Proportion of Reporting Units (RUs) reporting in Central IDSP, BY: 2014
reporting of P and stipulated time period against total RUs, for P MoHFW Data
L forms and L forms during a specific year. [pre-entered] RY: 2015
3.1.8 Proportion of CHCs with Proportion of CHCs that are graded above 3 points HMIS BY: 2014-15
grading above 3 points against total number of CHCs during a
specific year. RY: 2015-16
3.1.9 Proportion of public Proportion of specified type of public health State Report BY: As on
health facilities with facilities with accreditation certificates by a March 31, 2015
accreditation certificates standard quality assurance program against the
by a standard quality total number of following specified type of RY: As on
assurance program facilities during a specific year. March 31, 2016
(NQAS/NABH/ISO/AHPI) 1. District hospital (DH)/Sub-district
hospital (SDH)
2. CHC/Block PHC
3.1.10 Average number of days Average time taken (in number of days) by the Centre NHM Finance BY: 2014-15
for transfer of Central State Treasury to transfer funds to Data#
NHM fund from State implementation agencies during a specific year. [pre-entered] RY: 2015-16
Treasury to
implementation agency
(Department/Society)
based on all tranches
of the last financial year
*Criteria for fully operational FRUs: SDHs/CHCs - conducting minimum 60 C-sections per year (36 C-sections per year for Hilly and North-Eastern States except for
Assam); DHs - conducting minimum 120 C-sections per year (72 C-sections per year for Hilly and North-Eastern States except Assam).
**Criteria for functional 24x7 PHCs: 10 deliveries per month (5 deliveries per month for Hilly and North-Eastern States except Assam)
#
Centre NHM Finance data includes the RCH flexi-pool and NHM-Health System Strengthening flexi-pool data (representing a substantial portion of the NHM funds)
for calculating delay in transfer of funds.
2.5 LIMITATIONS OF THE INDEX
• Some critical areas such as infectious diseases, NCDs, mental health, governance, and financial
risk protection could not be fully captured in the Index due to non-availability of acceptable
quality of data on an annual basis.
• For several indicators, the data was limited to service delivery in public facilities due to the paucity
and uneven availability of private sector data on health services in the HMIS.
• As data was not available for various indicators at the time of Index development, analytical tools
could not be used to derive indicator or domain-specific weights and expert opinion was thus used
to assign weights. The data generated for this Index will be helpful in refining the Index and
assigning weights in the future. This will also be helpful in fixing the minimum and maximum
values of the scale for the next several years, instead of a year-to-year basis.
• For SRS related key outcome indicators, data was available only for Larger States. Hence, the
Health Index scores and ranks for Smaller States and UTs were calculated excluding these
indicators.
15
• Data for some indicators was available for formerly undivided States. In such instances, the
decision was based on data triangulation. For example, data on the SRB was available only for the
undivided State of Andhra Pradesh, and the same value was used for the States of Andhra
Pradesh and Telangana as this was comparable with other data sources. However, in the case of
MMR, it was observed that the estimates for separate States varied widely as compared with
formerly undivided States and it was decided to drop the indicator from the Index.
• For several indicators, HMIS data and program data was used without any field verification by the
IVA due to the lack of feasibility of conducting independent field surveys.
• Since the integrity of administrative data was to be measured in comparison with reliable
independent data, National Family Health Survey (NFHS-4) was used, which overlapped the base
and reference year period of the Index. Therefore, the same values of the indicator on data
integrity measure were used for base and reference years.
• In some instances, such as the TB case notification rate, the programmatically accepted definition
was used, which is based on the denominator per 100,000 population. The more refined indicator
of TB cases notified per 100,000 estimated number of TB cases would have been used if data was
available.
• In some cases, proxy indicators or proxy validation criteria were used. Thus, for the number of
functional First Referral Units (FRUs) and 24x7 Primary Health Centers (PHCs), the annual
number of C-sections and deliveries respectively were used as proxy criteria. The field validation
of functionality based on available human resources and infrastructure was not viable.
• Due to unavailability of detailed records at the State level for a few indicators, such as vacancies
of human resources and districts with functional CCUs, the validation agency had to rely on
certified statements provided by the State.
• For a few indicators, such as vacancies of healthcare providers, the proportion of people living
with HIV on ART and the average number of days for transfer of funds from the State Treasury;
the State level and Central level program data was inconsistent. In such instances the data was
reviewed and the most reliable source of data was considered by the IVA.
16
3. Processes – from idea to practice
3.1 KEY STAKEHOLDERS - ROLES AND RESPONSIBILITIES
Multiple stakeholders were involved in the entire exercise and their roles and responsibilities are
summarized in Table 3.1.
Table 3.1 - Key stakeholders: Roles and responsibilities
NITI Aayog States Technical Mentor Agencies5 Independent Validation

Assistance (TA) Agency Agency
(The World Bank) (IPE Global)
Development and Adopt and share Health TA to NITI Aayog in Assist States in Validation and
dissemination of the Health Index with various developing the Health understanding the Health acceptance of the data
Index along with necessary departments Index, protocols and Index, data being sought, submitted by the States for
guidance in close partnership guidelines and mechanism for various indicators including
with MoHFW providing the responses comparison with other data
sources as needed
Facilitate interaction between Input data on the indicators Support to NITI Aayog to Participate in Regional Review of supporting
States and TA, mentor and as per identified sources disseminate the Health and State-level workshops documents and
independent validation on web portal and submit Index in Regional/State-level organized by NITI Aayog participation in data
agencies data in a timely manner workshops validation workshops
with States
Host a web portal for States Co-ordination with different Technical oversight to the Provide guidance to the Submission of final
to input data, its validation districts, mentor and mentor agencies, portal States for submission of validation report with State
and dissemination of independent validation agency and the independent data by visiting State Health details to NITI Aayog
State-wise rankings agencies validation agency Departments/Directorates
Overall coordination and Provide technical support Follow up with States for Generation and validation
management for generation of composite timely submission of data/ of ranks and final
Index and report supporting documents on certification of data on the
the web portal portal
3.2 PROCESS FLOW
The process of development of the Health Index involved various steps (Table 3.2).
Table 3.2 - Timeline for development of Health Index
Sr No. Step/Activity 2016 2017-18

Jun-Nov Dec Jan Feb Mar-Apr May Jun Jul Aug Sep-Oct Nov-Jan
1 Development of the Index
2 Regional workshops with
States
3 Mentorship to States and
submission of data
on portal
4 Validation of data and
validation workshops
with States
5 Refinement of the
Index
6 Index and rank
generation
7 Report and dissemination
of ranks
5
United States Agency for International Development (USAID), Regional Resource Centre for North Eastern States (RRC-NE), Centre for Innovation in Public Systems (CIPS), The
Energy Research Institute (TERI).
17
3.2.1 Development of Index
The initial idea of a Health Index to benchmark improvements in the States’ performance on key health
outcomes originated in March 2016. Development of the Index commenced in June 2016. The
selection of indicators and the methodology for the composite Index were among the most challenging
tasks. For the selection of indicators, a thorough review of data sources, management information
systems and similar global indices was conducted. After detailed deliberations, an initial draft with over
100 indicators was developed and shared with several stakeholders including the States, MoHFW,
domestic and international experts, and development partners for review and feedback. A pre-test was
conducted in two States to identify state-level issues regarding availability of data, sources for data
collection and data validation. Through an iterative process, taking into account importance availability
(at least annually) of reliable data, 28 indicators were included in the Health Index (Annexure 2). Once
data collection and initial validation was completed, the availability and quality of data for all States was
reviewed in a meeting chaired by Member, NITI Aayog. Based on the observations shared by MoHFW,
the World Bank, and IVA, as well as inputs from States and experts, 23 indicators were retained and five
indicators were dropped for calculating the annual incremental performance and the overall
performance in the base and reference years. However, Index scores and ranks for the reference year
were also calculated independently, based on 24 indicators including an additional indicator on
out-of-pocket expenditure, as the data for this was available only for 2015-16 (Annexure 3).
3.2.2 Regional workshops with States
In order to guide the States on the Health Index and related processes, five regional workshops were
held by a team comprising NITI Aayog, MoHFW, the World Bank, mentor agencies, and the portal
agency covering all States and UTs (Table 3.3).
Table 3.3 - Health Index regional workshops
Region Venue Date States/UTs
North New Delhi 23.12.2016 Uttar Pradesh, Haryana, Punjab, Rajasthan, Uttarakhand, Jammu and Kashmir, Himachal
Pradesh, Delhi, Chandigarh
West Goa 13.01.2017 Gujarat, Maharashtra, Madhya Pradesh, Karnataka, Goa, Dadra & Nagar Haveli, Daman & Diu
East New Delhi 27.01.2017 Bihar, Jharkhand, Odisha, Chhattisgarh, Andaman & Nicobar Islands
South Vijayawada 03.02.2017 Andhra Pradesh, Telangana, Kerala, Tamil Nadu, Lakshadweep, Puducherry
North East Shillong 10.02.2017 Meghalaya, Assam, Nagaland, Mizoram, Manipur, Arunachal Pradesh, Sikkim, Tripura,
West Bengal
3.2.3 Submission of data on the portal
Mentors were assigned to most States to facilitate data collection and submission on the portal. The
Empowered Action Group (EAG) States and North-Eastern States were provided dedicated mentor
support which other States received on request. The mentor agencies assigned to various States are
listed in Table 3.4.
18
Table 3.4 - List of mentor agencies
Agency States
United States Agency for International Uttar Pradesh, Uttarakhand, Odisha, Chhattisgarh, Punjab, Himachal Pradesh, Bihar,
Development (USAID) Jharkhand, Rajasthan, Madhya Pradesh, Haryana, Chandigarh, West Bengal
Regional Resource Centre for North Eastern Assam, Meghalaya, Arunachal Pradesh, Mizoram, Manipur, Nagaland, Sikkim, Tripura
States (RRC-NE)
Centre for Innovation in Public Systems (CIPS) Andhra Pradesh, Telangana
The Energy Research Institute (TERI) Delhi
The dedicated interactive web portal, developed and hosted by NITI Aayog includes functions for
submission of data and its validation and generates and displays state-wise Index scores and ranks. Data
was entered in the portal by the States and UTs, except some designated indicators pre-entered on the
basis of data source identified at the outset. For State-level data entry, options were provided to the
States to either enter data at the State level or assign this to the districts. However, the final submissionof
data on the portal was done by the designated State-level competent authority. The process of data
entry and submission by the States began in February 2017 and ended in June 2017.
3.2.4 Independent validation of data
An Independent Validation Agency (IVA), namely, IPE Global, was hired by NITI Aayog through a
competitive selection process to review and validate the Health Index data and the State rankings. The
data submitted on the portal was validated by the IVA from May-October 2017 as summarized in
Figure 3.1.
Figure 3.1 - Steps for validating data
DESK REVIEW Interaction with Documenting Field Visits to

(FLV) State Nodal Gaps and States &
Officers (FLV) Inconsistencies Districts (SLV)
• Review of data for • Discrepancies • In case the nodal • Sample states and
completeness, found during the officer is unable to districts visited to
accuracy, desk review address the validate
consistancy. validated with discrepancies, results/figures
Comparison with State Nodal sample field visits provided by the
published sources officers undertaken state for specific
like NFHS, SRS indicators
etc. as specified
FLV - First level verification, SLV - Second level verification
Field visits were conducted to carry physical validation of the data in Assam, Chhattisgarh, Rajasthan,
Kerala, Himachal Pradesh, Bihar and Jharkhand6. A regional workshop was also held to cover the seven
North-Eastern States. The detailed note on discrepancies in data submitted and their resolution is
provided in Annexure 1.
3.2.5 Index and rank generation
The data validated and finalized by the IVA after resolving issues with the States was used in Index
generation and rankings. Once the data was accepted by the IVA, the ranks were automatically
generated by the portal hosted by the NITI Aayog. In addition, to ensure accuracy the indices and ranks
were manually calculated and cross-checked with the results from the portal and the final values were
certified by the IVA. The activity of Index and rank generation was undertaken in September and
October 2017.
6
Physical verification of the documents and meetings with State Nodal Officers were conducted by project offices of the IVA.
19
Results
And Findings
Performance of Larger States

Performance of Smaller States
Performance of Union Territories
States and UTs: Performance on indicators
20
4. Unveiling performance – encouraging actions
This chapter presents the States’ overall and incremental performance on the Health Index. The results
are presented for each group of States separately: Larger States, Smaller States, and UTs. Overall
performance is measured using the composite Index scores for base and reference years, and
incremental performance is calculated as the change in composite Index scores from base to reference
year.
4.1 PERFORMANCE OF LARGER STATES
4.1.1 Overall performance
In the base year (2014-15), the composite Health Index ranged from 28.14 in Uttar Pradesh to 80 in
Kerala. On an average, modest improvement was observed between the base and reference year, with
the difference between the worst and best performing States narrowing. In the reference year 2015-16,
Uttar Pradesh at 33.69 remained the poorest performing State, and Kerala remained the best
performing State despite a slight decline in the Health Index to 76.55.
Figure 4.1 displays the composite Index scores for base and reference years for the Larger States and
ranks the States based on their overall performance. The lines depict changes in the ranking: a blue line
denotes a negative change in the State’s ranking from base to reference year, a green line indicates a
positive change, and a grey line indicates no change in ranking.
The top five performing States in the reference year based on the composite Index score are Kerala
(76.55), Punjab (65.21), Tamil Nadu (63.38), Gujarat (61.99), and Himachal Pradesh (61.20). On the
other end of the spectrum, Uttar Pradesh (33.69) scored the lowest and ranks at the bottom preceded
by Rajasthan (36.79), Bihar (38.46), Odisha (39.43), and Madhya Pradesh (40.09). The EAG7 States
(except Chhattisgarh) and Assam lie at the tail end of the distribution, ranking between 14th and 21st
positions.
Among the 21 Larger States, only five States improved their position from base to reference year. These
States are Punjab, Andhra Pradesh, Jammu & Kashmir, Chhattisgarh and Jharkhand. The most
significant progress was observed in Jharkhand and Jammu & Kashmir. Both States moved up by four
positions in the ranking. Meanwhile, Punjab improved its performance in the ranking by three positions.
Andhra Pradesh and Chhattisgarh have shown modest improvement – both up by one position. Despite
increases in the composite Health Index scores, the rankings of Maharashtra, Madhya Pradesh, Bihar,
Rajasthan, and Uttar Pradesh did not change between base and reference years. Kerala continued to be
at the top position and the remaining States fell in ranking by 1-2 positions.
7
Eight states namely Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand, and are referred to as the Empowered Action Group (EAG)
States.
21
Figure 4.1 - Larger States: Overall performance - Composite Index score and rank, base and reference years
1 Kerala 80.00 76.55 Kerala 1
2 Tamil Nadu 63.28 65.21 Punjab 2
3 Gujarat 63.28 63.38 Tamil Nadu 3
4 Himachal Pradesh 62.12 61.99 Gujarat 4
5 Punjab 62.02 61.20 Himachal Pradesh 5
6 Maharashtra 60.09 61.07 Maharashtra 6
7 Karnataka 59.73 60.35 Jammu & Kashmir 7
8 West Bengal 57.87 60.16 Andhra Pradesh 8
Reference Year Rank

9 Andhra Pradesh 57.75 58.70 Karnataka 9
Base Year Rank
10 Telangana 54.94 58.25 West Bengal 10
11 Jammu & Kashmir 53.52 55.39 Telangana 11
12 Haryana 49.87 52.02 Chhattisgarh 12
13 Chhattisgarh 48.63 46.97 Haryana 13
14 Uttarakhand 45.32 45.33 Jharkhand 14
15 Assam 43.53 45.22 Uttarakhand 15
16 Odisha 39.23 44.13 Assam 16
17 Madhya Pradesh 38.99 40.09 Madhya Pradesh 17
18 Jharkhand 38.46 39.43 Odisha 18
19 Bihar 19
Bihar 34.70 38.46
20 Rajasthan 20
Rajasthan 34.55 36.79
21 Uttar Pradesh 21
Uttar Pradesh 28.14 33.69
Base Year Reference Year

2014-15 2015-16
Note: Lines depict changes in composite Index score rank from base to reference year. The composite Index score is presented in the circle.
Based on the composite Index scores for the reference year (2015-16), the States are grouped into three
categories: Aspirants, Achievers, and Front-runners (Table 4.1). Aspirants are the bottom one-third
states with an Index score below 48. These States are largely the EAG States (except Chhattisgarh) and
given the substantial scope for improvement, require concerted efforts. Achievers represent the middle
one-third States with an Index score between 48 and 62. Overall, these States have made good progress
and can move to the next group with sustained efforts. Front-runners, the top one-third States with an
Index score above 62 are the best performing States. Despite relatively good performance, however,
even the Front-runners could further benefit from improvements in certain indicators as the highest
observed Index score of 76.55 is well below 100.
Table 4.1 - Larger States: Overall performance in reference year - Categorization

Haryana Gujarat Kerala
Jharkhand Himachal Pradesh Punjab
Uttarakhand Maharashtra Tamil Nadu
Assam Jammu & Kashmir
Madhya Pradesh Andhra Pradesh
Odisha Karnataka
Bihar West Bengal
Rajasthan Telangana
Uttar Pradesh Chhattisgarh
Note: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>62), Achievers: middle one-third (Index
score between 48 and 62), Aspirants: lowest one-third (Index score<48).
22
4.1.2 Incremental performance
Incremental performance measures the change in the Health Index score from base to reference year,
which is masked by the year-specific rankings. It is important to identify the year-on-year pace of
improvement made by States. States that start at lower levels of Health Index are generally at an
advantage for higher incremental progress due to diminishing marginal returns for States that start at a
high Index score. This measure is particularly important for identifying States with negative
incremental progress.
In Figure 4.2, the left side, presents the State-wise movement in Health Index from base to reference
year along with their relative position and on the right side, actual increments are presented. Overall,
the incremental performance does not appear to be associated with the overall Index score. Importantly,
some of the better-performing Larger States have made negative incremental progress. Three of the
top five Larger States (Kerala, Gujarat, and Himachal Pradesh) recorded negative changes in the overall
performance Index score between base and reference years.
Figure 4.2 - Larger States: Overall and incremental performance, base and reference years and incremental rank
Jharkhand 38.46 45.33 6.87 1

Jammu & Kashmir 53.52 60.35 6.83 2
Uttar Pradesh 28.14 33.69 5.55 3
Bihar 34.70 38.46 3.76 4
Chhattisgarh 48.63 52.02 3.39 5
Punjab 62.02 65.21 3.19 6
Andhra Pradesh 57.75 60.16 2.41 7
Rajasthan 34.55 36.79 2.24 8
Madhya Pradesh 38.99 40.09 1.10 9
Maharashtra 60.09 61.07 0.98 10
Assam 43.53 44.13 0.60 11
Telangana 54.94 55.39 0.45 12
West Bengal 57.87 58.25 0.38 13
Odisha 39.23 39.43 0.20 14
Tamil Nadu 63.28 63.38 0.10 15
Uttarakhand 45.22 45.32 -0.10 16
Himachal Pradesh 61.20 62.12 -0.92 17
Karnataka 58.70 59.73 -1.03 18
Gujarat 61.99 63.28 -1.29 19
Haryana 46.97 49.87 -2.90 20
Kerala 80.00 21
76.55 -3.45
20 30 40 50 60 70 80 -4 0 4 8
Incremental
Overall Performance Index Score Incremental Change Rank
Base Year (2014-15) Reference Year (2015-16)
Among the 21 Larger States, 15 States displayed a positive incremental change in the Index score. The
remaining six States showed negative incremental change. Except for Uttarakhand that showed a slight
negative incremental performance, the EAG States registered positive incremental progress. Jharkhand
(ranked at top) followed by Jammu & Kashmir and Uttar Pradesh made significant incremental
progress, with more than a five-point change in Index score from base to reference year. However, for
Bihar, Chhattisgarh, Punjab, Andhra Pradesh and Rajasthan, the Index score increased by 2 to 4 points.
Further, limited improvement was observed in Madhya Pradesh, Maharashtra, Assam, Telangana and
West Bengal. Odisha, Tamil Nadu and Uttarakhand more or less maintained their respective Health
23
Index scores and made negligible incremental progress. Meanwhile, Himachal Pradesh, Karnataka,
Gujarat, Haryana and Kerala showed declines in the reference year as compared to the base year,
resulting in a negative incremental Index score.
Fifteen states observed positive incremental change in Index scores from base to reference year, whereas
only five States (Punjab, Andhra Pradesh, Jammu & Kashmir, Chhattisgarh, and Jharkhand) increased
in their overall performance ranks from base year to reference year. This depicts that only these five
States made significant incremental progress leading to improvement in the overall performance
position. The remaining States with modest or negative incremental progress have retained their earlier
position or have moved down in the ranking.
Based on their incremental performance, States are categorized into four groups: ‘not improved’ (<= 0
incremental change), ‘least improved’ (0.01 to 2 point increase), ‘moderately improved’ (2.01 to 4 point
increase), and ‘most improved’ (>4 point increase) (Table 4.2).
Table 4.2 - Larger States: Incremental performance from base to reference year - Categorization
Not improved Least improved Moderately improved Most improved
Uttarakhand Madhya Pradesh Bihar Jharkhand

Himachal Pradesh Maharashtra Chhattisgarh Jammu & Kashmir
Karnataka Assam Punjab Uttar Pradesh
Gujarat Telangana Andhra Pradesh
Haryana West Bengal Rajasthan
Kerala Odisha
Tamil Nadu
Note: The States are categorized on the basis of incremental Index score range into categories: ‘not improved’ (incremental Index score<=0), ‘least
improved’ (incremental Index score between 0.01 and 2), ‘moderately improved’ (incremental Index score between 2.01 and 4), ‘most improved’
(incremental Index score>4.0).
Among the most improved States in terms of incremental progress, Jharkhand is the top most improved
State and has showed maximum gains in improvement of health outcomes from base to reference year
in indicators such as U5MR (44 to 39 per 1000 live births), TFR (2.8 to 2.7), full immunization (81 to
88 percent) and institutional deliveries (61 to 67 percent). Jammu & Kashmir, ranked at second, has
shown good incremental progress on health outcomes of NMR (26 to 20 per 1000 live births), U5MR
(35 to 28 per 1000 live births), full immunization coverage (90 to 100 percent) and PLHIV on ART (89
to 96 percent). Similarly, Uttar Pradesh, ranked third has attained significant incremental improvement
on the parameters of U5MR (57 to 51 per 1000 live births), low birth weight (11.74 to 9.60 percent),
institutional deliveries (44 to 52 percent), and PLHIV on ART (51 to 58 percent).
Among the States which could not register positive incremental performance, Kerala is ranked at the
bottom mainly as it had already achieved low level of NMR and U5MR and replacement level fertility,
leaving very limited space for any further improvements. Additionally, Kerala also registered a decline
in sex ratio at birth from base to reference year (974 to 967 females per 1000 males). Haryana with a
negative incremental score performed poorly due to increase in U5MR (40 to 43 per 1000 live births)
and decline in the Sex Ratio at Birth (866 to 831 females per 1000 males) from base to reference year.
Gujarat registered a significant decline in sex ratio at birth (907 to 854 females per 1000 males) that
dragged down its incremental progress.
The indicators where most Larger States need to focus on include addressing the issue of sex ratio at
birth, establishment of functional district Cardiac Care Units, ensuring quality accreditation of public
health facilities, and institutionalization of Human Resources Management Information System.
24
4.1.3 Domain-specific performance
Overall performance is an aggregate measure of a State’s performance and does not reveal specific
areas requiring further attention. To identify such areas, the Index is disaggregated into the domains of
Health Outcomes, Governance and Information, and Key Inputs/Processes. The domain of
Governance and Information is not presented in this section as it has a limited number of indicators
(three) due to data limitations and thus might not be fully representative of the domain.
The overall performance of the States is not always consistent with the domain-specific performance
(Figure 4.3). Some top performing States fare significantly better in one domain suggesting that there is
scope to improve their performance in the lagging domain with specific targeted interventions. Most
States showed a better performance on health outcomes; however, Tamil Nadu, West Bengal, Assam,
Madhya Pradesh, Odisha and Rajasthan performed better in terms of Key Inputs/Processes.
Figure 4.3 - Larger States: Overall and domain-specific performance, reference year
80
70
60
Reference Year (2015-16) Score
50
40
30
20
10
0
Kerala
Punjab
Tamil Nadu
Gujarat
Himachal Pradesh
Maharashtra
Jammu & Kashmir
Andhra Pradesh
Karnataka
West Bengal
Telangana
Chhattisgarh
Haryana
Jharkhand
Uttarakhand
Assam
Madhya Pradesh
Odisha
Bihar
Rajasthan
Uttar Pradesh
Health Outcomes Key Inputs/Processes Overall Performance
Figure 4.4 and Figure 4.5 present the overall performance of Larger States in the domains of Health
Outcomes and Key Inputs/Processes for base and reference year. In these figures, from top to bottom,
States are presented in descending order of Health Index scores for the reference year. For the Health
Outcomes domain, Kerala is ranked at the top and Rajasthan is at the bottom, while for Key
Inputs/Processes, Tamil Nadu earned the top position and Uttar Pradesh received the lowest ranking.
25
In the domain of Health Outcomes, 11 States (Kerala, Punjab, Jammu & Kashmir, Telangana, Andhra
Pradesh, Chhattisgarh, Jharkhand, Assam, Bihar, Madhya Pradesh, and Uttar Pradesh) have improved
their Index score from base to reference year. The Index score has declined from base to reference year
for the other States. Jammu & Kashmir saw the largest positive incremental change (10.05) followed by
Uttar Pradesh (7.13) and Jharkhand (6.89), while negative changes of more than 2 points were observed
in West Bengal, Haryana, and Uttarakhand.
Figure 4.4 - Larger States: Performance in the Health Outcomes domain, base and reference years
Kerala 82.33 82.89 0.56

Punjab 64.54 69.87 5.33
Jammu & Kashmir 56.49 66.54 10.05
Himachal Pradesh 65.89 67.77 -1.88
Telangana 61.53 64.80 3.27
Andhra Pradesh 60.45 62.57 2.12
Tamil Nadu 62.56 64.04 -1.48
Karnataka 62.30 62.78 -0.48
Maharashtra 61.41 62.60 -1.19
Gujarat 59.78 60.30 -0.52
West Bengal 56.43 59.14 -2.71
Chhattisgarh 52.67 53.90 1.23
Jharkhand 44.93 51.82 6.89
Haryana 46.05 48.13 -2.08
Uttarakhand 45.56 47.91 -2.35
Assam 42.02 42.75 0.73
Bihar 34.01 38.83 4.82
Madhya Pradesh 35.92 37.00 1.08
Odisha 33.86 34.29 -0.43
Uttar Pradesh 26.09 33.22 7.13
Rajasthan 29.58 30.37 -0.79
20 30 40 50 60 70 80 90 -4 -2 0 2 4 6 8 10 12
Health Outcomes Index Score Incremental Change
BaseYear (2014-15)
Note: States ranked based on their reference year score in the Health Outcomes domain.
26
In the Key Inputs/Processes domain, the Index score has improved from base to reference year in 15 of
the 21 States. The Key Inputs/Processes score declined in Kerala, Karnataka, Punjab, Haryana,
Telangana and Uttar Pradesh. Large incremental increases of more than 10 points were observed in
Rajasthan, Chhattisgarh, Jammu & Kashmir, Bihar, and Jharkhand. Negative incremental change of
more than 2 points was observed in Kerala, Haryana, Telangana and UP.
Figure 4.5 - Larger States: Performance in the Key Inputs/Processes domain, base and reference years
Tamil Nadu 74.20 78.06 3.86

Kerala 69.62 74.17 -4.55
West Bengal 52.78 61.99 9.21
Andhra Pradesh 50.03 58.69 8.66
Gujarat 56.78 57.30 0.52
Karnataka 55.96 56.69 -0.73
Odisha 54.76 55.16 0.40
Maharashtra 47.57 53.17 5.60
Punjab 52.13 51.90 -0.23
Rajasthan 32.59 49.80 17.21
Himachal Pradesh 43.20 49.80 6.60
Haryana 46.41 48.86 -2.45
Assam 45.02 45.23 0.21
Chhattisgarh 29.81 44.29 14.48
Jammu & Kashmir 32.37 42.61 10.24
Madhya Pradesh 39.66 41.30 1.64
Uttarakhand 32.07 40.49 8.42
Bihar 20.20 32.54 12.34
Telangana 31.92 39.26 -7.34
Jharkhand 15.30 29.41 14.11
Uttar Pradesh 25.02 29.28 -4.26
10 20 30 40 50 60 70 80 -10 -5 0 5 10 15 20
Key Inputs/Processes Index Score Incremental Change
Base Year (2014-15)

Note: States ranked based on their reference year score in the Key Inputs/Processes domain.
4.1.4 Incremental performance on indicators
Figure 4.6 captures the incremental performance on indicators and sub-indicators and provides the
number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no
change’,‘deteriorated’ and ‘most detriorated’. Chattisgarh has the highest proportion of indicators
among Larger States (70 percent), which fall in the category of ‘most improved’ and ‘improved’. On the
other hand, Haryana has the highest proportion (43 percent) of indicators which fall in the category of
‘deteriorated’ and ‘most deteriorated’. Detailed indicator-specific performance snapshot of States is
presented in Annexure 4, which provides the direction as well as the magnitude of the incremental
change of indicators from base year to reference year.
27
Figure 4.6 - Larger States: Number of indicators/sub-indicators, by category of incremental performance
Number of Indicators/Sub-indicators
0 5 10 15 20 25 30
Chhattisgarh 8 13 4 2 1 2
Assam 5 13 5 4 1 2
Jharkhand 5 13 5 4 1 2
Rajasthan 5 13 3 6 1 2
Gujarat 3 15 0 6 4 2
Jammu Kashmir 6 11 4 5 1 3
Bihar 5 12 5 5 1 2
West Bengal 4 13 5 5 0 3
Uttar Pradesh 8 8 5 5 2 2
Karnataka 3 13 3 8 0 3
States
Andhra Pradesh 4 11 3 7 2 3
Maharashtra 2 13 3 7 1 4
Himachal Pradesh 5 9 3 4 5 4
Odisha 5 9 7 4 2 3
Tamil Nadu 5 9 2 4 5 5
Madhya Pradesh 3 11 4 9 1 2
Punjab 2 11 5 6 2 4
Uttarakhand 5 7 4 5 6 3
Telangana 1 10 8 4 4 3
Kerala 4 6 6 6 3 5
Haryana 3 6 5 10 3 3
Most Improved Improved No Change Deteriorated Most Deteriorated Not Applicable
Note: For a State, the incremental performance on an indicator is classified as not applicable (NA) in instances such as: (i) If State has achieved TFR <= 2.1
in both base and reference years; (ii) Data Integrity Measure indicator wherein the same data has been used for base year and reference year due to
overlapping periods of NFHS-4; (iii) Service coverage indicators with 100 percent values in both base and reference years; (iv) The data value for a particular
indicator is NA in base year or reference year or both.
28
4.2 PERFORMANCE OF SMALLER STATES
In the base year (2014-15), the overall performance among the Smaller States ranged from 45.26 in
Nagaland to 71.27 in Mizoram (Figure 4.7). Both states retained their respective rankings in the
reference year. Mizoram exhibited a small improvement since base year, with the Health Index score
rising to 73.70 in the reference year (2015-16). Meanwhile, Nagaland’s performance worsened
substantially - the State’s Health Index fell from 45.26 in the base year to 37.38 in the reference year.
Tripura received a score of 43.51 and is the second-to-last State among this group. Notably, while
Manipur, Meghalaya, Sikkim, Goa and Arunachal Pradesh are among the better performing Smaller
States, these States scored only between 50 and 58 points on the Health Index in the reference year.
This suggests that there is substantial scope for improvement even for these relatively better-performing
states.
Figure 4.7 - Smaller States: Overall performance - Composite Index score and rank, base and reference years
1 Mizoram 71.27 73.70 Mizoram 1
2 Sikkim 53.39 57.78 Manipur 2
3 Meghalaya 51.40 56.83 Meghalaya 3
Reference Year Rank

4 Manipur 50.60 53.20 Sikkim 4
Base Year Rank
5 Arunachal Pradesh 50.60 53.13 Goa 5
6 Tripura 48.35 49.51 Arunachal Pradesh 6
7 Goa 46.46 43.51 Tripura 7
8 Nagaland 45.26 37.38 Nagaland 8

2014-15 2015-16
Only two States, namely Manipur and Goa, improved their position from base year to reference year -
each up by two positions. Mizoram, Meghalaya, and Nagaland retained their first, third, and eighth
positions, respectively. The position of Sikkim worsened by two ranks (from second to fourth) and that
of Arunachal Pradesh and Tripura worsened by one position from fifth to sixth and sixth to seventh,
respectively.
Based on the composite Index score range for reference year (2015-16), Tripura and Nagaland (Table
4.3) are categorized as Aspirants, and have substantial scope for improvements, while Manipur,
Meghalaya, Sikkim, Goa and Arunachal Pradesh are Achievers, and though have demonstrated better
performance, still need to improve. Mizoram is categorized as a Front-runner - with the highest
observed performance among the Smaller States. Despite relatively good performance, even Mizoram
could further benefit from improvements.
29
Table 4.3 - Smaller States: Overall performance in reference year - Categorization

Tripura Manipur Mizoram
Nagaland Meghalaya
Sikkim
Goa
Arunachal Pradesh
Note: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>61.60), Achievers: mid
one-third (Index score between 49.49 and 61.60), Aspirants: lowest one-third (Index score<49.49).
Figure 4.8 presents the incremental progress made by the States along with their relative position to each
other as well as the respective increments and ranks.
Figure 4.8 - Smaller States: Overall and incremental performance, base and reference years and incremental rank
Manipur 50.60 57.78 7.18 1
Goa 46.46 53.13 6.67 2

Meghalaya 51.40 56.83 5.43 3
Mizoram 71.27 73.70 2.43 4
Sikkim 53.20 53.39 -0.19 5
Arunachal Pradesh 49.51 50.60 -1.09 6
Tripura 43.51 48.35 -4.84 7
Nagaland 37.38 45.26 -7.88 8
30 40 50 60 70 80 -10 5 0 5 10
Incremental
Base Year (2014-15)
From base to reference year, four States (Manipur, Goa, Meghalaya and Mizoram) showed positive
incremental progress, while the remaining four States (Sikkim, Arunachal Pradesh, Tripura and
Nagaland) registered negative incremental performance (Figure 4.8). The States of Manipur (ranked at
the top), Goa and Meghalaya made significant incremental progress – recording increases in the Health
Index score of 5 points or more between the base and reference years. Mizoram also made some
incremental progress with a 2.43 point change in Index scores from base to reference year. Sikkim has
observed almost no change in its Health Index score between the two periods. The Index score in
Arunachal Pradesh and Tripura declined by 1.09 and 4.84 points, respectively. Nagaland observed the
highest negative incremental change of -7.88 points between base and reference years.
Mizoram has shown incremental progress from base to reference year and has retained the top rank.
Although, three States (Manipur, Goa, and Meghalaya) have observed positive incremental change in
Index scores from base to reference year, only Manipur and Goa have been able to improve their overall
performance ranks from base year to reference year. The remaining States with modest or negative
incremental progress retained their base year position or have moved down in the ranking.
Based on their incremental performance from base to reference year, States are grouped into four
categories: ‘not improved’, ‘least improved’, ‘moderately improved’, and ‘most improved’ (Table 4.4).
Manipur, Goa, and Meghalaya are among the most improved states with an incremental Index score of
more than 4 points. Meanwhile, Sikkim, Arunachal Pradesh, Tripura, and Nagaland have not improved
and have in fact seen their overall Index scores decline between base and reference years.
30
Table 4.4 - Smaller States: Incremental performance from base to reference year - Categorization
Sikkim Mizoram Manipur

Arunachal Pradesh - Goa
Tripura Meghalaya
Nagaland
Note: The States are categorized on the basis of incremental Index score range into categories: ‘not improved’ (incremental Index score<=0), ‘least improved’
(incremental Index score between 0.01 and 2), ‘moderately improved’ (incremental Index score between 2.01 and 4), ‘most improved’ (incremental Index score>4).
Among the most improved States, Manipur registered maximum incremental progress from base to
reference year due to good progress on indicators such as PLHIVs on ART (54 to 64 percent), average
occupancy of 3 key state level officers (13 to 21 months), first trimester ANC registration (59 to 63
percent), IDSP reporting format for presumptive surveillance (P form) submission (35 to 63 percent),
and CHC grading (0 to 29 percent). Further, Goa, ranked second and progress from base to reference
year was notable on indicators such as low birth weight (17 to 16 percent), full immunization coverage
(91 to 95 percent), average occupancy of three key State-level officers (15 to 22 months), CHC grading
(25 to 75 percent), vacancy of medical officers at PHCs (31 to 14 percent) and specialists at district
hospitals (43 to 40 percent).
Among the States which have not shown any improvement from base year to reference year, Nagaland,
ranked at the bottom, and performed poorly on indicators such as TB treatment success rate (91 to 72
percent), average occupancy of three key State-level officers (12 to 7 months), first trimester ANC
registration (47 to 36 percent) and time taken to transfer Central NHM funds from State Treasury to
implementation agency (101 to 213 days). Tripura, ranked second from the bottom, and fared poorly
on indicators such as full immunization coverage (87 to 84 percent), TB case notification rate (195 to
61), PLHIVs on ART (23 to 6 percent), vacancies of Auxiliary Nurse Midwives (ANMs) at sub-centres
(15 to 39 percent), and level of birth registration (91 to 82 percent).
The indicators where almost all Smaller States need to focus include filling vacancies of ANMs at
sub-centres, establishment of functional district Cardiac Care Units, quality accreditation of public
health facilities, and institutionalization of Human Resources Management Information System.
The overall performance of the States is not always consistent with the domain-specific performance
(Figure 4.9). All Smaller States showed a better performance on Health Outcomes as compared to Key
Inputs/Processes.
31
Figure 4.9 - Smaller States: Overall and domain-specific performance, reference year
100
90
80
70
60
50
40
30
20
10
0
Mizoram Manipur Meghalaya Sikkim Goa Arunachal Tripura Nagaland
Pradesh
In the domain of Health Outcomes, five States (Mizoram, Manipur, Meghalaya, Goa and Sikkim)
improved their performance from base year to reference year and the performance of the remaining
three States (Arunachal Pradesh, Nagaland and Tripura) has worsened (Figure 4.10). Mizoram
achieved the highest score of 92.97 in the Health Outcomes domain. However, the range of scores was
wide. Manipur received a second highest score of 66.07, while the poorest performing State of Tripura
scored only 39.56 points.
Figure 4.10 - Smaller States: Performance in the Health Outcomes domain, base and reference years
Mizoram 88.77 92.97 4.20
Manipur 60.71 66.07 5.36
Meghalaya 60.63 63.40 2.77
Goa 45.62 52.79 7.17
Sikkim 48.97 50.17 1.20
Arunachal Pradesh 45.98 46.02 -0.04
Nagaland 44.80 60.55 -15.75
Tripura 39.56 54.85 -15.29
20 40 60 80 100 -20 -10 0 10 20
Base Year (2014-15)

32
In the Key Inputs/Processes domain, all Smaller States performed quite poorly and the range of scores
was significantly smaller. Goa received the highest score of only 44.65, while Manipur scored 32.18
points. Four States (Goa, Meghalaya, Tripura and Manipur) improved their performance; whereas the
performance of the remaining four States of Mizoram, Sikkim, Arunachal Pradesh and Nagaland
worsened (Figure 4.11).
Figure 4.11 - Smaller States: Performance in the Key Inputs/Processes domain, base and reference years
Goa 42.50 44.65 2.15
Mizoram 44.64 55.56 -10.92
Sikkim 41.31 43.55 -2.24
Arunachal Pradesh 41.03 42.00 -0.97
Nagaland 40.19 44.63 -4.44
Meghalaya 27.09 38.38 11.29
Tripura 33.96 36.38 2.42
Manipur 28.86 32.18 3.32
20 30 40 50 60 -15 -10 -5 0 5 10 15
Base Year (2014-15)

number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no change’,
‘deteriorated’and ‘most detriorated’. Among the Smaller States, even though Goa has the highest
number of indicators that have shown improvement, there are still nearly 30 percent of indicators that
have either remained stagnant or deteriorated. Apart from Goa, other Smaller States did not record any
improvements even in 40 percent of the indicators. Detailed indicator-specific performance snapshot of
States is presented in the Annexure 4, which provides the direction as well as the magnitude of the
incremental change of indicators from base year to reference year.
33
Figure 4.12 - Smaller States: Number of indicators/sub-indicators, by category of incremental performance
0 5 10 15 20 25
Goa 6 9 5 3 0 3
Meghalaya 3 7 4 8 1 3
Manipur 5 4 6 7 1 3
Sikkim 3 6 9 3 3 2
States
Tripura 2 6 5 5 5 3
Arunachal Pradesh 4 3 4 6 6 3
Nagaland 2 5 7 5 4 3
Mizoram 2 4 8 4 5 3
Note: For a State, the incremental performance on an indicator is classified as not applicable (NA) in instances such as: (i) Data Integrity Measure indicator wherein
the same data has been used for base and reference years due to overlapping periods of NFHS-4; (ii) Service coverage indicators with 100 percent values in both
base year and reference year; (iii) The data value for a particular indicator is NA in the base year or reference year or both.
34
4.3. PERFORMANCE OF UNION TERRITORIES
The overall performance based on the Health Index score of UTs for the base year ranged from 31.34
points for Dadra & Nagar Haveli to 57.49 points for Chandigarh.
Figure 4.13 - Union Territories: Overall performance - Composite Index score and rank, base and reference years
1 Chandigarh 57.49 65.79 Lakshadweep 1
2 Lakshadweep 56.23 52.27 Chandigarh 2
3 Delhi 48.05 50.02 Delhi 3
Reference Year Rank

4 Puducherry 46.54 50.00 Andaman & Nicobar Islands 4
Base Year Rank
5 Andaman & Nicobar Islands 46.18 47.48 Puducherry 5
6 Daman & Diu 44.77 36.10 Daman & Diu 6
7 Dadra & Nagar Haveli 31.34 34.64 Dadra & Nagar Haveli 7

2014-15 2015-16
Some improvements were observed in the reference year, but the best and worst scores still differed by
more than 30 points. Despite a modest improvement, Dadra & Nagar Haveli received the lowest score
of 34.64 points, while Lakshadweep moved to first place with a score of 65.79 points (Figure 4.13).
Only two UTs, namely Lakshadweep and Andaman & Nicobar Islands, improved their position from
base year to reference year - Lakshadweep from second to first and Andaman & Nicobar Islands from
fifth to fourth position. Delhi has retained its third position during the period. Similarly, Daman & Diu
and Dadra & Nagar Haveli did not change ranks and were ranked sixth and seventh, respectively.
Puducherry and Chandigarh both fell by one position in the rankings (Puducherry from fourth to fifth,
and Chandigarh from first to second).
Based on the composite Index score range for reference year (2015-16), the UTs are categorized into
three categories: Aspirants, Achievers, and Front-runners. Daman & Diu and Dadra & Nagar Haveli
are categorized as Aspirants, and are among the bottom one-third UTs, and have substantial scope for
improvement. Chandigarh, Delhi, Andaman & Nicobar Islands and Puducherry are grouped as
Achievers and also have significant room for improvement. Lakshadweep with the highest overall
performance is categorized as Front-runner, and could also benefit from improvements with an Index
score of 65.79, which is well below 100.
35
Table 4.5 - Union Territories: Overall performance in reference year - Categorization
Daman & Diu Chandigarh Lakshadweep

Dadra & Nagar Haveli Delhi
Andaman & Nicobar Islands
Puducherry
Note: The UTs are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>55), Achievers: mid one-third (Index score
between 45 and 55), Aspirants: lowest one-third (Index score<45).
Figure 4.14 shows that from base to reference year, five UTs (Lakshadweep, Andaman & Nicobar,
Dadra & Nagar Haveli, Delhi and Puducherry) registered positive incremental progress and the
remaining two UTs (Chandigarh and Daman & Diu) registered negative incremental change. From
base year to reference year, Lakshadweep (ranked at the top) observed the highest incremental
performance of 9.56 points. Andaman & Nicobar, Dadra & Nagar Haveli and Delhi saw an increase in
the Health Index score of between 2 to 4 points from base year to reference year. Puducherry achieved
approximately a one point incremental increase. Daman & Diu and Chandigarh reported negative
changes in the Health Index score, with the Health Index score declining by 8.67 and 5.22 points,
respectively, over the time period.
Figure 4.14 - Union Territories: Overall and incremental performance, base and reference years and incremental rank
Lakshadweep 56.23 65.79 9.56 1

Andaman & 3.82
46.18 50.00 2
Nicobar Islands
Dadra & Nagar Haveli 31.34 34.64 3.30 3
Delhi 48.05 50.02 1.97 4
Puducherry 46.54 47.48 0.94 5
Chandigarh 52.27 57.49 -5.22 6
Daman & Diu 36.10 44.77 -8.67 7
30 40 50 60 70 -10 -5 0 5 10
Incremental
Base Year (2014-15)

Furthermore, five UTs (Lakshadweep, Andaman & Nicobar, Dadra & Nagar Haveli, Delhi and
Puducherry) observed positive incremental performance in the Index scores from base to reference year,
but only two UTs (Lakshadweep and Andaman & Nicobar) could move up in the overall performance
ranks from base year to reference year. This suggests that only these two UTs made significant
incremental progress leading to improvement in its overall performance position. The remaining UTs
with modest or negative incremental progress retained their earlier position or have moved down in the
rankings.
36
The categorization of States based on incremental performance is shown in Table 4.6.
Table 4.6 - Union Territories: Incremental performance from base to reference year - Categorization
Chandigarh Delhi Andaman and Nicobar Islands Lakshadweep

Daman and Diu Puducherry Dadra and Nagar Haveli
Note: The UTs are categorized on the basis of incremental Index score range into categories: ‘not improved’ (incremental Index score<=0), ‘least improved’
(incremental Index score between 0.01 and 2), ‘moderately improved’ (incremental Index score between 2.01 and 4), ‘most improved’ (incremental Index score>4).
Lakshadweep is the most improved UT and ranked at the top with good incremental progress registered
from base to reference years for indicators such as institutional deliveries (76 to 85 percent), TB
treatment success rate (87 to 91 percent) and transfer of Central NHM funds from State Treasury to
implementation agency (143 to 0 days). Among the UTs which did not register any incremental progress
between the base and reference years, Daman & Diu fared poorly on indicators such as low birth weight
(17 to 24 percent), full immunization (85 to 80 percent), institutional deliveries (75 to 72 percent),
vacancy of specialists at district hospitals (38 to 47 percent), level of registration of births (98 to 76
percent), IDSP reporting format for presumptive surveillance (P-form) submission (100 to 75 percent)
and IDSP reporting format for laboratory surveillance (L-form) submission (86 to 75 percent). Similarly,
Chandigarh performed very poorly on first trimester ANC registration that fell from 50 percent in the
base year to 37 percent in the reference year.
The indicators where almost all UTs need to focus include filling vacancies of medical officers at PHCs
and specialists at district hospitals, establishment of functional First Referral Units, 24X7 PHCs, and
district Cardiac Care Units, CHC grading, quality accreditation of public health facilities, and
institutionalization of Human Resources Management Information System.
The overall performance of the UTs differs with the domain-specific performance and suggests some
opportunities to improve the performance in the lagging domain(s) (Figure 4.15). While most UTs
showed a better performance on most Health Outcomes, Daman & Diu and Dadra & Nagar Haveli
performed better in terms of Key Inputs/Processes.
37
Figure 4.15 - Union Territories: Overall and domain-specific performance, reference year
80
70
60
50
40
30
20
10
0
Lakshadweep Chandigarh Delhi Andaman & Puducherry Daman & Diu Dadra & Nagar
Nicobar Haveli
Islands
Note: For Chandigarh and Daman and Diu, the Key Input/Processes domain score is the same as the overall performance score.
In the domain of Health Outcomes, all UTs except Chandigarh and Daman & Diu have improved their
performance from base year to reference year (Figure 4.16). For the Health Outcomes domain in the
reference year, the range of Index scores is very wide and Lakshadweep scored highest with 74.37 points
compared to Daman & Diu’s lowest score of 15.89.
Figure 4.16 - Union Territories: Performance in the Health Outcomes domain, base and reference years
Lakshadweep 60.15 74.37 14.22

Chandigarh 63.58 73.14 -9.56
Andaman & Nicobar Islands 40.24 60.85 20.61
Delhi 53.82 56.83 3.01
Puducherry 50.90 53.58 2.68
Dadra & Nagar Haveli 19.82 23.64 3.82
Daman & Diu 15.89 32.10 -16.21
10 20 30 40 50 60 70 80 -20 -10 0 10 20

Base Year (2014-15)
In the case of the Key Inputs/Processes domain, three UTs (Delhi, Dadra & Nagar Haveli and
Lakshadweep) improved their performance; whereas the performance of the remaining four UTs
(Puducherry, Chandigarh, Daman & Diu and Andaman & Nicobar) has fallen. The range is smaller for
the Key Inputs/Processes domain. In this domain, Puducherry scored highest with 52.99 points, while
Andaman & Nicobar scored the lowest with 26.75 points. Overall, the range of scores is quite low and
indicates that all UTs need to focus on this domain.
38
Figure 4.17 - Union Territories: Performance in the Key Inputs/Processes domain, base and reference years
Puducherry 52.99 54.28 -1.29

Chandigarh 52.10 56.27 -4.17
Delhi 42.18 45.96 3.78
Dadra & Nagar Haveli 37.09 40.97 3.88
Lakshadweep 29.55 38.33 8.78
Daman & Diu 36.11 40.05 -3.94

Andaman & Nicobar 26.75 30.13 -3.38
20 30 40 50 60 -4 0 4 8
Base Year (2014-15)

number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no
change’, ‘deteriorated’ and ‘most deteriorated’. Though Delhi had the highest number of indicators
where performance has improved between the reference and base years, it has half the indicators where
the performance had remained stagnant or deteriorated. This shows that there is substantial scope of
improvement for all UTs to improve their performance on various indicators. Detailed indicator-specific
performance snapshot of UTs is presented in Annexure 4, which provides direction as well as the
magnitude of the incremental change of indicators from base year to reference year.
Figure 4.18 - Union Territories: Number of indicators/sub-indicators, by category of incremental performance
0 5 10 15 20 25
Delhi 3 8 4 4 3 3
Puducherry 1 8 6 5 1 4
Chandigarh 1 7 9 3 1 4
Union Territories
Dadra & Nagar Haveli 3 5 9 4 1 3
Daman & Diu 3 4 8 1 7 2
Andaman & Nicobar Islands 4 2 11 2 4 2
Lakshadweep 3 1 12 3 1 5
Note: For a UT, the incremental performance on an indicators is classified as not applicable (NA) in instances such as: (i) Data Integrity Measure indicator
wherein the same data has been used for base year and reference year due to overlapping periods of NFHS-4; (ii) Service coverage indicators with 100
percent values in both base and reference years; (iii) The data value for a particular indicator is NA in base year or reference year or both.
39
4.4 STATES AND UNION TERRITORIES: PERFORMANCE ON INDICATORS
This section presents the findings related to State-wise performance by each indicator included in the
Health Index. It also draws comparisons between the base year and reference year performance by each
indicator.
DOMAIN 1: HEALTH OUTCOMES

SUB-DOMAIN 1.1: KEY OUTCOMES
Indicator 1.1.1: Neonatal Mortality Rate (NMR)

Figure 4.19 - Indicator 1.1.1: Neonatal Mortality Rate - Larger States
40
36
35 35
35 34
32 32
31
30
30
28 28 28
27 27
26 26 26 26
Neonatal deaths per 1000 live births
25 25 25 25
25 24
23
24
23
24
23 23
20 20
20 19 19 19
18
16
15
15 14 1414
13
10
6 6
5
0
la
ab
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ra
sh
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ir
an
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Ch
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Base Year (2014) Reference Year (2015) Source: SRS
The NMR or the number of neonatal deaths (occurring in the first 28 days of life) per 1000 live births
during a specific year reflects the quality of prenatal, intrapartum, and neonatal care services. This is an
important indicator as approximately 68 percent of infant deaths in India occur during the neonatal
period8. The NMR is available for the Larger States and is the highest in Odisha and the lowest in
Kerala for both the base year (2014) and reference year (2015). All States reported a decline in the NMR
from the base year (2014) to reference year (2015) except for Haryana, Bihar and Uttarakhand where it
increased marginally, remaining static in Kerala and Tamil Nadu. The most progressive decline in the
NMR was observed in Himachal Pradesh and Jammu & Kashmir where the decline was approximately
23 to 24 percent. Despite reductions, the NMR remains high in many States and concerted efforts need
to be made to reach the NMR national policy goal of 16 deaths per 1000 live births by 20259and 12
deaths per 1000 live births by 2030 (the SDGs). Kerala, Punjab, Tamil Nadu and Maharashtra have
already attained the National Health Policy (NHP) 2017 NMR goal for 2025, while Kerala also has the
notable distinction of surpassing the SDG 2030 target.
8
Office of the Registrar General and Census Commissioner (India). India SRS Statistical Report 2015. New Delhi, India.
9
Ministry of Health and Family Welfare, Government of India. National Health Policy – 2017. New Delhi: MoHFW; 2017.
40
Indicator 1.1.2: Under-five Mortality Rate (U5MR)
The U5MR reflects the probability of dying before attaining the age of 5. The U5MR or the number
of deaths under the age of 5 per 1000 live births during a specific year reflects a combination of several
factors, such as the nutritional status of children, health knowledge of mothers, level of immunization
and oral rehydration therapy, access to maternal and child health services, income of the family, and
availability of safe drinking water and basic sanitation services. The U5MR is available only for the
Larger States; a comparison between the base year and reference year shows that U5MR declined in 14
States, remained stagnant in four (Kerala, Punjab, West Bengal, and Karnataka) and increased in three
States (Maharashtra, Uttarakhand and Haryana). Jammu & Kashmir, Jharkhand, Bihar, and Uttar
Pradesh recorded significant decline (between 9 to 20 percent) in U5MR between the base year (2014)
and the reference year (2015). Kerala and Tamil Nadu have already achieved the National Health
Policy 2017 U5MR target for 2025 of 23 deaths per 1000 live births. However, 12 States, namely
Uttarakhand, Andhra Pradesh, Gujarat, Jharkhand, Haryana, Bihar, Chhattisgarh, Rajasthan, Uttar
Pradesh, Odisha, Assam and Madhya Pradesh, with U5MR above 35 deaths per 1000 live births will
require concerted effort to ensure that this target is achieved.
Figure 4.20 - Indicator 1.1.2: Under-five Mortality Rate - Larger States
66 65 62
70 60 62
57 56
60 53 49 51 51
Under-five child deaths
50
per 1000 live births
48 48
50 44
38 40 39 41 39 39 40 43
40 35 31 36 37 36
30 33 34
27 28 30 31
30 21 24 27
20 23
20 13
13
10
0
ra
h
sh
ab
sh
nd
sh
t
la
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Ta
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Base Year (2014) Reference Year (2015)

Source: SRS
Indicator 1.1.3: Total Fertility Rate (TFR)
The TFR represents the average number of children that would be born to a woman if she experiences
the current age-specific fertility rate throughout her reproductive years (15-49 years). A high level of
fertility is associated with extreme poverty, gender inequality, maternal mortality, and other dimensions
of sustainable development. The TFR indicator is available only for the Larger States. In 2015, 12 of
the 21 Larger States (Andhra Pradesh, Himachal Pradesh, Jammu & Kashmir, Karnataka, Kerala,
Maharashtra, Odisha, Punjab, Tamil Nadu, Telangana, Uttarakhand and West Bengal) have achieved
the replacement level fertility (TFR ≤ 2.1). The fertility rate remains at 2.7 or above in Bihar,
Jharkhand, Madhya Pradesh, Rajasthan and Uttar Pradesh. The remaining three States (Assam,
Gujarat, and Haryana) are close to achieving the replacement level of fertility with TFR levels between
2.2 and 2.3. A comparison between the base year (2014) and reference year (2015) indicates that six
States (Chhattisgarh, Gujarat, Haryana, Jharkhand, Rajasthan and Uttar Pradesh) have showed a
decline of 0.1 in TFR.
41
Indicator 1.1.4: Proportion of Low Birth Weight (LBW) among newborns
The LBW (≤2.5 kg) among newborns is an important predictor of newborn health and survival. There
are several risk factors related to the mother that may contribute to low birth weight, such as child
bearing at a young age, multiple pregnancies, poor nutrition, heart disease or hypertension, untreated
coeliac disease, and insufficient prenatal care. Reduction in the proportion of babies born with LBW
therefore requires the convergence of interventions across several determinants of health. The HMIS
MoHFW data for base year (2014-15) and reference year (2015-16) show that the proportion of LBW
among newborns is high in many States and UTs. Among all States and UTs, Dadra & Nagar Haveli
report the highest percentage of LBW (35 percent in the base year and 29 percent in the reference year).
Other States with a high (≥15 percent) proportion of LBW newborns include Haryana, West Bengal,
Assam, Odisha, Rajasthan, Goa and all UTs except Lakshadweep. Across all States and UTs there has
been little progress in reducing the proportion of LBW newborns between the base year and the
reference year and, in fact, this has increased in several States. Hence, almost all States and UTs need
to focus on strategies and interventions to address this issue and break the inter-generational cycle of
malnutrition.
Figure 4.21 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Larger States
27.4
30.0
25.5
Low birth weight among newborns (%)
25.0
20.1
19.2
18.2
20.0
16.7
16.5
15.5
14.6
14.9
14.6
14.2
14.1
13.7
13.0
12.2
12.6
15.0
11.7
11.5
11.7
11.6
10.6
10.5
10.5
10.8
10.8
9.6
7.8
7.8
8.7
7.3
7.2
10.0
6.7
6.9
7.4
6.1
6.3
6.7
6.0
5.6
5.7
5.9
5.0
0.0
u & ana
ir
ab
sh
la
sh
du
ra
sh
an
ra
ga
ha
es
an
an
ak
ar
an
ish
m
ra
sa
ht
de
de
de
nj
Na
sth
ja
en
Bi
isg
sh
ad
at
ng
kh
kh
ry
Ke
as
Od
As
Pu
Gu
ra
ra
ra
rn
ja
Ha
tB
Ka
il
Pr
ra
ar
la
ar
rP
lP
aP
t
Ra
Ka
ha
Te
ta
Jh
es
ah
ra
Ta
ha
ta
Ut
Ch
hy
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja

Source: HMIS
Figure 4.22 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Smaller States and UTs
Smaller States Union Territories

16.7
18.0 40.0
34.7
15.6
16.0 35.0
29.4
14.0 30.0
24.4
11.1
22.5
10.6
12.0
21.4
25.0
20.9
20.8
18.5
17.2
10.0
16.9
20.0
16.1
15.5
8.2
7.8
7.7
8.0
6.8
6.6
15.0
5.8
6.0
4.7
4.7
10.0
4.1
3.9
3.9
5.6
3.5
4.9
4.0
5.0
2.0
0.0
0.0
p
ry
rh
i
lh
el
ba
ee
Di
er
ga
ur
nd
sh
ya
im
De
av
co
ur
Go
dw
&
ra
ip
di
de
la
rH
la
kk
Ni
ip
du
an
an
an
izo
ha
ha
ga
ra
Si
Tr
ga
&
Pu
m
M
Ch
ks
eg
Na
lP
Na
an
Da
La
M
ha
a&
ac
da
un
dr
An
Da
Ar
Base Year (2014-15) Reference Year (2015-16) Base Year (2014-15) Reference Year (2015-16)
Source: HMIS Source: HMIS
42
Indicator 1.1.5: Sex Ratio at Birth (SRB)
Sex Ratio at Birth or the number of girls born for every 1000 boys born during a specific year is an
important indicator and reflects the extent to which there is reduction in the number of girl children
born by sex-selective abortions. This indicator was only available for the category of Larger States. The
SRB is substantially lower in almost all Larger States - 17 out of 21 States have SRB of less than 950
females per 1000 males. Further, in most States, SRB has declined between the base year (2012-14)
and reference year (2013-15), except for Bihar, Punjab and Uttar Pradesh where improvements in
SRB were noted, and Jammu & Kashmir where it stagnated. Chhattisgarh, Karnataka, Himachal
Pradesh, Assam, Maharashtra, Rajasthan, Gujarat, Uttarakhand and Haryana recorded substantial
drops (10 or more points) in this indicator. There is a clear need for States to effectively implement the
Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 and take appropriate
measures to promote the value of the girl child.
Figure 4.23 - Indicator 1.1.5: Sex Ratio at Birth - Larger States
1000
974
973
967
961
952
953
951
950
950
950
939
938
927
924
921
919
919
919
918
918
918
916
911
910
Number of girls born for every 1000 boys born
907
907
902
899
900
899
896
900
893
889
879
878
871
870
869
866
861
854
850
844
831
800
750
h
d
l
du
ab
sh
a
sh
an
a
la
ir
ra
t
ga
es
aP h
an
ha
ra
d
ish
an
ar
ak
an
m
sa
s
ra
de
ht
an
Na
nj
de
sth
ad
de
en
ja
kh
Bi
sg
sh
ry
at
ng
Ke
As
as
Pu
Od
ra
kh
ra
Gu
Pr
ra
tB
ja
ar
Ha
rn
il
tti
Ka
la
ar
rP
m
ra
Ra
lP
Jh
Ka
ha
es
ra
Te
ah
Ta
u&
ta
ta
hy
ha
dh
Ch
Ut
Ut
ad
ac
An
m
m
M
m
Ja
Hi
Source: SRS !
SUB-DOMAIN 1.2: INTERMEDIATE OUTCOMES
Indicator 1.2.1: Full immunization coverage
This indicator reflects upon the success of the immunization programme and captures the proportion
of infants between the ages of 9-11 months who have received one dose of BCG, 3 doses of DPT, 3
doses of OPV, and one dose of measles vaccine. Reference year data shows that 19 States and UTs have
full immunization coverage of at least 90 percent, the 2025 target specified in the National Health
Policy 2017. Jammu & Kashmir, Mizoram, Andaman & Nicobar Islands and Lakshadweep have 100
percentcoverage during the reference year (2015-16). Madhya Pradesh (75 percent), Nagaland
43
(64 percent) and Dadra & Nagar Haveli (77 percent) have the lowest coverage among the Larger States,
Smaller States and UTs respectively. From base to reference year, Maharashtra, West Bengal, Kerala,
Andhra Pradesh, Telangana, Odisha, Tamil Nadu, Rajasthan, Meghalaya, Tripura and Daman & Diu
reported a decline in immunization coverage. It is evident that several States need to implement specific
strategies to attain the goals set out in National Health Policy 2017, which targets more than 90 percent
full immunization coverage by 2025. Telangana, Jharkhand, Assam, Odisha, Uttar Pradesh, Haryana,
Tamil Nadu, Rajasthan, Madhya Pradesh, Tripura, Sikkim, Arunachal Pradesh, Nagaland, Daman &
Diu, Puducherry and Dadra & Nagar Haveli fall short of the target of 90 percent coverage.
Importantly, while the average full immunization coverage among the Larger States is 90 percent, it is
significantly lower for Smaller States at 84 percent.
Figure 4.24 - Indicator 1.2.1: Full immunization coverage - Larger States
120.0 100.0
100.0
100.0
99.6
98.6
99.3
98.2
97.6
96.2
95.9
95.5
95.2
96.1
94.9
94.6
100.0
92.3
91.6
91.8
Full immunization coverage among infants
90.6
90.5
90.3
89.8
89.7
89.1
88.0
88.1
88.0
between ages of 9-11 months (%)
85.5
85.8
85.3
84.8
84.1
83.5
82.7
82.9
82.5
82.1
80.8
79.0
78.1
74.8
74.3
80.0
60.0
40.0
20.0
0.0
ir
ab
ra
sh
sh
du
an
sh
ga
ra
ha
an
ak
al
es
ar
an
an
ish
an
m
sa
ht
de
de
de
nj
Na
th
ja
en
er
sg
Bi
sh
at
ad
kh
ng
kh
ry
as
Od
As
Pu
s
Gu
ra
ra
ra
K
rn
ja
tB
tti
Ha
Ka
il
ra
Pr
ar
la
ar
lP
rP
aP
m
Ra
Ka
ha
ta
Te
Jh
es
ah
ra
u&
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja

Source: HMIS
Figure 4.25 - Indicator 1.2.1: Full immunization coverage - Smaller States and UTs

Full immunization coverage among infants
120.0 120.0
Full immuinization coverage among infants
100.0
100.0
100.0
100.0
100.0
96.2
95.2
96.3
96.4
93.6
92.3
94.4
93.3
90.9
100.0
91.3
100.0
between 9-11months (%)
85.0
84.6
87.4
84.3
79.7
77.6
77.1
75.5
between 9-11 months (%)
73.9
74.1
74.4
80.0 80.0
65.0
63.9
61.9
60.6
60.0
60.0
40.0
40.0
20.0
20.0
0.0
0.0
r
rh
ry
i
lh
el
ba
ee
Di
er
ga
De
av
co
dw
ch
&
m
ur
ya
im
sh
nd
di
rH
Go
ur
Ni
ra
ip
an
du
la
de
an
la
ha
kk
ip
ga
an
izo
ha
&
ga
Pu
Si
ra
Ch
ks
Tr
Na
M
an
Da
eg
M
lP
Na
La
m
M
ha
a&
da
ac
dr
An
un
Da
Ar
Source: HMIS
44
Indicator 1.2.2: Proportion of institutional deliveries
Institutional deliveries (public and private) can play a substantial role in addressing maternal and infant
mortality and morbidity. In the reference year (2015-16), only six States and UTs achieved more than
90 percent coverage - Gujarat and Kerala among Larger States; Mizoram and Goa among Smaller
States; and Chandigarh and Puducherry among UTs. Other States need to make substantial efforts to
improve the coverage of institutional deliveries, particularly Madhya Pradesh, Chhattisgarh,
Uttarakhand, Bihar, Uttar Pradesh, Meghalaya, Nagaland and Arunachal Pradesh, where less than
two-thirds of deliveries currently take place at health facilities. In terms of incremental progress,
approximately 40 percent of the States and UTs made modest or no progress in institutional deliveries
coverage. Andhra Pradesh (64 percent) and Telangana (44 percent) made the most notable progress and
the coverage increased by more than 40 percent between base year (2014-15) and reference year
(2015-16).
Figure 4.26 - Indicator 1.2.2: Proportion of institutional deliveries - Larger States

97.8
96.0
100.0
92.6
90.8
89.2
87.1
86.0
85.4
85.3
90.0
83.2
82.3
81.8
81.5
81.3
80.8
80.5
80.3
79.9
78.8
77.1
80.0
74.8
74.7
74.3
73.9
73.5
72.7
67.5
67.5
67.4
70.0
64.8
64.5
64.3
63.1
62.6
60.5
59.6
59.2
57.1
Institutional Deliveries (%)
60.0
53.1
53.0
52.4
50.0
43.6
40.0
30.0
20.0
10.0
0.0
al
m
h
an
sh
nd
na
ab
du
sh
t
la
ra
ir
sh
d
ra
es
ak
r
ng
an
ar
ish
sa
an
m
ha
ra
de
ht
sth
ha
de
a
nj
Na
de
ja
sg
ad
at
sh
e
ng
ry
As
kh
Ke
as
Bi
Pu
Od
ra
Gu
rk
ra
tB
ra
rn
ja
Ha
tti
il
Pr
Ka
la
ra
ar
lP
rP
aP
m
Ra
Ka
es
ha
Jh
Te
ta
ah
ra
Ta
u&
ha
ta
W
Ch
hy
Ut
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja

Source: HMIS
45
Figure 4.27 - Indicator 1.2.2: Proportion of institutional deliveries - Smaller States and UTs
120.0 120.0
100.0
100.0
100.0
100.0
100.0
96.3
92.5
91.3
88.2
100.0
87.1
100.0
85.4
80.6
80.2
79.4
76.4
76.2
79.4
75.3
78.5
72.0
74.9
73.5
72.0
80.0
70.2
80.0
62.1
59.6
58.1
57.0
56.5
56.0
60.0
60.0
40.0
40.0
20.0
20.0
0.0
0.0
rh
rry
u
el
lh
ba
ee
Di
ga
av
De
he
m
ur
im
ya
nd
sh
co
dw
&
Go
ur
di
ra
rH
ip
uc
la
de
la
kk
Ni
ip
an
an
ha
an
izo
ha
ga
ud
Si
ra
ga
Tr
&
m
Ch
ks
M
eg
M
Na
lP
Na
an
Da
La
M
ha
m
a&
ac
da
dr
un
An
Da
Ar
Indicator 1.2.3: Total case notification rate of tuberculosis (TB)
Total case notification rate is the number of new and relapsed TB cases notified, in both public and
private facilities per 100,000 population during a specific year. It is an important indicator reflecting
diagnosis and reporting of TB cases in the National Surveillance System and is an essential element for
effective implementation of the End TB Strategy. The total case notification varied between 72 per
100,000 population in Jammu & Kashmir to 207 per 100,000 population in Himachal Pradesh. The
total case notification rate increased by 10 cases per 100,000 population or more in Gujarat, Madhya
Pradesh, Kerala, Chhattisgarh, Uttar Pradesh, Tamil Nadu, Telangana, Bihar, Tamil Nadu, Uttar
Pradesh, Chhattisgarh, Kerala, Madhya Pradesh, Gujarat, Sikkim, Delhi and Daman & Diu and has
decreased by 10 cases per 100,000 population or more in Nagaland, Meghalaya, Tripura, Andaman &
Nicobar and Lakshadweep.
Figure 4.28 - Indicator 1.2.3: Total case notification rate of TB - Larger States
210
207
193
200
172
170
164
165
164
155
145
145
143
143
150
138
139
137
138
139
137
136
136
128
Total case notification rate of TB
125
123
123
123
122
per 100,000 population
113
113
108
106
105
100
100
99
100
93
93
87
84
74
72
72
50
0
a
ha
sh
ra
an
ab
du
Te am
ir
a P na
sh
sh
Ra sh
ha la
Ka nd
Ka r
rP d
Ha t
l
u & ha
ak
ra
ga
ar
an
m
n
ht
ra
de
s
de
sth
nj
Na
de
e
a
a
ha
ja
s
sg
at
sh
Bi
en
ng
ad
ry
kh
s
Od
Ke
As
Pu
ra
ra
ra
ra
Gu
rn
k
ja
tti
il
tB
la
Pr
ar
ra
lP
Jh
ah
ta
es
ra
Ta
ta
ha
Ch
hy
Ut
M
dh
W
Ut
ac
ad
m
An
m
m
Ja
Hi

Source: RNTCP MIS, MoHFW
46
Figure 4.29 - Indicator 1.2.3: Total case notification rate of TB - Smaller States and UTs

300 400

348
337
241
350
222
305
250
300
195
186
186
183
300
183
173
170
200
139
250
137
131
127
150
166
157
200
146
139
138
133
82
100
81
150
103
61
95
50 100
61
35
0 50
0
im
sh
nd
ya
ur
a
Go
ur
ra
rh
ry
p
ip
de
la
la
kk
lh
el
ba
Di
ee
ip
er
an
izo
ga
ha
ga
De
av
Si
ra
Tr
co
dw
ch
n&
M
di
eg
M
lP
Na
rH
Ni
du
an
ha
M
ha
ga
&
Pu
m
Ch
ks
ac
Na
an
Da
La
un
a&
Ar
da
dr
An
Da
Base Year (2015) Reference Year (2016) Base Year (2015) Reference Year (2016)
Source: RNTCP MIS, MoHFW Source: RNTCP MIS, MoHFW
Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases
Treatment success rate of TB cases is the proportion of new cases cured and their treatment completed
against the total number of new microbiologically confirmed TB cases registered during a specific year.
It is an important indicator that reflects the performance of the Revised National Tuberculosis Control
Programme. The National Health Policy 2017 establishes a target of ≥85 percent for treatment success
rate of TB cases, which was achieved by most States and UTs except Karnataka, Maharashtra,
Manipur, Sikkim, Nagaland (dropped from base year) and Daman & Diu.
Figure 4.30 - Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Larger States
92.0
90.9
90.4
90.4
90.3
90.3
Treatment success rate of new microbiologically
90.0
89.8
89.7
89.7
89.7
89.6
89.6
90.0
89.1
89.0
88.9
88.9
88.5
88.5
88.3
88.2
88.2
87.6
87.5
87.5
87.5
87.4
87.2
88.0
86.9
confirmed TB cases (%)
86.5
86.4
86.2
86.0
86.0
86.0
85.5
85.4
85.4
86.0
84.7
84.2
83.9
83.3
84.0
82.3
82.0
80.0
78.0
d
sh
an
sh
u & esh
ir
la
sh
ab
du
ra
ra
ga
ha
an
an
ar
sh
an
an
ak
m
ra
sa
ht
de
de
de
sth
nj
Na
ja
en
Bi
sg
sh
di
ad
at
kh
ng
ry
kh
Ke
as
As
Pu
Gu
ra
ra
ra
ja
rn
tti
Ha
tB
Ka
il
ar
Pr
ra
la
ar
aP
lP
rP
m
Ra
Ka
ha
Jh
Te
ta
es
ah
ra
Ta
ha
ta
Ut
hy
Ch
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja

Source: RNTCP MIS, MoHFW
47
Figure 4.31 - Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Smaller States and UTs
91.5
91.3
mircobiolgically confirmed TB cases (%)
microbiologically confirmed TB cases (%)
89.5
90.6
89.2
90.7
88.5
88.6
88.5
86.7
86.7
88.0
86.3
86.2
87.3
85.6
85.5
85.2
86.5
86.4
86.4
85.8
85.0
83.1
82.6
82.3
79.5
90.0 90.0
78.8
77.2
Treatment success rate of new

Treatment success rate of new
71.9
80.0 80.0
70.0 70.0
60.0
60.0
50.0
50.0 40.0
40.0 30.0
30.0 20.0
20.0 10.0
10.0 0.0
0.0
ry
rh
u
lh
el
ba
ee
Di
er
ga
De
av
co
dw
ch
&
di
rH
m
sh
ya
ur
im
nd
Ni
du
an
an
ur
Go
ha
ra
ip
de
la
ga
la
kk
&
ip
Pu
m
Ch
ks
an
izo
ha
ga
ra
Si
Na
Tr
an
Da
La
M
eg
M
lP
Na
a&
M
ha
da
dr
ac
An
Da
un
Ar
Source: RNTCP MIS, MoHFW Source: RNTCP MIS, MoHFW
Indicator 1.2.5: Proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)
This indicator tracks progress in access to treatment for PLHIV for the category of Larger and Smaller
States, but not for UTs (data not available for some UTs). The National Health Policy 2017 sets a
specific goal corresponding to achieving the global target of 2020, namely to ensure that 90 percent of
all people tested positive for HIV receive sustained ART. Out of 29 States, three (Jammu & Kashmir,
Meghalaya and Mizoram) have achieved this target while five have 80 to 90 percent of PLHIV on ART
in the reference year (2015-16). Eight states have less than 50 percent of the PLHIV on ART (reference
year 2015-16), namely Rajasthan, Jharkhand, Bihar, West Bengal, Odisha, Sikkim, Arunachal Pradesh
and Tripura. Apart from Tripura, the other 28 states have shown some incremental progress in this
indicator. However, significant improvements are needed to achieve 90 percent coverage.
Figure 4.32 - Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Larger States
120.0
96.4
88.7
88.7
87.7
87.1
100.0
84.6
83.5
83.3
81.9
79.9
79.2
77.2
76.1
76.1
72.4
PLHIV on ART (%)
72.4
66.7
80.0
65.3
64.6
62.7
61.8
61.0
58.9
57.8
53.1
53.0
52.4
52.3
51.5
51.3
50.2
47.2
60.0
46.4
42.4
39.4
37.2
36.1
35.9
33.0
30.7
31.0
28.3
40.0
20.0
0.0
ir
ra
du
ab
sh
la
sh
sh
an
a
ra
ga
ha
ak
es
an
an
ar
an
an
ish
m
ra
sa
ht
de
de
de
Na
nj
sth
ja
en
sg
Bi
sh
at
ad
ng
kh
ry
kh
as
Ke
Od
As
Pu
Gu
ra
ra
ra
rn
ja
tti
Ha
tB
Ka
il
Pr
ra
ar
la
ar
lP
aP
rP
m
Ra
Ka
ha
Te
ta
Jh
es
ah
ra
u&
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja

Source: Central MoHFW Data
48
Figure 4.33 - Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Smaller States
120.0
100.0
100.0
98.7
96.7
100.0
73.8
72.8
80.0
70.9
PLHIV on ART (%)
63.9
63.8
54.0
60.0
33.5
32.5
40.0
28.2
23.1
18.7
20.0
5.8
0.0
Meghalaya Mizoram Nagaland Goa Manipur Sikkim Arunachal Tripura
Pradesh

Source: Central MoHFW Data
Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility
The National Family Health Survey (NFHS)-4 data on average out-of-pocket (OOP) expenditure per
delivery in public health facility is considered here as a proxy indicator for overall OOP expenditure.
This data is available only for 2015-16 and hence the indicator is reported only for the reference year.
There is significant variation in the average OOP expenditure across the States. The expenditures range
from as low as INR 471 in Dadra & Nagar Haveli to as high as INR 10,076 in Manipur. The top five
States and UTs with average expenditure above INR 6,000 per delivery in a public facility are Manipur
(INR 10,076), Delhi (INR 8,719), West Bengal (INR 7,782), Kerala (INR 6,901), and Arunachal
Pradesh (INR 6,474). The average OOP expenditure per delivery in public health facility for Larger
States is INR 3,080, for Smaller States it is INR 5,170, and for UTs it is INR 2,995. Given the number
of NHM interventions targeting pregnant women, such as Janani Suraksha Yojana (JSY), Janani Shishu
Suraksha Karyakram (JSSK), and Referral Transport to ensure free delivery at public health facilities,
the States should aim to reduce the OOP expenditure.
Figure 4.34 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Larger States
9000
Average OOP expenditure per delivery
7782
in public health facility (in INR)
8000
6901
7000
6000
4225
4192
5000
4020
3893
3487
3329
3210
4000
3052
2496
2399
3000
2138
2136
1956
1890
1724
1476
1503
1480
1387
2000
1000
0
sh
sh
Ra du
an
sh
ra
na
ir
la
l
ra
ga
ha
an
ar
an
ja
es
an
ak
ish
m
ra
sa
ht
de
de
de
Na
sth
ga
ja
n
en
sg
Bi
sh
ad
at
kh
ry
kh
as
Ke
Od
As
Pu
Gu
ra
ra
ra
n
ja
rn
tti
Ha
tB
Ka
il
ar
Pr
ra
la
ar
aP
rP
lP
m
Ka
ha
Jh
ta
Te
es
ah
ra
u&
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
M
Hi
Ja
Source: NFHS-4 (2015-16)
49
Figure 4.35 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Smaller States and UTs
per delivery in public health facility
per delivery in public health facility

Average OOP expenditure
10076
8719
Average OOP expenditure
12000 10000
10000
8000
(in INR)
6474
8000
(in INR)
5834
4836
6000
4580
4412
4327
6000
2892
2509
4000 4000
2357
1999
2000
1581
1258
2000
471
0
0
im
ya
sh
ur
ur
Go
an
ra
ip
la
de
kk
ip
al
an
izo
ha
Si
ra
Tr
ry
rh
i
M
eg
el
lh
M
Na
lP
ba
Di
ee
er
ga
av
De
M
co
ha
dw
ch
&
di
rH
Ni
ac
an
du
an
ha
ga
un
&
Pu
Ch
ks
Na
Ar
an
Da
La
m
a&
da
dr
An
Da
Source: NFHS-4 (2015-16) Source: NFHS-4 (2015-16)
DOMAIN 2: GOVERNANCE AND INFORMATION

SUB-DOMAIN 2.1: HEALTH MONITORING AND DATA INTEGRITY
Indicator 2.1.1: Data Integrity Measure: Institutional deliveries and ANC registered within first
trimester
This indicator captures the percentage deviation of HMIS reported data from the NFHS-4 data in
order to assess the quality and integrity of reported data. Specifically, data from HMIS for last 5 years
(2011-12 to 2015-16) on the proportion of institutional deliveries and ANC registered within the first
trimester is compared with NFHS-4 conducted during 2015-16.
Figure 4.36 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Larger States
40.0
36.6
Deviation of HMIS data with NFHS -4 data
35.0
for institutional deliveries (%)
30.0
23.5
23.1
22.3
25.0
21.2
21.1
18.2
20.0
14.9
13.8
12.7
12.4
12.4
12.4
15.0
10.9
10.0
8.0
4.6
3.7
5.0
2.1
1.2
0.7
0.3
0.0
m
ra
la
du
ir
an
sh
sh
ra
ga
ha
an
an
ja
ish
an
an
ak
ar
es
es
m
ra
sa
ht
de
de
Na
sth
ja
en
un
Bi
g
sh
at
ad
ad
ry
kh
kh
ng
as
Ke
Od
As
s
Gu
ra
ra
ja
rn
tB
Ha
i
Ka
il
ar
ra
Pr
la
ar
t
lP
aP
rP
t
m
Ra
Ka
ha
Jh
ta
Te
es
ah
ra
u&
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja
Source: HMIS & NFHS-4
50
Deviation of HMIS data with
Deviation of HMIS data with
NFHS - 4 data for ANC registered
NFHS - 4 data for institutional Deviation of HMIS data with NFHS -
within first trimester (%)
deliveries (%) 4 data for ANC registered within
Ar
un first trimester (%)
ac Ar
un
20.0
40.0
60.0
80.0
0.0
100.0
120.0
ha ac
10.0
20.0
30.0
40.0
50.0
60.0
0.0
lP ha Ut
ra ta
10 .0
20 .0
30 .0
40 .0
50 .0
60 .0
0.0
de lP
sh ra rP
M 5.6
de ra
de
eg sh 1.4
ha M sh
la an 0 .9
ya ip Gu
10.6 ur ja
2.9 M ra
Tr
ip Hi aha t 2 .1
ur Tr m ra
a 10.9 ip ac sh
ur
M a 3.4 ha t 5 .6
izo l P ra
ra ra
m 18.7 Go de
M a 5.0 Ka sh 7 .3
Go eg M rn
at
a ha ad
23.7 ak
Smaller States
la hy a
Smaller States
ya 13.4 aP 8 .2
Si
kk M ra
de
im 26.8
izo
sh
M ra 9 .2
an m 22.0 Pu
ip
ur Ut n ja
28.2 Si
kk ta b 1 0 .0
Na im Ja ra
ga 29.2 m kh
la Na m
u & and
nd 107.9 ga 1 0 .8
la

An Kas
nd 54.8 dh h
1 3 .5

ra mir
Pr
Deviation of HMIS data with ad
es
NFHS - 4 data for ANC registered Te h 1 5 .4
within first trimester (%) la
ng
An an
da Deviation of HMIS data with a 1 5 .8
m
10.0
20.0
30.0
40.0
50.0
60.0
0.0
an NFHS - 4 data for institutional Bi
& h
Ni deliveries (%) Ra ar 1 6 .3
co ja
ba sth
La r 2.8 an
ks 1 8 .4
20.0
40.0
60.0
80.0
0.0
100.0
ha Ha
dw Da ry
deviation is minimized by adopting robust data quality mechanisms.

an
ee
p 12.2
dr De a 1 9 .1
Figure 4.38 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Smaller States and UTs
a&
Da lh
m Na i 10.8 As
sa
Figure 4.37 - Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester - Larger States
Da an ga m
dr & rH 2 1 .2
a&
15.3
Di av Od
u Da el 15.1 ish
Na
m i a
ga
An a
Ta
m 2 2 .1
rH n& il
av da
Figure 4.39 - Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester - Smaller States and UTs
el 22.1 m Di
u 17.4
Na
i an du 2 2 .8
& Ke
Ni
co Ch ral
De
lh La ba 18.1 ha a 2 4 .9
Union Territories
i 27.8 ks r tti
Union Territories
Ch ha sg
an dw W ar
di es h 2 5 .9
ee 29.4 tB
ga Ch p
rh 27.9 an
en
Pu
du
di
ga
Jh gal
ar 42 .4
ch Pu rh 58.0 kh
er an
ry 48.8 du d 53 .5
ch
er
ry 90.5
51
variation between the HMIS and NFHS-4 data. The States, UTs and MoHFW need to ensure that this
registered within the first trimester, where Jharkhand, Nagaland, and Puducherry have the widest
discrepancy between HMIS and NFHS-4 data. The trend is somewhat different in the case of ANC
In the case of institutional deliveries, Uttar Pradesh, Nagaland and Puducherry have the widest
SUB-DOMAIN 2.2: GOVERNANCE
Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level
for last three years
This indicator reflects the average occupancy of key administrative officials (in months), combined for
the posts of Principal Secretary, Mission Director (NHM) and Director (Health Services) in the last
three years. A stable tenure for key administrative positions is very critical for effective implementation
of the programs. The data reveals that the average occupancy of Principal Secretary, Mission Director
(NHM), and Director (Health Services) or equivalent positions in a period of 36 months (3 years) is the
highest in West Bengal (28 months) among the Larger States, Sikkim (24 months) among the Smaller
States and Lakshadweep (27 months) among UTs. Many States have an average occupancy per officer
for the three key administrative positions of less than 12 months - Chhattisgarh, Haryana, Uttarakhand,
Telangana, Karnataka, Tripura, Mizoram, Nagaland and Delhi in the reference year (2013-16).
Significant improvements (5 months or more) have been achieved in West Bengal, Uttar Pradesh,
Madhya Pradesh, Goa and Manipur, but in Jammu & Kashmir, Kerala, Arunachal Pradesh, Nagaland
and Andaman & Nicobar, the occupancy has declined substantially from the base year (2012-15) to the
reference year (2013-16). Among the Larger States between the base year (2012-15) and reference year
(2013-16), Uttar Pradesh has shown the maximum progress where the average occupancy doubled from
10 to 20 months, while Kerala has shown the maximum decline in the tenure of these officers where the
tenure has almost halved from 22 to 12 months.
Figure 4.40 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years - Larger States
30.0
28 .0
25.0
22 .8
22 .0
22 .0
21 .8
20 .7
20 .4
20 .2
20 .0
19 .6
19 .0
20.0
17 .7
17 .5
16 .5
Average occupancy of an officer
16 .0
(in months) for three key posts
15 .7
15 .0
13 .8
13 .8
15.0
13 .0
13 .0
for last three years
12 .4
12 .1
12 .0
12 .0
12 .0
11 .9
11 .4
11 .4
11 .4
11 .2
11 .1
10 .9
10 .8
10 .7
10 .4
10 .2
9.6
10.0
8.7
7.8
6.9
6.5
5.0
0.0
Ra al
an
du
sh
u & htra
ir
ar
sh
la
a
ra
ja
es
es
ish
an
ar
an
an
an
ak
m
g
ra
sa
h
de
de
sth
Na
ja
en
Bi
sg
sh
d
ad
at
kh
ry
kh
ng
s
Ke
Od
As
Pu
Gu
ra
ra
ra
a
ja
rn
tB
tti
Ha
Ka
il
Pr
ar
ra
la
ar
rP
aP
lP
m
Ka
ha
Jh
ta
Te
es
ah
ra
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja
Source: State Report

Note: Three key posts are Principal Secretary (Health), Mission Director (NHM) and Director (Health Services).
52
Figure 4.41 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years
- Smaller States and UTs
30.0 30.0
26 .8
26 .8
26 .0
24 .0
24 .0
25.0
22 .0
25.0

at state level for last three years
21 .7
21 .0
20 .4
21 .0
at UT level for last three years
20 .0
20 .0
19 .9
19 .3
20.0 20.0
15 .0
14 .4
14 .4
14 .8
13 .7
13 .9
13 .3
15.0
12 .0
15.0
10 .8
12 .0
11 .6
11 .1
10 .9
9 .6
9 .8
10.0
10.0
7 .3
5.0
5.0
0.0
0.0
ry
rh
i
el
lh
ba
ee
Di
er
ga
av
De
ico
dw
ch
&
im
ur
ya
sh
nd
di
rH
Go
ur
ra
ip
an
du
an
la
de
la
ha
kk
ip
ga
an
izo
ha
&
ga
Pu
Ch
Si
ra
ks
Tr
Na
M
an
Da
eg
lP
Na
La
m
M
ha
a&
da
ac
dr
An
un
Da
Ar
Source: State Report Source: State Report
Note: Three key posts are Principal Secretary (Health), Mission Director (NHM) and Director (Health Services).
Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three
years - CMOs or equivalent post (heading District Health Services)
In one-third of the States and UTs, the average occupancy of a full-time Chief Medical Officer (CMO)
or equivalent post heading the Health Services at the district level is 12 months or less, which hinders
effective implementation of programs. A small number of States and UTs (Chhattisgarh, Mizoram,
Sikkim, Daman & Diu and Puducherry) reported an average occupancy of more than 24 months.
Bihar, Sikkim and Andaman & Nicobar Islands have shown a decline of five or more months in the
average occupancy of the CMO from the base year (2012-15) to the reference year (2013-16). This
indicator was modified for Andaman & Nicobar Islands and Dadra & Nagar Haveli, where the CMO
equivalent posts of Medical Superintendent and regular medical officer were included in the calculation
of average occupancy. In Lakshadweep, there was no CMO or equivalent post and hence this indicator
is not applicable.
53
54
Average occupancy of a CMO (in months) Average occupancy of a CMO (in months)
for all districts in last three years for all districts in last three years
10.0
15.0
20.0
25.0
30.0
0.0
5.0
Ch
ha
10.0
15.0
20.0
25.0
30.0
35.0
0.0
5.0
tti
M sg
ar 21.9
izo
ra h
m 25.4
20.5 M Gu
26.0
ad ja
hy ra 18.7
Si
kk aP t
im ra 18.1
31.5 de
25.5 M
Base Year (2012-15)

Ar
Na
ga ah sh 18.1
un la ar
as 17.6
ac nd 17.4 ht
ha Ut ra
lP 19.9 ta
rP 12.3
ra 15.6
CMOs or equivalent post - Larger States
de ra
sh 19.3
de
W sh 11.6
Smaller States
M 17.5 es
tB 14.2
an
ip en
ur 18.6 ga
CMOs or equivalent post - Smaller States and UTs

l 10.3
17.3 14.1
Tr Od
ip ish
ur a
a 14.3 Ut
ta 10.0
M 17.3 ra 14.0
eg kh
ha an
la d 11.6
ya 15.5 Ka 13.9
Base Year (2012-15)

14.8 rn

An at
dh ak
Go ra a 14.8
a 15.0 Pr 13.2
12.0 ad
es
h 12.8

Ha 13.2
ry
an
a 13.4
Ra 12.6
Average occupancy of a CMO (in months) ja
sth
for all districts in last three years an 12.3
Ja 1 1.9
m B
m
10.0
15.0
20.0
25.0
30.0
35.0
40.0
0.0
5.0
u & ihar
Da 17.6
m Ka 1 1.9
an sh
& m
ir 11.7
Di 36.0
u Ke 1 1.8
Pu 36.0 ra
la
Da
du
ch Jh 16.5
dr er ar
kh 1 1.7
a& ry 23.1 an
Base Year (2012-15)

Na 25.3 Te d 11.2
ga Hi
m lan 1 1.5
rH ac ga
An av ha na
da el 18.0 lP 11.7
m i ra 1 1.2
18.0
Union Territories
an de
& sh
Figure 4.42 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years -
13.9
Figure 4.43 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years -
Ni
co Pu 10.5
ba 25.5
r nj
ab
17.4 9.1
As 10.2
De sa
lh 15.8 Ta m 7.9
i m 8.0
Ch 16.7 il
an Na
di du 6.9
ga
rh 15.5 7.3

15.6

DOMAIN 3: KEY INPUTS/PROCESSES
SUB-DOMAIN 3.1: HEALTH SYSTEMS AND SERVICE DELIVERY
Indicator 3.1.1: Proportion of vacant healthcare provider positions (regular + contractual) in public
health facilities
Vacancies of key health staff are linked with both access to healthcare services as well as their quality.
The vacancy status vis-a-vis the total sanctioned positions, for both regular and contractual healthcare
providers for key positions in public health facilities including ANMs at sub-centres (SCs), staff nurses
at PHCs and CHCs, medical officers (MOs) at PHCs, and Specialists at district hospitals (DHs) is
provided below.
a. ANMs at sub-centres: Among the Larger States, less than 25 percent of ANM positions were
vacant except for Gujarat and Bihar, which reported 28 percent and 59 percent vacancies respectively.
Odisha, Uttar Pradesh, West Bengal and Kerala reported less than 5 percent vacancy of ANM
positions. Similarly, among the Smaller States and UTs, less than 25 percent positions were vacant
except in Manipur (30 percent), Goa (30 percent), Tripura (39 percent) and Chandigarh (29 percent).
Between the base year (2014-15) and reference year (2015-16), Uttar Pradesh, Jammu & Kashmir,
Andhra Pradesh, Rajasthan, Karnataka and Bihar have shown significant progress and the ANM
vacancies have declined by 5 or more percentage points. Madhya Pradesh, Haryana, Gujarat,
Mizoram, Arunachal Pradesh, Manipur, Goa, Tripura and Delhi have shown significant increases (5 or
more percentage points) in ANM vacancies during the same period.
Figure 4.44 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions - ANMs at sub-centres - Larger States
80.0
67.9
70.0
59.3
60.0
Vacancy of ANMs at SCs (%)
50.0
36.1
40.0
28.1
27.9
30.0 22.6
20.6
20.2
19.7
19.6
19.2
18.0
17.7
17.1
16.9
16.0
15.5
15.2
20.0
15.7
14.2
14.1
12.6
12.4
1 1.8
10.9
10.3
9.9
9.5
9.7
9.2
9.0
8.6
8.5
8.3
7.2
10.0
4.9
4.5
2.2
0.8
0.0
0.0
0.0
0.0
a
sh
la
ab
ah arh
ra
u & esh
ir
sh
du
an
r
ga
ra
ha
ish
an
es
an
an
an
ak
m
ra
sa
ht
de
de
nj
Na
sth
ja
en
sg
Bi
sh
ad
ad
at
y
kh
ng
kh
Ke
as
Od
As
Pu
Gu
ra
ra
ja
rn
tB
tti
Ha
Ka
Pr
Pr
ra
ar
la
ar
il
rP
aP
Ra
Ka
ha
ta
Te
Jh
es
ra
ha
ta
Ta
Ut
hy
Ch
W
dh
Ut
ac
ad
m
An
m
M
Hi
Ja

55
Figure 4.45 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions - ANMs at sub-centres - Smaller States
45.0
38.9
40.0
Vacancy of ANMs at SCs (%)
35.0
30.1
29.9
30.0
24.8
22.4
25.0
20.6
20.0
19.6
20.0
16.1
15.4
1 1.3
1 1.0
15.0
7.8
10.0
5.0
2.1
0.0
0.0
0.0
Sikkim Nagaland Mizoram Meghalaya Arunachal Manipur Goa Tripura
Pradesh

b. Staff nurses at PHCs and CHCs: Among the Larger States, the vacancy of staff nurses in
PHCs and CHCs was more than 40 percent in Haryana (43 percent), Rajasthan (47 percent), Bihar (50
percent) and Jharkhand (75 percent). From base year (2014-15) to reference year (2015-16), there was
significant reduction (16 to 36 percent) in the proportion of vacant position for staff nurses in West
Bengal, Karnataka, Jammu & Kashmir and Bihar. Among the Smaller States, Sikkim has the highest
vacancy rate (62 percent) followed by Meghalaya (31 percent) and both these States have shown no
progress in addressing the vacancies of staff nurses at PHCs and CHCs between the base year and
reference year. Tripura made tremendous progress with 22 percentage points reduction in vacancies,
bringing the vacancy position of staff nurses at CHCs and PHCs to zero. The vacancies of staff nurses
at PHCs and CHCs has increased significantly in Manipur (from 5 to 19 percent) and Arunachal
Pradesh (from 4 to 29 percent). The vacancy rate in all UTs is less than 8 percent except Delhi where it
increased substantially from 32 to 41 percent.
Figure 4.46 - Indicator 3.1.1b: Proportion of vacant healthcare provider positions - Staff nurses at PHCs and CHCs - Larger States
86.2
90.0
74.9
71.8
80.0
Vacancy of SNs at PHCs and CHCs (%)
70.0
60.0 50.3
48.1
47.3
46.0
45.2
44.3
43.2
42.9
50.0
37.7
37.3
36.5
36.5
36.2
34.0
33.5
27.2
40.0
27.5
20.5
26.0
25.7
20.0
21.8
21.5
30.0
19.1
17.3
16.7
15.7
13.1
12.8
12.8
20.0
9.7
9.0
5.5
4.6
5.3
10.0
1.9
1.9
0.0
0.0
0.0
a
sh
la
ra
du
nd
u & esh
ir
sh
ab
an
d
ga
ra
ha
ish
an
es
ak
ar
an
an
m
ra
sa
ht
de
de
Na
ha
nj
sth
ja
en
sg
Bi
sh
ad
at
d
ng
ry
kh
Ke
as
Od
As
Pu
Gu
ra
ra
ra
k
rn
ja
tB
tti
Ha
Ka
ra
Pr
ar
la
ar
il
rP
lP
aP
Ra
Ka
ha
m
Te
ta
Jh
es
ah
ra
ha
ta
Ta
Ut
hy
Ch
W
dh
Ut
ac
ad
m
An
M
Hi
Ja

56
c. Medical officers (MOs) at PHCs: Among the Larger States, the vacancy of MOs at PHCs is
the highest in Bihar (64 percent) followed by Madhya Pradesh (58 percent), Jharkhand (49 percent),
Chhattisgarh (45 percent) and West Bengal (41 percent). It is the lowest in Kerala (6 percent) followed
by Tamil Nadu (8 percent) and Punjab (8 percent). From base to reference year, there has been
reduction in MO vacancies in the range of 5 to 25 percentage points in Uttarakhand, Andhra Pradesh,
Haryana, Uttar Pradesh, Gujarat and West Bengal. In Himachal Pradesh, MO vacancies increased by
5 percentage points. Among the Smaller States, Meghalaya, Mizoram, Arunachal Pradesh and
Manipur also have a high proportion (36 to 43 percent) of vacant positions of MO at PHCs and no
reduction in MO vacancies from base to reference year. Tripura and Goa have shown a reduction of 15
percentage points and 17 percentage points in vacant MO positions at PHCs respectively, whereas these
have increased in Arunachal Pradesh (from 9 to 39 percent). Among the UTs, Chandigarh has the
highest proportion of vacant MO positions at PHCs (69 percent) followed by Andaman & Nicobar (36
percent) with no reduction from base to reference year. There was no MO vacancy in Lakshadweep,
while vacancies in the remaining UTs lay in the range of 7 to 17 percent.
Figure 4.47 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions - Medical officers at PHCs - Larger States
70.0
63.6
63.6
58.3
57.8
60.0
48.7
48.4
45.3
45.0
50.0
Vacancy of MOs at PHCs (%)
41.8
41.2
39.8
38.6
37.2
36.8
34.9
40.0
32.0
30.2
26.9
26.7
25.4
30.0
23.2
22.3
22.3
21.7
19.9
18.0
17.8
17.0
16.8
16.2
20.0
14.9
14.9
13.4
12.8
12.2
1 1.5
9.8
7.8
7.6
7.6
10.0
5.9
5.6
0.0
ra
a
a
sh
ir
ab
r
a
an
la
du
d
t
Te sh
an
ha
ga
sh
an
ra
ar
ak
es
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ht
an
sh
an
ra
sa
de
nj
sth
Na
de
ja
ry
as
sh
sg
Bi
en
de
ng
at
ad
di
kh
kh
Ke
Pu
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Gu
Ha
ra
rn
ja
A
ar
Ka
tti
O
tB
ra
il
la
Pr
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ar
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Ra
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Ka
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Hi

Figure 4.48 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions - Medical officers at PHCs - Smaller States
42.8
42.8
45.0
38.8
38.1
40.0
35.7
35.0
31.9
31.6
31.1
27.4
Vacancy of MOs at PHCs (%)
30.0
26.9
25.0
20.0
17.0
14.2
15.0
9.4
10.0
5.0
2.1
0.0
0.0
0.0
Sikkim Tripura Goa Nagaland Meghalaya Mizoram Arunachal Manipur
Pradesh

57
d. Specialists at district hospital (Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics,
Anaesthesia, Ophthalmology, Radiology, Pathology, Ear-Nose-Throat, Dental, Psychiatry):
Figure 4.49 - Indicator 3.1.1.d: Proportion of vacant healthcare provider positions - Specialists at district hospitals - Larger States
90.0
78.0
77.7
80.0
65.0
70.0
62.9
Vacancy of Specialists at DHs (%)
60.6
60.3
59.8
55.5
55.4
54.8
60.0
51.0
51.0
50.6
50.3
47.7
45.8
43.5
50.0
41.7
41.5
40.6
38.3
35.7
40.0
32.4
30.4
30.3
24.5
30.0
23.0
22.2
22.2
21.7
21.5
21.5
20.9
20.2
19.5
19.0
17.9
16.7
20.0
10.0
0.0
0.0
0.0
ra
an
a
ab
sh
a
l
ir
sh
d
a
du
la
r
ga
ra
ish
an
h
ha
ak
an
ht
an
es
an
m
sa
sth
ra
de
ar
nj
de
Na
ja
en
as
sh
ng
at
Bi
kh
ad
ry
kh
Od
Ke
As
Pu
sg
ra
Gu
ra
ja
rn
ar
tB
Ka
Ha
il
la
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Pr
ar
aP
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Ra
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m
Ka
ah
Te
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Ja

Several Larger States have a high proportion of vacant specialist positions in district hospitals,
particularly in Chhattisgarh (78 percent), Bihar (61 percent), Uttarakhand (60 percent), Gujarat (56
percent), Telangana (55 percent), Madhya Pradesh (51 percent), Jharkhand (50 percent) and Punjab (48
percent). Most States have made limited progress (<5 percentage points) in reducing the vacancies of
specialists at district hospitals from base to reference year, except Odisha, Andhra Pradesh, Assam,
Jharkhand and Telangana; at the same time, Maharashtra, Punjab and Uttarakhand have shown
substantial increases of specialists, ranging between 11 to 26 percentage points. Among the Smaller
States, the vacancies among specialist positions is high in Manipur (48 percent), Goa (40 percent) and
Arunachal Pradesh (89 percent). While all specialist positions have been filled in Nagaland, specialist
vacancies in the remaining States range from 15 to 40 percent. Overall, the Smaller States have shown
little or no reduction in vacancies among specialists at district hospitals from base to reference year. A
similar situation was observed among the UTs as shown in Figure 4.50.
Figure 4.50 - Indicator 3.1.1d: Proportion of vacant healthcare provider positions - Specialists at district hospitals - Smaller States and UTs

100.0
100.0
89.1
87.6
100.0 120.0
100.0
76.5
76.5
80.0
80.0
47.7
47.7
42.7
47.1
60.0
39.7
40.2
38.7
38.2
34.4
34.4
60.0
29.7
29.3
23.4
40.0
20.6
18.2
18.2
40.0
15.2
15.2
20.0 20.0
0.0
0.0
0.0
0.0
0.0 0.0
ry
r
rh
u
lh
ba
el
ya
im
ur
sh
nd
ee
Di
er
ga
Go
De
av
ip
ra
la
co
de
kk
la
dw
ch
&
di
an
rH
ha
izo
ga
Ni
Si
ra
du
an
an
ha
M
eg
lP
ga
Na
&
Pu
m
Ch
ks
M
Na
ha
an
Da
La
ac
m
a&
da
un
dr
An
Ar
Da
Source: State Report Source: State Report
58
Indicator 3.1.2: Proportion of total staff (regular and contractual) for whom an e-payslip can be
generated in the IT enabled Human Resources Management Information System (HRMIS)
It is expected that a well-functioning HRMIS leads to efficient financial and personnel management.
However, in 2015-16, among the 21 Larger States, only 9 States used e-payslips to disburse staff salaries,
using HRMIS. Among them, the proportion of staff receiving such payments varies from as low as 8 to
100 percent. The States with the highest rates of e-payments are Kerala (100 percent), Maharashtra (68
percent), Odisha (76 percent), Tamil Nadu (85 percent) and West Bengal (81 percent), while Andhra
Pradesh, Gujarat and Karnataka are using HRMIS based e-payments for 36 to 59 percent of their staff.
It is important for other States to initiate and fully operationalize HRMIS for effective human resources
management. All the Smaller States except Arunachal Pradesh (39 percent) have not yet initiated
HRMIS based e-payments to staff. Among the UTs, Andaman & Nicobar, Dadra & Nagar Haveli,
Daman & Diu and Lakshadweep are yet to initiate e-payments. The remaining UTs are making use of
HRMIS based e-payslip generation (61 to 78 percent).
Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units (FRUs)
This is a proxy indicator to assess the functionality of the FRUs and captures the number of facilities
conducting a specified number of C-sections per year against the number of required FRUs per
MoHFW guidelines (one FRU per 500,000 population) during a specific year. Functional FRUs provide
specialized services close to the community and can help to improve access and decongest the client load
at higher level facilities. The proxy criteria for a facility to be considered as fully operational FRUs is:
• For sub-district hospitals and CHCs: conducting a minimum of 60 C-Sections per year (36
C-sections per year for Hilly and North-Eastern States, except Assam).
• For district hospitals: conducting a minimum of 120 C-Sections per year (72 C-sections per year
for Hilly and North-Eastern States, except Assam).
Figure 4.51 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Larger States
196.0
200.0
180.0
180.0
Functional FRUs as against required number (%)
160.0
141.8
138.2
129.2
140.0
122.9
121.4
121.0
121.0
1 16.4
107.1
105.7
120.0
100.0
95.0
100.0
80.0
80.0
72.6
67.7
80.0
65.5
61.9
57.6
52.9
51.0
50.0
48.5
49.2
60.0
45.0
45.4
43.0
32.2
32.4
31.1
29.2
40.0
23.4
23.5
22.7
21.6
15.8
15.3
15.2
1 1.5
12.5
20.0
0.0
ir
ab
du
sh
la
sh
ra
an
sh
r
ga
ra
ha
ak
an
an
ish
es
an
ar
an
m
ra
sa
ht
de
de
de
nj
Na
sth
ja
en
sg
Bi
sh
at
ad
kh
ng
ry
kh
Ke
as
Od
As
Pu
Gu
ra
ra
ra
rn
ja
Ha
tB
tti
Ka
il
ra
Pr
ar
la
ar
lP
aP
rP
m
Ra
Ka
ha
ta
Te
Jh
es
ah
ra
u&
Ta
ha
ta
Ut
hy
Ch
W
M
dh
Ut
ac
ad
m
An
m
m
M
Hi
Ja
Base Year (2014-15) Reference Year (2015-16) Source: State Report & MoHFW
Note: The number of required FRUs is based on MoHFW guidelines.
59
As shown in Figures 4.51 and 4.52, many States have achieved the numerical target of functional FRUs
(Jammu & Kashmir, Punjab, Tamil Nadu, Himachal Pradesh, Kerala, Karnataka, Mizoram,
Meghalaya, Goa, Nagaland, Arunachal Pradesh and Sikkim). However, several States (West Bengal,
Gujarat, Maharashtra, Rajasthan, Chhattisgarh, Jharkhand, Uttar Pradesh and Bihar) lag behind
substantially with 50 percent or less of the required functional FRUs. These States need to plan
strategically for operationalizing more facilities as FRUs, which are critical for saving the lives of
mothers and children. Almost all UTs have the required number of fully functional FRUs. From base to
reference year, most States and UTs have either maintained the earlier level or shown minimal increase
in the percentage of functional FRUs. None of the facilities in Andaman & Nicobar function as FRU
despite the need of one functional FRU as per MoHFW guidelines.
Figure 4.52 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Smaller States
250.0
Functional FRUs as against required
200.0
200.0
150.0
150.0
number (%)
133.3
125.0
150.0
100.0
100.0
100.0
100.0
100.0
100.0
83.3
83.3
100.0
66.7
57.1
42.9
50.0
0.0
Sikkim Arunachal Nagaland Goa Meghalaya Mizoram Manipur Tripura
Pradesh

Source: State Report & MoHFW
Note: The number of required FRUs is based on MoHFW guidelines.
Indicator 3.1.3.b: Proportion of functional 24x7 PHCs
The functioning of 24x7 PHCs is important for providing a basic package of health services to the
community and for reducing the workload at higher level facilities. To assess the proportion of
functional 24x7 PHCs providing all stipulated healthcare services round the clock during a specific year,
the norm of at least ten (five in Hilly States) deliveries per month was considered. The required number
of functional 24x7 PHCs per state was calculated using the norm of one 24x7 PHC per 100,000
population. On the basis of this norm, only Assam, Sikkim, Meghalaya, Nagaland, Mizoram, Tripura,
Andaman & Nicobar and Dadra & Nagar Haveli have achieved the target of the required number of
24x7 PHCs, whereas Kerala, Chandigarh, Lakshadweep and Puducherry are yet to operationalize a
single 24x7 PHC. Most Larger States need to substantially increase the number of functional 24x7
PHCs in order to reach the required target. Among the Smaller States, Manipur, Arunachal Pradesh
and Goa need to deploy strategic effort to operationalize more 24x7 PHCs. From base to reference year,
an increase of five or higher percentage points in functional 24x7 PHCs as against required number was
observed in Assam (7 percentage points), Sikkim (50 percentage points), Meghalaya (13 percentage
points), Manipur (24 percentage points), Arunachal Pradesh (22 percentage points), and Dadra & Nagar
Haveli (33 percentage points), whereas a decline of five or more percentage points was observed in
Karnataka (9 percentage points), Jammu & Kashmir (8 percentage points), Tamil Nadu (19 percentage
points), Punjab (9 percentage points), Mizoram (55 percentage points) and Tripura (8 percentage
points).
60
Figure 4.53 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Larger States
200.0
176.9
169.6
180.0
160.0
as against required number (%)
140.0
Functional 24x7 PHCs
120.0
100.0
78.1
77.6
73.6
73.6
70.9
69.2
68.0
67.3
80.0
58.4
56.5
56.4
54.5
53.6
54.2
48.0
46.7
45.6
60.0
40.4
36.5
35.7
35.0
33.2
33.0
33.0
31.5
30.0
30.0
29.2
27.8
27.0
27.0
26.4
40.0
17.9
17.4
5.9
20.0
5.7
5.8
5.8
0.0
0.0
0.0
ra
d
r
du
a
a
sh
sh
la
m
an
ir
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l
t
ha
an
ga
sh
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ak
an
ar
ht
an
ish
a
m
ra
sa
Na
de
de
sth
nj
Bi
ja
kh
as
sg
de
ad
en
ng
at
sh
kh
ry
Ke
Od
As
Pu
ra
ra
Gu
rn
ar
ar
tti
ja
il
Ha
ra
Pr
Ka
tB
la
ra
aP
m
Ka
Ra
Jh
ha
ah
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ta
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ta
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hy
Ch
M
ha
dh
W
Ut
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ac
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M
m
Ja
Hi
Base Year (2014-15) Reference Year (2015-16) Source: State Report & MoHFW
Note: The number of required 24x7 PHCs is based on MoHFW guidelines.
Figure 4.54 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Smaller States
250.0
216.7
190.9
180.0
166.7
200.0
166.7
165.0
165.0
as against required number (%)
136.4
Functional 24x7 PHCs
124.3
150.0
116.2
100.0
65.5
42.9
41.4
50.0
21.4
6.7
0.0
0.0
Sikkim Meghalaya Nagaland Mizoram Tripura Manipur Arunachal Goa
Pradesh

Source: State Report & MoHFW
Note: The number of required 24x7 PHCs is based on MoHFW guidelines.
Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units (CCUs)
A functioning CCU is important for the availability of specialized cardiac care services at the district
level and for reducing the workload at tertiary level facilities. The State-provided data on the number of
functional CCUs in district hospitals alongside the total number of districts was considered. However,
CCUs in medical colleges were not considered for this indicator, except for Delhi where hospitals are
not designated as district hospitals.
61
Figure 4.55 - Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units - Larger States
100.0
91.7
91.7
90.0
76.9
76.9
Districts with functional CCUs (%)
70.6
80.0
64.3
64.3
63.6
63.6
70.0
56.3
56.3
57.7
53.9
53.9
60.0
48.5
43.3
43.3
50.0
40.0
27.3
22.9
22.9
30.0
19.1
19.1
18.2
20.0
9.8
9.8
2.9
10.0
3.7
3.7
3.3
3.3
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
sh
an
la
ab
du
ka
ir
ra
na
sh
sh
d
ga
ra
ha
es
ar
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an
an
an
m
ra
sa
ht
de
de
de
sth
nj
Na
ya
ja
en
sg
Bi
sh
ad
kh
ng
kh
Ke
as
a
Od
As
Pu
Gu
ra
ra
ra
ja
rn
tB
Ha
tti
Ka
il
Pr
ar
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la
ar
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m
Ra
Ka
ha
Jh
Te
ta
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ah
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Ta
ha
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Assam, Bihar, Jharkhand, Telangana, Uttar Pradesh, Uttarakhand, Arunachal Pradesh, Goa, Manipur,
Meghalaya, Sikkim, Tripura, Andaman & Nicobar, Chandigarh, Dadra & Nagar Haveli and Daman &
Diu do not have a single district with functional CCUs in public hospitals. Himachal Pradesh, West
Bengal, Rajasthan, Kerala, Punjab, Tamil Nadu, Andhra Pradesh, Lakshadweep and Delhi have made
satisfactory progress by establishing CCUs in 50 percent or more districts. The remaining States need
to operationalize CCUs, given the increasing load of cardiovascular diseases. Among UTs, only Delhi
and Lakshadweep have the required number of CCUs. From base to reference year, notable increases
in the percentage of districts with CCUs was observed in Rajasthan (68 percentage points), Jammu &
Kashmir (9 percentage points) and Nagaland (9 percentage points), whereas a decline of 9 percentage
points was observed in Gujarat.
Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations
The ANC registration in the first trimester is a critical indicator depicting the effectiveness of a health
service delivery system to enrol pregnant women in early pregnancy, this being necessary for maternal
and foetal well-being. Among the 21 Larger States, 11 have more than 70 percent of ANCs registered
in the first trimester. Telangana, Bihar, Jammu & Kashmir, Uttar Pradesh and Jharkhand, with less than
60 percent ANC registration in the first trimester, need to improve performance in this regard. Almost
all States (except Karnataka, Telangana, Jammu & Kashmir and Uttar Pradesh) have shown
incremental progress in the registration of ANCs in the first trimester.
62
Figure 4.56 - Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Larger States
100.0
94.4
92.7
ANC registered within 1st trimester against total registrations (%)
90.0
81.4
81.0
80.6
80.6
78.6
77.2
77.0
75.8
80.0
74.9
74.6
74.4
73.0
73.6
72.8
73.0
71.2
71.2
68.5
66.8
70.0
64.4
63.8
63.6
62.5
62.2
61.5
61.3
60.7
60.0
59.1
58.5
57.7
55.9
55.5
60.0
54.4
53.0
51.4
51.2
48.7
50.0
36.4
40.0
33.7
30.0
20.0
10.0
0.0
ra
a
la
sh
an
sh
m
ab
d
du
sh
r P ir
ar
ra
ha
ga
ak
an
ish
an
es
an
an
ht
ra
m
sa
de
de
sth
nj
de
isg
Na
ja
Bi
en
at
as
ry
kh
ad
Ke
sh
kh
ng
Od
As
Pu
Gu
ra
ra
ra
rn
ja
Ha
t
ar
tB
il
ar
Ka
t
Pr
ra
la
aP
ha
lP
Ra
m
Ka
ah
Jh
ta
Te
es
ra
Ta
u&
Ch
ta
ha
hy
Ut
M
W
dh
Ut
ac
ad
m
An
m
m
Hi
Ja
Source: HMIS
Similarly, among the Smaller States, Sikkim (80 percent) and Mizoram (74 percent) have achieved more
than 70 percent first trimester registration and the remaining States need to put in special efforts to
increase first trimester registrations. From base to reference year, some incremental progress (1 to 8
percentage points) was observed in Sikkim, Mizoram, Manipur and Goa, whereas some decline was
observed in Tripura (1 percentage point), Arunachal Pradesh (2 percentage points), Nagaland (11
percentage points). No change was observed in Meghalaya where the first trimester registration remains
at 32 percent. Among UTs, Dadra & Nagar Haveli, Andaman & Nicobar, and Lakshadweep have
achieved satisfactory performance levels (ranging between 73 to 85 percent), while the remaining UTs
need to significantly improve their performance.
Figure 4.57 - Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Smaller States and UTs

ANC registered within 1st trimester against
ANC registered within 1st trimester against
84.8
90.0
79.9
90.0
77.8
77.8
76.9
73.6
74.9
72.3
73.2
80.0 80.0
63.2
62.8
61.9
total registrations (%)
total registrations (%)
70.0
59.1
58.7
70.0
57.0
60.0
46.8
60.0
49.6
49.3
47.3
47.3
45.5
50.0
38.7
37.0
50.0
35.8
39.5
32.2
32.1
36.8
40.0
34.7
33.7
40.0
30.0
20.0 30.0
10.0 20.0
0.0 10.0
0.0
ur
sh
nd
ya
im
a
ur
Go
ip
ra
de
la
la
kk
ip
rh
i
an
ry
izo
ha
ga
lh
el
ba
ee
ra
Di
Si
Tr
ga
er
M
De
av
eg
lP
Na
M
co
dw
&
ch
di
rH
M
ha
Ni
an
an
du
ha
ga
ac
&
Ch
Pu
ks
Na
un
Da
an
La
Ar
m
a&
da
dr
An
Da
63
Indicator 3.1.6: Level of registration of births
Registration of birth not only provides the child with an official identification document, but also allows
for area-specific estimation of birth rates. The level of registration is defined as the proportion of births
registered under the Civil Registration System (CRS) against the estimated number of births during a
specific year. Seventeen States/ UTs including Andhra Pradesh, Assam, Chhattisgarh, Haryana,
Kerala, Maharashtra, Punjab, Tamil Nadu, Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram,
Nagaland, Chandigarh, Puducherry and Delhi have achieved 100 percent registration of births.
However, Uttarakhand, Madhya Pradesh, Jharkhand, Jammu & Kashmir, Uttar Pradesh, Bihar,
Tripura, Sikkim, Daman & Diu, Andaman & Nicobar, Dadra & Nagar Haveli and Lakshadweep, (with
level of registration in the range of 60 to 86 percent) need to make rapid progress in this regard. From
base to reference year, the States and UTs showing a decline in registration are Telangana (4 percentage
points), Gujarat (5 percentage points), Himachal Pradesh (7 percentage points), Tripura (9 percentage
points), Sikkim (6 percentage points), Daman and Diu (22 percentage points), Andaman and Nicobar
(25 percentage points) and Dadra and Nagar Haveli (7 percentage points). The states with 5 percentage
points or more increase in birth registration are Chhattisgarh (12 percentage points), Odisha (5
percentage points), Uttarakhand (9 percentage points) and Bihar (7 percentage points).
Figure 4.58 - Indicator 3.1.6: Level of registration of births - Larger States
120.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
98.5
98.5
98.4
98.2
97.8
97.7
96.0
95.6
100.0 95.0
93.9
93.1
92.8
92.5
87.8
86.0
84.1
82.6
82.0
77.7
76.6
75.5
80.0
71.8
Level of registration of births (%)
68.6
68.3
64.2
57.4
60.0
40.0
20.0
0.0
du
a
h
nd
sh
a
ra
ab
an
r
h
la
sh
sh
ir
ra
ga
an
ha
ar
ak
an
an
es
ish
Na
m
ht
ra
sa
de
a
nj
sth
de
de
a
en
sg
ng
Bi
at
kh
ry
kh
ad
uj
sh
as
Ke
Pu
Od
As
ra
ra
ra
il
rn
tti
tB
ja
Ha
la
ar
Ka
Pr
ar
rP
lP
aP
r
Ka
Ra
ha
Te
ta
es
Jh
ah
Ta
ra
u&
ta
ha
Ut
Ch
hy
W
M
dh
Ut
ac
ad
m
An
m
M
Hi
Ja

Source: CRS
64
Figure 4.59 - Indicator 3.1.6: Level of registration of births - Smaller States and UTs


100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
120.0 120.0
100.0
100.0
100.0
100.0
100.0
100.0
98.4
97.2
91.4
100.0
81.7
79.9
100.0
74.1
76.4
71.9
80.0
71.8
80.0
65.1
60.0
59.5
60.0
60.0
40.0
20.0 40.0
0.0 20.0
0.0
ur
ya
nd
im
sh
ur
Go
ip
ra
la
la
de
kk
ip
an
izo
ha
ga
Si
ra
Tr
p
M
rh
ry
r
lh
eg
el
Na
lP
ba
Di
ee
er
ga
De
av
M
co
ha
dw
&
ch
di
rH
Ni
ac
an
du
an
ha
ga
un
&
m
Pu
Ch
ks
Na
Da
Ar
an
La
m
a&
da
dr
An
Da
Source: CRS Source: CRS
Indicator 3.1.7: Completeness of Integrated Disease Surveillance Programme (IDSP) reporting of

P and L forms
This indicator captures the proportion of Reporting Units (RUs) reporting in the stipulated time for
IDSP reporting format for presumptive surveillance (P form) and IDSP reporting format for laboratory
surveillance (L form) during a specific year and is an important monitoring indicator reflecting the
functioning of IDSP.
Seven of the Larger States (Andhra Pradesh, Telangana, Kerala, Gujarat, Karnataka, Uttarakhand and
Tamil Nadu) have at least 90 percent of the reporting units submitting P form in a timely manner. The
performance of Himachal Pradesh and Uttar Pradesh is poor wherein only 66 percent and 42 percent
units, respectively,report in a timely manner. From base to reference year, there has been a decline in the
percentage of reporting units in Assam, Haryana, Madhya Pradesh, Punjab and Uttar Pradesh,
whereas reporting has increased in the remaining States, Karnataka, Tamil Nadu, Odisha, Jammu &
Kashmir, West Bengal, Rajasthan and Himachal Pradesh where the increase was more than 10
percentage points. Among the Smaller States and UTs, all (except Mizoram, Dadra & Nagar Haveli,
Chandigarh and Daman & Diu) had incremental progress. Manipur (63 percent), Mizoram (48
percent), Andaman & Nicobar (50 percent), Lakshadweep (0 percent) and Delhi (56 percent) need to
take corrective steps to improve the reporting completeness of P form.
65
Figure 4.60 - Indicator 3.1.7: Completeness of IDSP reporting of P form - Larger States
99 97
100 94 96 96 95 95
94 94 93 92
88 90 88 88 89
83 84 84 83
82 80 81 80
79
Completeness of IDSP reporting of P form (%)
80 77 78 77
73 73 73
70 71 69
66 66 65 66
64
59
60
41 42
40
20
a
a
ir
ra
l
la
sh
ab
sh
t
du
ah esh
d
h
an
ga
ra
ish
ha
an
an
ar
sa
an
es
an
ak
ra
ht
de
de
nj
Na
ja
sth
en
sh
sg
Bi
ry
As
Od
kh
d
ad
at
as
Ke
kh
ng
Pu
Gu
ra
ra
ra
Ha
tB
Ka
tti
rn
ja
il
ra
ar
ar
Pr
la
lP
rP
aP
m
ha
Ka
Ra
es
ta
Jh
Te
u&
ra
Ta
ha
ta
Ut
Ch
hy
W
M
dh
Ut
ac
m
ad
An
m
m
Hi
Ja
Source: Central IDSP, MoHFW
Figure 4.61 - Indicator 3.1.7: Completeness of IDSP reporting of P and L forms - Smaller States
P form (%) L form (%)

Completeness of IDSP reporting of P form (%)
Completeness of IDSP reporting of L form (%)
120 120
100
97
97
94
91
100 100
88
86
84
82
82
80
79
79
77
75
74
80 80
67
65
65
63
63
62
61
61
58
51
60 60
48
43
38
35
33
32
40 40
20 20
0 0
ya
sh
nd
ur
ya
nd
ur
im
im
sh
a
ur
Go
ur
Go
ra
ra
ip
ip
la
de
la
la
la
de
kk
kk
ip
ip
an
an
izo
izo
ha
ha
ga
ga
ra
Si
Si
ra
Tr
Tr
M
M
eg
eg
lP
Na
Na
M
lP
M
M
ha
ha
ac
ac
un
un
Ar
Ar
Source: Central IDSP, MoHFW
The status of L form reporting is similar to the P form reporting. Thus, Rajasthan
(68 percent), Himachal Pradesh (62 percent), Uttar Pradesh (57 percent), Manipur
(38 percent), Mizoram (58 percent), Andaman & Nicobar (21 percent) and Lakshadweep (0 percent)
need to make concerted efforts to raise the percentage of reporting units timely L form reporting.
66
Indicator 3.1.8: Proportion of CHCs with grading above 3 points
CHCs are graded under the MoHFW’s grading system using the data on service utilization, client
orientation, service availability, drugs and supplies, human resource and infrastructure. This indicator
represents the share of CHCs that receive a score greater than 3 (out of 5 points) of the total number
of CHCs in that State.
Larger States have made substantial incremental progress in increasing the proportion of CHCs with a
score of more than 3 points. This, however, could be due to a reporting issue. The grading system was
first introduced in 2014-15 (base year), and reporting has improved significantly in 2015-16 (reference
year). Many of the Smaller States and UTs (Arunachal Pradesh, Mizoram, Nagaland, Sikkim, Tripura,
Andaman and Nicobar, Dadra and Nagar Haveli, Daman and Diu, Delhi and Lakshadweep) are yet to
report on this indicator.
Figure 4.62 - Indicator 3.1.8: Proportion of CHCs with grading above 3 points - Larger States
76.1
80.0
70.0
61.9
57.2
54.5
54.4
60.0
53.7
CHCs with grading above 3 points (%)
49.4
47.7
44.1
50.0
38.5
37.2
40.0
31.3
31.1
26.7
25.3
30.0
22.8
22.0
20.3
16.7
20.0
1 1.6
12.0
10.3
10.1
9.8
9.0
8.3
7.1
10.0
5.1
4.6
4.5
3.5
3.2
3.2
2.5
1.7
1.6
1.0
NA
0.4
NA
0.0
0.0
0.0
h
a
sh
a
an
ra
la
du
ir
es nd
sh
ab
nd
ar
ga
ra
ak
ha
es
ish
an
an
m
sh
sa
ra
ht
de
sth
de
sg
Na
nj
ja
ha
at
en
ad
Bi
ry
sh
ng
kh
as
Ke
de
Od
As
Pu
Gu
ra
tti
rn
ra
k
Ha
ja
tB
Pr
Ka
il
la
ar
ar
ra
aP
ha
Ka
rP
m
Ra
r
Te
Jh
ah
ta
lP
ra
u&
Ta
Ch
ta
hy
Ut
W
dh
M
ha
Ut
ad
m
An
ac
m
m
Ja
Hi
Base Year (2014-15) Reference Year (2015-16) Source: HMIS
Indicator 3.1.9: Proportion of public health facilities with accreditation certificates by a standard quality
assurance program (NQAS/ NABH/ ISO/ AHPI)
To ensure a high quality of health services, the Government of India encourages public health facilities
across States to apply for quality assurance programs such as National Quality Assurance Standards
(NQAS), National Accreditation Board for Hospitals and Healthcare Providers (NABH), International
Organization for Standardization (ISO), and Association of Healthcare Providers (India) (AHPI). The
performance of health facilities is assessed against pre-determined standards. Only a few States, namely
Bihar, Kerala, Odisha, Tamil Nadu, Arunachal Pradesh, Manipur, and Delhi have initiated
accreditation under the standard quality assurance program, but less than 15 percent facilities have
been accredited under such programs by any State.
67
Indicator 3.1.10: Average number of days for transfer of Central National Health Mission (NHM)
funds from State Treasury to implementation agency (Department/ Society) based on all tranches of
the last financial year
This is an important indicator for assessing the system’s efficiency in timely flow of funds to the
implementing agencies. The average number of days taken by the State to transfer money to the
implementation agency ranged between 0 (Daman & Diu and Lakshadweep) and 287 (Telangana) days.
The data came from records and analysis shared by the central NHM finance department of MoHFW.
As shown in the graphs below, almost all States and UTs (except Daman & Diu and Lakshadweep) have
lengthy delays in transfer of funds from the State Treasury to State health societies, thereby adversely
affecting timely implementation of various NHM initiatives. There is a need to take urgent steps to
reduce this delay. From base to reference year, Gujarat, Uttarakhand, Bihar, Himachal Pradesh,
Rajasthan, West Bengal, Chhattisgarh, Maharashtra, Jharkhand and Punjab have shown good progress
(reduction by 19 or more days), whereas delays have increased in Uttar Pradesh, Jammu & Kashmir,
Kerala, Andhra Pradesh, Karnataka, Assam, Telangana and in all Smaller States (except Meghalaya
and Tripura).
Figure 4.63 - Indicator 3.1.10: Average number of days for transfer of Central NHM funds from State Treasury to implementation agency
(Department/ Society) based on all tranches of the last financial year - Larger States
350
287
Average number of days for transfer
300
of NHM funds from State Treasury
242
to implementation agency
250
200
140
140
139
135
127
122
150
107
107
102
98
97
97
97
97
93
100
80
79
78
71
71
70
67
66
59
58
57
56
51
50
48
47
42
41
40
35
50
30
27
27
24
24
0
du
ra
a P ar
u & esh
ir
sh
sh
an
a
d
ab
a
t
ga
m
ish
an
ar
es
an
m
an
an
al
ra
ht
ak
Na
h
de
de
sth
nj
sa
Bi
sh
sg
en
er
d
as
ja
kh
ad
ng
kh
ry
at
Od
Pu
ra
ra
ra
il
As
K
Gu
ja
Ka
tti
ar
Ha
tB
rn
ar
Pr
la
ra
rP
lP
Ra
ha
ah
Ka
Jh
Te
ta
Ta
es
ra
ta
ha
hy
Ch
Ut
M
W
dh
Ut
ac
m
ad
An
m
m
M
Ja
Hi
Base Year (2014-15) Reference Year (2015-16) Source: Central NHM Finance Data
Figure 4.64 - Indicator 3.1.10: Average number of days for transfer of Central NHM funds from State Treasury to implementation agency (Department/ Society)
based on all tranches of the last financial year - Smaller States and UTs
300 160
147
143
Average number of days for transfer of NHM funds
Average number of days for transfer of NHM funds

258
from State Treasury to implementation agency
from State Treasury to implementation agency
140
250
216
213
120
101
199
200
177
92
100
89
154
153
78
149
76
143
80
140
68
150
64
62
118
55
60
101
98
100
35
40
69
68
20
38
50
0
0
0
rh
ry
i
u
li
lh
ba
Di
ee
ve
ga
er
De
co
Ha
dw
ch
sh
&
im
nd
ur
di
ya
Ni
ur
Go
ra
ip
an
du
de
an
la
la
ha
kk
r
ip
ga
an
izo
&
ga
ha
Ch
Pu
ra
m
Si
ks
Tr
Na
M
an
lP
Da
M
Na
eg
La
m
ha
M
a&
da
ac
dr
An
un
Da
Ar
Source: Central NHM Finance Data Source: Central NHM Finance Data
68
Way
Forward
69
5. Institutionalization – taking the Index ahead
The composite Health Index has been prepared and disseminated as a first attempt to promote a
co-operative and competitive spirit among the States and UTs to rapidly bring about transformative
action in achieving the desired health outcomes. The Health Index will be calculated and disseminated
annually, with a focus on measuring and highlighting annual incremental improvements by the States
and UTs. The MoHFW has underlined the importance of such an exercise to link the Index with
incentives to States and UTs under the NHM. The Index is also a tool for States and UTs to identify
problem areas and focus their interventions in these areas.
During the process of development of the Health Index, rich learnings have emerged which will guide
the refining of the Index for the coming year. It is envisaged that a thorough review of indicators will be
undertaken to include data on new thrust areas and addition of new data sources. The current
methodology will also be reconsidered to address some of the limitations listed earlier.
The exercise calls for urgent improvement of the data system in health for timeliness, accuracy and
relevance. The quality of HMIS and program-specific MIS data needs to be improved in terms of
consistency between Center and State data, coverage of private sector data, data scrutiny, thrust area
indicators and data definitions. The MIS also needs strengthening to provide appropriate
denominators. For example, the HMIS captures the number of anemic women but does not provide
data on the appropriate denominator (i.e. total number of women tested for anemia). Furthermore, the
SRS needs to generate data in a timely manner and should explore the possibility of generating the data
on key health outcomes including NMR, U5MR, TFR, MMR and SRB for all States and UTs. Data
sourced at the State-level on key areas such as human resources and finances needs to be strengthened
in terms of availability and its quality. Thus, in the successive rounds, continuous improvement of both
the methods and the data will be undertaken to make the Index better.
70
ANNEXURES
71
Annexure 1: Discrepancies in data and resolution
The data was finalized by the IVA after resolution of all discrepancies in consultation with State and
Central governments, who, after thorough review of the data and supporting documentation, identified
gaps and data discrepancies which were then discussed with state nodal officers (SNOs) and State-level
authorities. A State-specific validation report was prepared and shared with the Principal Secretaries,
Mission Directors and SNOs highlighting the results of the validation exercise. The States were
requested to review the validation report and provide feedback. Subsequently, the IVA also presented
the validation results through five video conferences held during August 16-18, 2017, with groups of 7-8
States to share the findings and discuss discrepancies, data gaps, variations and deviations.
Specific issues encountered during validation were discussed with stakeholders (NITI Aayog, MoHFW,
the World Bank, validation agency and subject experts) and the following decisions were taken:
• For States that have achieved replacement level of fertility (TFR≤2.1), it was decided to assign the
weight of this indicator on a pro-rata basis to the remaining parameters in that sub-domain, i.e.
key health outcomes.
• For service delivery indicators, such as ‘full immunization’, ‘institutional delivery’, ‘ANC registered
within first trimester’, and ‘people living with HIV on antiretroviral therapy,’ in instances where
percentages exceeded 100 percent, it was decided to cap them at 100 percent.
• For calculating the functionality of FRUs and 24x7 PHCs, the denominator was captured as the
required number of FRUs and 24x7 PHCs as per MOHFW norms of one FRU per 500,000
population and one 24x7 PHC per 100,000 population.
• CHC grading for Dadra & Nagar Haveli (reference year), Kerala and Tamil Nadu (base year) was
not available and the value against this indicator for that specific year was considered as not
applicable (NA). The weight of the indicator was distributed among other indicators in that
domain.
• In several States, the specified health worker positions were not sanctioned and/or overlapped
with other functions. Lakshadweep for example, did not have a sanctioned position of a CMO or
a Medical Superintendent. Therefore, for Lakshadweep this indicator was considered as NA. In
Dadra & Nagar Haveli, the Director of Health was also in charge of the District Hospital and thus
his tenure was considered for CMO as well. In Tripura and Himachal Pradesh, there were no
designated specialist positions (with General Duty Medical Officers filling the positions of
specialists), and hence the IVA accepted the NA entry submitted against the vacancy of specialist.
In the case of Chandigarh, in place of sanctioned positions the required number of specialists was
used for the denominator. Uttar Pradesh and Bihar did not share the total number of staff
(regular and contractual) for Indicator 3.1.2 on HRMIS generated e-payslip and thus the IVA
treated the entry as zero.
72
Annexure 2: Original Health Index
At the launch of the Guidebook on Performance on Health Outcomes10 in December 2016, the Index
comprised 28 indicators. Table A.2.1 provides an overview of the original set of indicators. However,
this Index was subsequently revised as described in Section 2, Table 2.3 and the revised Index has been
used for the generation of ranks.
Based on issues related to availability and quality of data, certain indicators had to be excluded or
modified from the original Index and the rationale for this is summarized at the end of the table.
Table A.2.1 - Original Health Index indicators: A snapshot
Domain Sub-domain Number of Weight

Indicators
Health Outcomes Key Outcomes 07 700
Intermediate Outcomes 07 350
Governance and Health Monitoring and Data Integrity 01 70
Information Governance 02 60
Key Inputs/ Health Systems/Service Delivery 11 220
Processes
TOTAL 28 1400
Table A.2.2 - Original Health Index: Indicators, definitions and data sources
Indicators Definition Data Source Remarks
DOMAIN 1 - HEALTH OUTCOMES
Sub-domain 1.1 - Key Outcomes (Weight – 700)
Still Birth Rate (SBR) Number of still births per thousand live SRS Excluded in
births during a specific year. final Health Index
Neonatal Mortality Number of infant deaths of less than 29 SRS

Rate (NMR) days per thousand live births during a
specific year.
Under-five Mortality Number of child deaths of less than 5 SRS

Rate (U5MR) years per thousand live births during a
specific year.
Maternal Mortality Number of maternal deaths from any cause SRS Excluded in final
Ratio (MMR) related to or aggravated by pregnancy Health Index
or its management during pregnancy,
childbirth, or within 42 days of termination
of pregnancy, per 100,000 live births
during the specific period.
Total Fertility Rate Average number of children that would be SRS

(TFR) born to a woman if she experiences the
current fertility pattern throughout her
reproductive span (15-49 years),
during a specific year.
Proportion of Low Proportion of low birth weight (<=2.5 kg) HMIS

Birth Weight among newborns out of the total number of
newborns newborns weighed during a specific year.
Sex Ratio at Birth (SRB) The number of girls born for every 1,000 SRS
boys born during a specific year.
Sub-domain 1.2 - Intermediate Outcomes (Weight – 350)
Full immunization coverage Proportion of infants 9-11 months old who have received BCG, HMIS
3 doses of DPT, 3 doses of OPV and measles against estimated
number of infants during a specific year.
10
Performance on Health Outcomes, A Reference Guidebook, NITI Aayog, December 2016.
73
Proportion of Proportion of deliveries conducted in HMIS

institutional deliveries public and private health facilities against
the number of estimated deliveries during
a specific year.
Proportion of Proportion of pregnant women aged 15-49 HMIS Excluded in

pregnant women years who are anemic (<11.0 g/dl) against final Health
aged 15-49 years total number of pregnant women registered Index
who are anemic for ANC during a specific year.
Total case notification Number of new and relapsed TB cases RNTCP MIS Indicator source
rate of tuberculosis notified (public + private) per 100, 000 modified as
(TB) population during a specific year. ‘RNTCP MIS,
MoHFW data’
Treatment success Proportion of new cured and their treatment RNTCP MIS Indicator source
rate of new completed against the total number of new modified as
microbiologically microbiologically confirmed TB cases ‘RNTCP MIS,
confirmed TB cases registered during a specific year. MoHFW data’
Proportion of people Proportion of PLHIV receiving ART NACO State Excluded for
living with HIV treatment against the number of Report the category
(PLHIV) on estimated PLHIVs who needed ART of UTs
antiretroviral therapy treatment for the specific year.
(ART)
Out-of-pocket Average out-of-pocket expenditure (INR) Mother and Excluded in

expenditure on drugs on drugs and diagnostics incurred per Child final Index for
and diagnostics delivery in public health facilities during Tracking incremental
incurred per delivery a specific year. Facilitation ranking;
in public health Centre Retained for
facilities (using (MCTFC) reference year
pregnant women as ranking only
proxy to all patients)
DOMAIN 2 – GOVERNANCE AND INFORMATION
Sub-domain 2.1 – Health Monitoring and Data Integrity (Weight – 70)
Data Integrity Percentage deviation of reported data from HMIS and

Measure: standard survey data to assess the quality/ NFHS-4
a. Institutional integrity of reported data for a
deliveries specific period.
b. ANC registered
within first trimester
Sub-domain 2.2 – Governance (Weight – 60)

Average occupancy of Average occupancy of an officer (in State Report
an officer (in months), months), combined for following key
combined for posts at State-level in last three years:
following three key
posts at State-level 1. Principal Secretary
for last three years: 2. Mission Director (NHM)
1. Principal Secretary 3. Director (Health Services)
2. Mission Director (NHM)
3. Director (Health Services)
Average occupancy of Average occupancy of a full time CMO State Report
a full-time officer (in months) for all the districts in last
(in months) for all three years.
the districts in last
three years - District
Chief Medical Officers
(CMOs) or equivalent
post (heading District
Health Services)
74
DOMAIN 3 – KEY INPUTS/PROCESSES
Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 220)
Proportion of vacant Vacant healthcare provider positions in State Report
health care provider public health facilities against total
positions (regular + sanctioned health care provider positions
contractual) in public for following cadres (separately for each
health facilities cadre) during a specific year:
a. ANMs at sub-centres (SCs)
b. Staff nurse at Primary Health Centers
(PHCs) and Community Health
Centers (CHCs)
c. MOs at PHCs
d. Specialists at DH (Medicine, Surgery,
Obstetrics and Gynaecology, Pediatrics,
Anesthesia, Ophthalmology, Radiology,
Pathology, ENT, Dental, Psychiatry)
Proportion of total Proportion of staff (regular + contractual)for whom an e-payslip State Report
staff (regular + can be generated in the IT enabled HRMIS against total
contractual) for whom number of staff (regular + contractual) during a specific year.
an e-payslip can be
generated in the IT
enabled Human
Resources
Management
Information System
(HRMIS)
a. Proportion of Proportion of facilities of specified type HMIS Indicator
specified type of conducting specified number of C-sections definition
facilities functioning per year (FRUs) against total number of modified
as First Referral specified type of facilities (CHCs, SDHs,
Units (FRUs) DHs) during a specific year.
b. Proportion of Proportion of PHCs providing all stipulated MIS Report, Indicator
functional 24x7 healthcare services round the clock against MoHFW definition
PHCs total number of PHCs during a specific year. modified
Proportion of Proportion of districts with functional CCUs State Report
districts with [with desired equipment (ventilator,
functional Cardiac monitor, defibrillator, CCU beds, portable
Care Units (CCUs) ECG machine, pulse oxymeter etc.),
drugs, diagnostics and desired staff as per
programme guidelines] against total
number of districts.
Proportion of ANC Proportion of pregnant women registered HMIS
registered within for ANC within 12 weeks of pregnancy
first trimester during a specific year.
against total
registrations
Level of registration Proportion of births registered under Civil CRS
of births Registration System (CRS) against the
estimated number of births during a
specific year.
Completeness of IDSP Proportion of Reporting Units (RUs) IDSP Report Indicator source
reporting of P and reporting in stipulated time period against modified as
L forms total RUs, for P and L forms during a ‘Central IDSP,
specific year. MoHFW data’
Proportion of CHCs Proportion of CHCs that are graded above HMIS
with grading above 3 points against total number of CHCs
3 points during a specific year.
Proportion of public Proportion of specified type of public health State Report
health facilities with facilities with accreditation certificates by a
accreditation standard quality assurance program
certificates by a against the total number of following
standard quality specified type of facilities during a
assurance program specific year.
(NQAS/ NABH/ ISO/ 1. District hospital (DH)/ Sub-district hospital (SDH)
AHPI) 2. CHC/ Block PHC
75
Average number of Average time taken (in number of days) by State Report Indicator source
days for transfer of the State Treasury to transfer funds to modified as ‘Central NHM
Central NHM funds implementation agencies during a Finance data’
from State Treasury specific year.
to implementation
agency (Department/
Society) based on all
tranches of the last
financial year
Proportion of National Proportion of funds utilized against the State Report Excluded in final
Health Mission (NHM) total funds allocated under NHM by the Health Index
funds utilized by the end of 3rd quarter of specific year.
end of 3rd quarter
The estimates for SRS-related indicators such as NMR, U5MR, TFR, MMR and SRB in the Index
were not available for Smaller States and UTs. Experts were consulted to generate estimates for these
States and UTs from the SRS raw data obtained by NITI Aayog. However, it was decided that these
estimates could not be generated due to the insufficient sample size. Further, in the Larger States
category, MMR estimates were not available separately for eight states, which belonged previously to
four undivided States, and also not available for Himachal Pradesh and Jammu & Kashmir. In the case
of Still Birth Rate (SBR), the States as well as the IVA reported that data for this indicator was
unreliable. In case of the indicator ‘proportion of pregnant women age 15-49 years who are anemic’,
data on the appropriate denominator (i.e. total number of women tested for anemia) was not available
in the HMIS. Besides, the indicator for ‘proportion of people living with HIV (PLHIV) on ART’ was
excluded for the UTs category since no ART center was available in four UTs. For the indicator
‘proportion of NHM funds utilized by the end of 3rd quarter’, neither State nor central level data was
found to be valid.
For the sake of uniformity and comparability across the States, central data was used for a few indicators
such as ‘proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)’, ‘average
number of days for transfer of central NHM funds from State Treasury to implementation agency’ and
‘completeness of IDSP reporting of P and L forms’. The NFHS-4 data for the indicator ‘out-of-pocket
expenditure on drugs and diagnostics incurred per delivery in public health facilities’ was used in the
reference year Index. However, for the base year, this data was not available and could therefore not be
factored in for generating base year ranks or incremental ranks or drawing comparisons between the
base and reference years.
76
Annexure 3: Reference Year Index (with and without
the indicator on out-of-pocket expenditure)
As described in the background section, the OOP expenditure data was available only for 2015-16 and
hence was used to calculate the reference year Index and rank independently. Overall, the inclusion of
the OOP expenditure indicator in the Index score calculations does not substantially change the
rankings (Figure A.3.1). The only exceptions are Andhra Pradesh and Bihar which, after the inclusion
of OOP expenditure, move up by two and one positions, respectively; while Maharashtra, Jammu &
Kashmir, and Odisha move down by one position in the ranking.
Figure A.3.1 - Larger States: Ranking for reference year (2015-16) with and without the OOP expenditure indicator
1 Kerala 76.55 73.77 Kerala 1
2 Punjab 65.21 66.41 Punjab 2
3 Tamil Nadu 63.38 64.23 Tamil Nadu 3
4 Gujarat 61.99 63.15 Gujarat 4
5 Himachal Pradesh 61.20 61.58 Himachal Pradesh 5
6 Maharashtra 61.07 61.41 Andhra Pradesh 6
7 Maharashtra 7
Reference Year Ranking (Excluding OOP Indicator)
Jammu & Kashmir 60.35 61.34
Reference Year Ranking (including OOP Indicator)

8 Andhra Pradesh 60.16 60.16 Jammu & Kashmir 8
9 Karnataka 58.70 58.79 Karnataka 9
10 West Bengal 58.25 55.67 West Bengal 10
11 Telangana 55.39 55.74 Telangana 11
12 Chhattisgarh 52.02 54.08 Chhattisgarh 12
13 Haryana 46.97 49.23 Haryana 13
14 Jharkhand 45.33 47.69 Jharkhand 14
15 Uttarakhand 45.22 46.94 Uttarakhand 15
16 Assam 44.13 45.34 Assam 16
17 Madhya Pradesh 40.09 42.74 Madhya Pradesh 17
18 Odisha 39.43 40.95 Bihar 18
19 Bihar 38.46 40.15 Odisha 19
20 Rajasthan 36.79 38.44 Rajasthan 20
21 Uttar Pradesh 33.69 36.23 Uttar Pradesh 21
Without OOP expenditure With OOP expenditure
Note: Lines depict changes in composite Index score rank. The composite Index score is presented in the circle.
77
For the Smaller States, the inclusion of OOP expenditure in the Health Index results in some changes
in the rankings (Figure A.3.2), whereby Meghalaya, Sikkim, and Goa move up by one position, while
Manipur falls by three positions (from second to fifth place).
Figure A.3.2 - Smaller States: Ranking for reference year (2015-16) with and without OOP expenditure indicator
1 Mizoram 73.70 73.86 Mizoram 1
2 Manipur 57.78 59.44 Meghalaya 2

Reference Year Ranking (excluding OOP indicator)
Reference Year Ranking (including OOP indicator)

3 Meghalaya 56.83 56.41 Sikkim 3
4 Sikkim 53.20 54.24 Goa 4
5 Goa 53.13 53.82 Manipur 5
6 Arunachal Pradesh 49.51 49.38 Arunachal Pradesh 6
7 Tripura 43.51 45.66 Tripura 7
8 Nagaland 37.38 38.66 Nagaland 8
The inclusion of the OOP expenditure indicator in calculation of the Health Index results in some
changes in the reference year ranking among the UTs (Figure A.3.3). Notably, Andaman & Nicobar and
Puducherry move up by one position in the ranking, while Delhi moves down by two positions. The
inclusion of OOP expenditure does not affect the rankings of the other UTs.
Figure A.3.3 - Union Territories: Ranking for reference year (2015-16) with and without OOP expenditure indicator
1 Lakshadweep 65.79 64.64 Lakshadweep 1
2 Chandigarh 52.27 54.10 Chandigarh 2

Reference Year Ranking (excluding OOP indicator)
Reference Year Ranking (including OOP indicator)
3 Delhi 50.02 52.98 Andaman & Nicobar 3
4 Andaman & Nicobar 50.00 49.98 Puducherry 4
5 Puducherry 47.48 46.35 Delhi 5
6 Daman & Diu 36.10 39.81 Daman & Diu 6
7 Dadra & Nagar Haveli 34.64 39.45 Dadra & Nagar Haveli 7
78
Annexure 4: Snapshot: State-wise performance on
indicators
Section 4 of the report on ‘Unveiling performance - encouraging actions’, provided insights about the
State-wise overall, incremental and domain-specific performance. This Annexure presents a quick
snapshot of State-wise performance on all indicators included in the Index. This can help the States to
easily identify specific areas requiring attention. The tables present data for base year (BY) and reference
year (RY) of each indicator for all States. The direction as well as the magnitude of incremental change
in the value of indicators from the base year to reference year is depicted by categorization (‘most
improved’, ‘improved’, ‘no change’, ‘deteriorated’, ‘most deteriorated’, ‘not applicable’) and is visually
identifiable by appropriate color coding.
1. Incremental change in performance for an indicator is calculated by subtracting base year value from
reference year value. For indicators, such as NMR, U5MR, and vacancies, a negative change from base
to reference year denotes improvement, while a positive change denotes deterioration. In the case of
indicators such as those that reflect service coverage, a positive change denotes improvement, while a
negative change denotes deterioration. The range of improvement is calculated by subtracting the
minimum value of change from the maximum value of change. This range is then divided into two
equal parts and the half towards maximum value of change is termed as 'most improved' and the half
towards the minimum value of change is termed as ‘improved’.
2. Similarly, the range of deterioration is calculated by subtracting the minimum value of change from the
maximum value of change. This range is then divided into two equal parts and the half towards
maximum value of change is termed as 'deteriorated' and the other half towards minimum value of
change is termed as 'most deteriorated' respectively. If the indicator value is stagnant and there has been
no incremental change from base to reference year, the indicator is labeled as ‘no change’.
3. For a State, the incremental performance on an indicator is classified as ‘not applicable’ (NA) in
instances such as: (i) If State has achieved TFR <= 2.1 in both base and reference years; (ii) Data
Integrity Measure indicator wherein the same data has been used for base year and reference year due
to overlapping periods of NFHS-4; (iii) Service coverage indicators with 100 percent values in both base
and reference years; (iv) The data value for a particular indicator is NA in base year or reference year or
both.
79
Table A.4.1 - Larger States: Health Outcomes domain indicators, base and reference years
1.1.5 SRB
1.1.1 NMR 1.1.2 U5MR (no. of girls
1.1.4 LBW
(per '000 live (per '000 live 1.1.3 TFR* born for every
States (percentage)
births) births) 1,000 boys
born)
BY RY BY RY BY RY BY RY BY RY
Andhra Pradesh 26 24 40 39 1.8 1.7 5.62 6.73 919 918
Assam 26 25 66 62 2.3 2.3 18.19 16.68 918 900
Bihar 27 28 53 48 3.2 3.2 6.70 7.22 907 916
Chhattisgarh 28 27 49 48 2.6 2.5 11.61 12.15 973 961
Gujarat 24 23 41 39 2.3 2.2 10.58 10.51 907 854
Haryana 23 24 40 43 2.3 2.2 14.61 14.90 866 831
Himachal
25 19 36 33 1.7 1.7 8.66 12.63 938 924
Pradesh
Jammu & Kashmir 26 20 35 28 1.7 1.6 6.33 5.93 899 899
Jharkhand 25 23 44 39 2.8 2.7 7.81 7.42 910 902
Karnataka 20 19 31 31 1.8 1.8 10.76 11.49 950 939
Kerala 6 6 13 13 1.9 1.8 10.81 11.72 974 967
Madhya Pradesh 35 34 65 62 2.8 2.8 14.16 14.10 927 919
Maharashtra 16 15 23 24 1.8 1.8 14.57 13.74 896 878

Odisha 36 35 60 56 2.1 2.0 20.10 19.16 953 950
Punjab 14 13 27 27 1.7 1.7 5.95 6.88 870 889
Rajasthan 32 30 51 50 2.8 2.7 27.43 25.51 893 861
Tamil Nadu 14 14 21 20 1.7 1.6 10.46 13.03 921 911
Telangana 25 23 37 34 1.8 1.8 6.11 5.70 919 918
Uttar Pradesh 32 31 57 51 3.2 3.1 11.74 9.60 869 879

Uttarakhand 26 28 36 38 2.0 2.0 7.77 7.26 871 844
West Bengal 19 18 30 30 1.6 1.6 15.48 16.45 952 951
**The data shown in grey color is for ‘not applicable’ category wherein the States with TFR <= 2.1 (replacement level fertility) in both base and reference years
are not considered for incremental change.
80
Table A.4.1 (Continued) - Larger States: Health Outcomes domain indicators, base and reference years
1.2.3 TB case
1.2.2 1.2.4 TB
1.2.1 Full notification 1.2.5 PLHIV 1.2.6 OOP
Institutional treatment
immunization rate on ART expenditure
deliveries success rate
States (percentage) (per 100,000 (percentage) (in INR)
#
(percentage) (percentage)
population)
BY RY BY RY BY RY BY RY BY RY RY
Andhra
97.58 91.62 53.09 87.08 136 145 90.40 88.50 72.39 76.11 2138
Pradesh
Assam 84.10 88.00 72.70 74.25 122 123 85.40 86.20 58.94 64.58 3210
Bihar 82.10 89.73 52.96 57.10 72 84 89.00 89.70 30.73 37.18 1724
Chhattisgarh 85.81 90.53 59.64 64.51 128 138 88.20 89.10 47.20 53.06 1480
Gujarat 90.26 90.55 90.83 97.78 170 193 88.50 88.90 50.23 52.43 2136
Haryana 82.54 83.47 80.76 80.25 165 172 86.00 87.50 52.31 51.53 1503
Himachal
94.90 95.22 67.50 67.49 210 207 89.70 89.60 79.22 79.89 3329
Pradesh
Jammu &
89.80 100.00 81.45 80.51 74 72 87.60 88.30 88.72 96.41 4192
Kashmir
Jharkhand 80.82 88.10 60.52 67.36 100 108 89.80 90.90 36.07 39.40 1476
Karnataka 92.30 96.24 77.12 78.78 100 105 83.30 84.70 83.25 88.68 3893
Kerala 95.50 94.61 95.99 92.62 87 139 86.00 87.50 61.79 66.72 6901
Madhya
74.26 74.78 63.07 64.79 143 164 89.70 90.30 53.04 61.01 1387
Pradesh
Maharashtra 98.55 98.22 89.19 85.30 155 164 83.90 84.20 83.46 87.71 3487
Odisha 88.03 85.32 74.76 73.49 106 99 87.40 88.90 28.33 32.95 4225
Punjab 96.08 99.64 83.23 82.33 137 136 86.90 87.20 77.22 84.62 1890
Rajasthan 78.95 78.06 74.67 73.85 139 143 90.40 90.30 42.44 46.41 3052
Tamil Nadu 85.54 82.66 85.97 81.82 113 125 82.30 85.40 81.93 87.06 2496
Telangana 100.00 89.09 59.15 85.35 113 123 90.00 89.60 72.39 76.11 4020
Uttar Pradesh 82.88 84.82 43.55 52.38 123 137 88.20 87.50 51.30 57.81 1956
Uttarakhand 91.77 99.30 64.32 62.63 145 138 85.50 86.00 62.67 65.25 2399
West Bengal 100.00 95.85 79.92 81.28 93 93 86.40 86.50 31.00 35.92 7782
#Data for this indicator is available and used only for reference year and hence this indicator comes under ‘not applicable’ category.
81
Table A.4.2 - Larger States: Governance and Information domain indicators, base and reference years
2.2.1 Average
2.1.1.a Data Integrity: 2.1.1.b Data Integrity: 2.2.2 Average
occupancy: State-
Institutional deliveries First trimester ANC occupancy: CMOs
level 3 key posts
States (percentage) registration (percentage) (in months)
(in months)
BY** RY BY** RY BY RY BY RY
Andhra
23.53 23.53 15.42 15.42 17.70 17.51 12.80 13.22
Pradesh
Assam 0.25 0.25 21.16 21.16 10.17 12.11 7.92 7.95
Bihar 18.21 18.21 16.33 16.33 15.00 13.01 17.62 11.88
Chhattisgarh 22.34 22.34 25.90 25.90 11.39 11.40 21.88 25.40
Gujarat 0.68 0.68 2.06 2.06 20.22 20.71 18.68 18.09
Haryana 4.62 4.62 19.08 19.08 13.80 11.21 13.43 12.56

Himachal
12.72 12.72 7.30 7.30 11.38 12.39 13.86 10.50
Pradesh
Jammu &
12.42 12.42 13.50 13.50 22.80 13.81 11.72 11.77
Kashmir
Jharkhand 7.95 7.95 53.48 53.48 12.98 12.00 11.19 11.46
Karnataka 21.22 21.22 8.20 8.20 6.85 6.49 14.83 13.23
Kerala 3.71 3.71 24.86 24.86 21.84 12.02 16.47 11.72

Madhya
23.09 23.09 9.19 9.19 10.75 16.00 18.14 17.62
Pradesh
Maharashtra 1.16 1.16 5.61 5.61 10.86 15.74 12.25 15.64
Odisha 13.82 13.82 22.09 22.09 11.07 12.01 9.97 13.95
Punjab 12.41 12.41 9.97 9.97 20.00 20.42 9.12 10.19
Rajasthan 12.44 12.44 18.43 18.43 19.00 22.02 12.26 11.94
Tamil Nadu 10.92 10.92 22.75 22.75 11.94 16.51 6.85 7.29
Telangana 21.06 21.06 15.80 15.80 8.71 7.81 11.72 11.19
Uttar Pradesh 36.59 36.59 0.92 0.92 9.62 19.64 11.57 14.15
Uttarakhand 14.93 14.93 10.77 10.77 10.65 10.35 11.63 13.93
West Bengal 2.12 2.12 42.44 42.44 22.00 28.02 10.29 14.10
** Same data has been used for base and reference years due to overlapping periods of NFHS-4. Hence this indicator comes under ‘not applicable’ category.
82
Table A.4.3 - Larger States: Key Inputs/Processes domain indicators, base and reference years
3.1.1.d
3.1.1.a 3.1.1.b 3.1.1.c
Vacancy:
Vacancy: ANMs Vacancy: SNs at Vacancy: MOs 3.1.2 E-payslip
Specialists at
at SCs PHCs and CHCs at PHCs (percentage)
States DHs
(percentage) (percentage) (percentage)
(percentage)
Andhra Pradesh 20.56 15.67 17.33 20.48 17.97 12.76 40.55 30.41 59.60 58.65
Assam 10.93 8.99 4.57 8.95 19.92 17.77 62.91 41.72 0.00 0.00
Bihar 67.86 59.30 86.15 50.28 63.60 63.60 64.96 60.58 0.00 0.00
Chhattisgarh 12.35 9.23 44.27 37.28 41.83 45.02 77.98 77.68 0.00 0.00
Gujarat 17.13 28.08 37.71 36.46 39.78 32.03 51.02 55.50 35.60 35.61
Haryana 9.66 15.23 45.95 43.24 38.64 25.35 0.00 0.00 0.00 0.00
Himachal Pradesh 12.57 9.87 21.51 27.19 16.19 21.73 NA NA 3.32 8.07
Jammu & Kashmir 17.65 10.28 42.88 27.48 34.92 30.15 24.52 22.22 0.00 0.00
Jharkhand 19.57 19.73 71.80 74.94 45.29 48.67 55.37 50.32 0.00 0.00
Karnataka 27.85 22.59 45.20 25.97 13.35 11.48 20.90 21.53 48.89 49.35
Kerala 4.88 4.49 5.54 5.30 5.59 5.86 22.15 21.48 88.61 100.00
Madhya Pradesh 8.58 14.23 36.45 33.50 57.81 58.34 50.56 50.98 0.00 0.00
Maharashtra 8.25 9.46 16.74 15.67 16.82 16.96 19.47 30.34 66.55 67.60
Odisha 0.00 0.00 0.00 0.00 23.17 26.91 43.53 19.04 75.79 75.79
Punjab 7.17 8.48 36.22 33.98 9.83 7.77 21.74 47.72 0.00 0.00
Rajasthan 36.12 19.24 48.12 47.26 14.93 14.86 41.47 45.77 0.00 0.00
Tamil Nadu 11.82 15.97 21.78 19.09 7.56 7.58 17.86 16.73 84.62 84.72
Telangana 20.20 18.01 12.79 12.79 22.31 22.31 59.83 54.81 0.00 0.00
Uttar Pradesh 14.06 0.00 1.89 1.89 36.83 26.73 35.74 32.41 0.00 0.00
Uttarakhand 15.47 16.88 13.11 20.02 37.16 12.19 38.30 60.33 0.00 0.00
West Bengal 2.16 0.77 25.72 9.70 48.43 41.23 22.97 20.18 81.78 81.23
83
Table A.4.3 (Continued) - Larger States: Key Inputs/Processes domain indicators, for base and reference years
3.1.3.b 3.1.4 Districts 3.1.5 Proportion 3.1.6 Level of

3.1.3.a
Functional 24x7 with functional of first trimester birth
Functional FRUs
PHCs CCUs ANC registration
States (percentage)
(percentage) (percentage) (percentage) (percentage)
Andhra Pradesh 48.48 57.58 33.20 29.15 53.85 53.85 64.42 74.38 98.50 100.00
Assam 67.74 72.58 169.55 176.92 0.00 0.00 77.24 80.55 97.70 100.00
Bihar 12.50 11.54 70.89 73.58 0.00 0.00 51.43 55.47 57.40 64.20
Chhattisgarh 21.57 23.53 36.47 40.39 3.70 3.70 59.99 74.60 87.80 100.00
Gujarat 32.23 42.98 27.81 31.46 57.69 48.48 73.58 74.91 100.00 95.00
Haryana 52.94 50.98 73.62 77.56 19.05 19.05 57.68 62.20 100.00 100.00
Himachal Pradesh 107.14 121.43 5.80 5.80 91.67 91.67 78.62 81.39 100.00 93.10
Jammu & Kashmir 180.00 196.00 53.60 45.60 18.18 27.27 54.37 52.95 71.80 75.50
Jharkhand 15.15 22.73 33.03 33.03 0.00 0.00 33.67 36.36 77.70 82.00
Karnataka 105.74 116.39 78.07 69.23 43.33 43.33 72.82 71.22 96.00 97.80
Kerala 120.90 120.90 0.00 0.00 64.29 64.29 80.98 80.63 100.00 100.00
Madhya Pradesh 44.83 49.66 58.40 56.47 9.80 9.80 61.54 63.79 84.10 82.60
Maharashtra 31.11 32.44 48.04 46.71 22.86 22.86 63.58 66.82 100.00 100.00
Odisha 61.90 65.48 30.00 30.00 3.33 3.33 68.48 75.75 93.90 98.50
Punjab 138.18 141.82 35.74 26.35 63.64 63.64 71.16 73.01 100.00 100.00
Rajasthan 23.36 29.20 67.30 68.03 2.94 70.59 58.50 60.66 98.40 98.20
Tamil Nadu 129.17 122.92 54.23 34.95 56.25 56.25 92.72 94.35 100.00 100.00
Telangana 80.00 80.00 26.99 26.99 0.00 0.00 61.26 55.90 100.00 95.60
Uttar Pradesh 15.25 15.75 17.92 17.42 0.00 0.00 51.19 48.72 68.60 68.30
Uttarakhand 100.00 95.00 56.44 54.46 0.00 0.00 59.06 62.47 76.60 86.00
West Bengal 45.36 49.18 5.70 5.91 76.92 76.92 73.03 77.00 92.80 92.50
84
Table A.4.3 (Continued) - Larger States: Key Inputs/Processes domain indicators, base and reference years
3.1.10
3.1.7 IDSP 3.1.7 IDSP 3.1.9 Quality 3.1.9 Quality
3.1.8 CHC Fund
reporting of reporting of accreditation accreditation
grading transfer
States P form L form DH-SDH CHC-PHC
(percentage) (no. of
days)
BY RY BY RY BY RY BY RY BY RY BY RY
Andhra
94 99 94 99 1.02 37.24 0.00 0.00 0.00 0.00 97 127
Pradesh
Assam 92 88 92 88 4.64 31.13 0.00 0.00 0.00 0.00 97 242
Bihar 83 88 83 87 0.00 20.34 27.16 27.16 2.36 1.52 135 40
Chhattisgarh 77 84 66 82 3.23 47.74 0.00 0.00 0.00 0.00 79 57
Gujarat 96 95 98 96 10.25 49.40 6.35 2.99 1.24 0.60 58 24
Haryana 89 84 90 88 10.09 22.02 0.00 0.00 0.00 0.00 27 42

Himachal
41 66 35 62 2.53 5.06 0.00 1.37 0.00 0.00 102 47
Pradesh
Jammu &
66 80 61 75 7.14 61.90 0.00 0.00 0.00 0.00 97 107
Kashmir
Jharkhand 69 73 68 72 1.55 54.40 0.00 0.00 0.00 0.00 140 67
Karnataka 82 95 82 94 25.34 31.27 0.00 0.53 0.00 0.00 122 139
Kerala 94 96 93 96 NA 0.44 10.00 10.00 5.07 6.52 80 107

Madhya
81 80 82 80 8.98 57.19 0.00 0.00 0.29 0.57 35 41
Pradesh
Maharashtra 71 79 72 76 16.67 38.52 0.00 0.00 0.27 0.27 140 66
Odisha 66 83 63 74 9.81 22.81 15.25 15.25 0.00 0.00 24 59
Punjab 77 73 93 85 12.00 26.67 0.00 0.00 0.00 0.00 98 78
Rajasthan 59 73 57 68 3.19 54.48 0.00 0.00 0.00 0.00 71 48
Tamil Nadu 70 90 72 87 NA 76.10 0.74 4.29 7.27 4.94 56 50
Telangana 94 97 94 95 0.00 11.63 0.00 0.00 0.00 0.00 70 287

Uttar
64 42 70 57 4.53 44.13 0.00 0.00 0.00 0.00 30 93
Pradesh
Uttarakhand 88 93 84 93 1.67 8.33 0.00 0.00 0.00 0.00 97 27
West Bengal 65 78 72 80 3.49 53.74 0.00 0.00 0.00 0.00 71 51
85
Table A.4.4 - Smaller States: Health Outcomes domain indicators, base and reference years
1.2.3 TB
1.2.2 case 1.2.4 TB
1.2.1 Full 1.2.5 PLHIV 1.2.6 OOP
1.1.4 LBW Institutional notification treatment
immunization on ART expenditure
States (percentage) deliveries rate (per success rate #
(percentage) (percentage) (in INR)
(percentage) 100,000 (percentage)
population)
BY RY BY RY BY RY BY RY BY RY BY RY RY
Arunachal
5.79 6.55 60.58 64.95 55.99 56.46 186 183 88.00 86.40 18.69 28.19 6474
Pradesh
Goa 16.72 15.56 91.26 95.24 91.27 92.46 127 131 86.40 87.30 70.92 72.75 4836
Manipur 3.90 3.53 94.39 96.32 74.93 73.47 82 81 85.00 82.60 53.95 63.87 10076
Meghalaya 8.19 7.65 96.43 93.34 59.57 62.11 170 137 82.30 85.80 98.66 100.00 2892
Mizoram 4.73 4.65 100.00 100.00 100.00 96.29 183 186 86.50 90.60 96.68 100.00 4327
Nagaland 4.10 3.89 61.91 63.86 56.95 58.07 173 139 90.70 71.90 63.81 73.80 5834
Sikkim 6.78 7.76 74.07 74.44 71.96 70.19 222 241 78.80 77.20 32.45 33.51 2509
Tripura 10.56 11.11 87.43 84.33 78.48 79.36 195 61 88.60 88.50 23.14 5.80 4412
Table A.4.5 - Smaller States: Governance and Information domain indicators, base and reference years
2.1.1.b Data Integrity: 2.2.1 Average

2.1.1.a Data Integrity: 2.2.2 Average
First trimester ANC occupancy: State-
Institutional deliveries occupancy: CMOs
States registration level 3 key posts
(percentage) (in months)
Arunachal
1.36 1.36 5.62 5.62 19.85 13.87 19.29 17.50
Pradesh
Goa 5.01 5.01 23.74 23.74 14.84 21.69 15.00 12.00
Manipur 2.87 2.87 28.19 28.19 13.29 21.02 18.64 17.31
Meghalaya 13.44 13.44 10.56 10.56 19.99 19.25 15.49 14.76

Mizoram 22.00 22.00 18.71 18.71 11.12 9.77 20.51 25.98
Nagaland 54.79 54.79 107.87 107.87 11.61 7.25 17.43 19.94
Sikkim 29.16 29.16 26.76 26.76 24.00 24.02 31.50 25.52

Tripura 3.35 3.35 10.89 10.89 11.99 10.87 14.32 17.26
86
Table A.4.6 - Smaller States: Key Inputs/Processes domain indicators, base and reference years
3.1.1.b Vacancy:
3.1.1.a Vacancy: 3.1.1.c Vacancy: 3.1.1.d Vacancy: 3.1.2 E-
SNs at PHCs and
ANMs at SCs MOs at PHCs Specialists at DHs payslip
States CHCs
(percentage)
Arunachal
2.07 22.37 4.05 28.78 9.38 38.75 87.55 89.11 45.89 38.75
Pradesh
Goa 24.75 30.10 12.54 11.68 31.11 14.22 42.71 39.70 0.00 0.00
Manipur 20.57 29.89 5.08 18.98 42.76 42.76 47.67 47.67 0.00 0.00
Meghalaya 19.56 20.00 30.90 31.05 31.85 35.67 29.28 29.73 0.00 0.00
Mizoram 11.33 16.07 6.11 6.11 31.58 38.10 15.22 15.22 0.00 0.00
Nagaland 7.80 11.01 0.00 0.00 26.89 27.36 0.00 0.00 0.00 0.00
Sikkim 0.00 0.00 61.96 61.96 0.00 0.00 34.38 34.38 0.00 0.00
Tripura 15.37 38.90 22.20 0.00 17.03 2.06 NA NA 0.00 0.00
Table A.4.6 (Continued) - Smaller States: Key Inputs/Processes domain indicators, base and reference years
3.1.4 Districts 3.1.5

3.1.3.a 3.1.3.b Functional with Proportion of 3.1.6 Level of
Functional FRUs 24x7 PHCs functional first trimester birth registration
States (percentage) (percentage) CCUs ANC (percentage)
Arunachal Pradesh 100.00 133.33 21.43 42.86 0.00 0.00 38.66 36.99 100.00 100.00
Goa 100.00 100.00 0.00 6.67 0.00 0.00 57.00 58.74 100.00 100.00
Manipur 83.33 66.67 41.38 65.52 0.00 0.00 59.07 63.23 100.00 100.00
Meghalaya 83.33 100.00 166.67 180.00 0.00 0.00 32.24 32.07 100.00 100.00
Mizoram 150.00 100.00 190.91 136.36 11.11 11.11 72.26 73.61 100.00 100.00
Nagaland 150.00 125.00 165.00 165.00 0.00 9.09 46.80 35.83 100.00 100.00
Sikkim 100.00 200.00 166.67 216.67 0.00 0.00 77.81 79.89 79.90 74.10
Tripura 42.86 57.14 124.32 116.22 0.00 0.00 62.75 61.85 91.40 81.70
87
Table A.4.6 (Continued) - Smaller States: Key Inputs/Processes domain indicators, base and reference years

3.1.8 CHC 3.1.10 Fund
reporting of reporting of L accreditation accreditation
grading transfer
States P form form DH-SDH CHC-PHC
(percentage) (no.of days)
Arunachal
43 82 33 77 0.00 0.00 5.00 5.00 0.00 0.00 98 143
Pradesh
Goa 65 79 67 88 25.00 75.00 0.00 0.00 0.00 0.00 149 154
Manipur 35 63 32 38 0.00 29.41 12.50 12.50 0.00 0.00 199 258
Meghalaya 62 84 63 82 3.70 7.41 0.00 0.00 0.00 0.00 216 38
Mizoram 51 48 74 58 0.00 0.00 0.00 0.00 0.00 0.00 140 177
Nagaland 80 79 61 65 0.00 0.00 0.00 0.00 0.00 0.00 101 213
Sikkim 91 97 86 100 0.00 0.00 0.00 0.00 0.00 0.00 68 153
Tripura 75 97 61 94 0.00 0.00 0.00 0.00 0.00 0.00 118 69
Table A.4.7 - Union Territories: Health Outcomes domain indicators, base and reference years
Most Improved Improved No Change Deteriorated 1.2.3 TB

Most Deteriorated Not 1.2.6 OOP
Applicable
1.2.2 case 1.2.4 TB expenditure
1.2.1 Full #
1.1.4 LBW Institutional notification treatment (in INR)
immunization
UTs (percentage) deliveries rate (per success rate
(percentage) 100,000
population)
BY RY BY RY BY RY BY RY BY RY RY
Andaman &
Nicobar 16.13 17.17 84.62 100.00 76.21 80.20 157 139 85.50 91.50 1258
Islands
Chandigarh 22.49 20.77 92.30 93.58 100.00 100.00 300 305 89.50 85.60 2357
Dadra &
34.70 29.39 75.48 77.06 88.20 87.09 138 133 85.20 86.30 471
Nagar Haveli
Daman & Diu 16.91 24.37 85.04 79.67 75.29 72.00 146 166 83.10 79.50 1581
Delhi 20.85 21.43 90.88 96.21 79.41 80.60 337 348 86.20 86.70 8719
Lakshadweep 4.85 5.56 100.00 100.00 76.44 85.40 61 35 86.70 91.30 4580
Puducherry 18.48 15.50 73.93 77.60 100.00 100.00 95 103 88.50 89.20 1999
88
Table A.4.8 - Union Territories: Governance and Information domain indicators, base and reference years
2.1.1.b Data
2.1.1.a Data 2.2.1 Average
Integrity: First 2.2.2 Average
Integrity: Institutional occupancy: State-
trimester ANC occupancy: CMOs
UTs deliveries level 3 key posts
registration (in months)
(percentage)
Andaman &
18.05 18.05 2.84 2.84 26.00 15.01 25.49 17.43
Nicobar Islands
Chandigarh 57.98 57.98 27.88 27.88 10.80 12.01 15.53 15.55
Dadra & Nagar
15.11 15.11 22.12 22.12 14.40 14.41 18.00 18.01
Haveli
Daman & Diu 17.43 17.43 15.27 15.27 20.40 21.02 36.00 36.03
Delhi 10.76 10.76 27.77 27.77 13.70 9.63 15.82 16.72
Lakshadweep 29.35 29.35 12.19 12.19 26.77 26.79 NA NA
Puducherry 90.52 90.52 48.82 48.82 21.96 19.98 23.05 25.32
Table A.4.9 - Union Territories: Key Inputs/Processes domain indicators, base and reference years
3.1.1.a 3.1.1.b Vacancy:

3.1.1.c Vacancy: 3.1.1.d Vacancy: 3.1.2 E-
Vacancy: ANMs SNs at PHCs and
MOs at PHCs Specialists at DHs payslip
UTs at SCs CHCs
(percentage) (percentage) (percentage)
Andaman &
7.84 7.84 7.45 7.45 36.36 36.36 100.00 100.00 0.00 0.00
Nicobar Islands
Chandigarh 31.25 29.41 6.19 6.19 69.17 69.17 0.00 0.00 59.97 61.33
Dadra & Nagar
0.00 0.00 4.88 4.88 16.67 16.67 18.18 18.18 0.00 0.00
Haveli
Daman & Diu 13.56 11.86 2.38 0.00 7.14 7.14 38.24 47.06 0.00 0.00
Delhi 4.88 19.75 32.00 40.75 8.33 14.21 38.74 40.21 0.00 68.81
Lakshadweep 0.00 0.00 0.00 0.00 0.00 0.00 76.47 76.47 0.00 0.00
Puducherry 7.23 8.73 1.19 2.38 12.78 12.78 23.36 20.56 80.74 78.35
89
Table A.4.9 (Continued) - Union Territories: Key Inputs/Processes domain indicators, base and reference years
3.1.5
3.1.3.b
3.1.3.a 3.1.4 Districts with Proportion of 3.1.6 Level of
Functional 24x7
Functional FRUs functional CCUs first trimester birth registration
UTs PHCs
(percentage) (percentage) ANC (percentage)
(percentage)
(percentage)
Andaman &
0.00 0.00 500.00 500.00 0.00 0.00 77.84 76.94 97.20 71.90
Nicobar Islands
Chandigarh 150.00 150.00 0.00 0.00 0.00 0.00 49.63 36.79 100.00 100.00
Dadra & Nagar
100.00 100.00 100.00 133.33 0.00 0.00 47.27 84.77 71.80 65.10
Haveli
Daman & Diu 100.00 100.00 50.00 50.00 0.00 0.00 47.32 49.26 98.40 76.40
Delhi 91.18 100.00 0.60 0.60 90.91 90.91 34.74 33.69 100.00 100.00
Lakshadweep 100.00 100.00 0.00 0.00 100.00 100.00 74.88 73.24 60.00 59.50
Puducherry 300.00 200.00 0.00 0.00 25.00 25.00 45.53 39.54 100.00 100.00
Table A.4.9 (Continued) - Union Territories: Key Inputs/Processes domain indicators, base and reference years
3.1.10
3.1.8 CHC Fund
reporting of reporting of L accreditation accreditation
grading transfer
UTs P form form DH-SDH CHC-PHC
(percentage) (no. of
days)
Andaman &
Nicobar 12 50 5 21 0.00 0.00 0.00 0.00 0.00 0.00 147 78
Islands
Chandigarh 84 78 93 88 100.00 100.00 0.00 0.00 0.00 0.00 68 35
Dadra &
100 91 100 89 0.00 NA 0.00 0.00 0.00 0.00 64 62
Nagar Haveli
Daman & Diu 100 75 86 75 0.00 0.00 0.00 0.00 0.00 0.00 76 0
Delhi 40 57 42 56 0.00 0.00 1.79 8.93 0.00 0.00 92 89
Lakshadweep 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 143 0
Puducherry 82 90 77 88 25.00 25.00 0.00 0.00 0.00 0.00 101 55
90

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Ministry of Health

& Family Welfare

Healthy States, Progressive India

Table 2.1 - Categorization of States and UTs 12

Table 4.1 - Larger States: Overall performance in reference year - Categorization 22

Table A.2.1 - Original Health Index indicators: A snapshot 73

Background and Methodology

Kerala 76.55 80.00 -3.45 1 21

Punjab 62.02 65.21 3.19 2 6

Tamil Nadu 63.28 63.38 0.10 3 15

Mizoram 71.27 73.70 2.43 1 4

Lakshadweep 56.23 65.79 9.56 1 1

Chandigarh 52.27 57.49 -5.22 2 6

Delhi 48.05 50.02 1.97 3 4

Daman & Diu 36.10 44.77 -8.67 6 7

Dadra & Nagar Haveli 31.34 34.64 3.30 7 3

Incremental Performance Overall Performance

Aspirants Achievers Front-runners

Moderately Improved Bihar Chhattisgarh Punjab

Incremental Performance Overall Performance

Aspirants Achievers Front-runners

Not Improved Tripura Sikkim -

Moderately Improved - - Mizoram

Most Improved - Manipur -

Incremental Performance Overall Performance

Aspirants Achievers Front-runners

Not Improved Daman & Diu Chandigarh -

Least Improved - Delhi

Moderately Improved Dadra & Nagar Haveli Andaman &

Most Improved - Lakshadweep

Overview – evolution and rationale

3. To build transparency through independent validation of data by an independent agency.

2.3 SALIENT FEATURES

• A composite Index is calculated as a weighted average of various indicators, focused on measuring

2.4.1 Computation of Index scores and ranks

(Maximum value – Xi) x 100

where Wi is the weight for ith indicator.

2.4.2 Categorization of States for ranking

Category Number of States and UTs

This categorization was adopted due to the following reasons:

2.4.3 The Health Index - List of indicators and weightage

Larger States Smaller States Union Territories

Health Key Outcomes 5 500 1 100 1 100

TOTAL 24 1130 20 730 19 680

S. No. Indicator Definition Data Source Base Year (BY) Remarks

1.2.2 Proportion of Proportion of deliveries conducted in public HMIS BY: 2014-15

Sub-domain 2.2 – Governance (Weight – 60)

DOMAIN 3 – KEY INPUTS/PROCESSES

Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 200)

2.5 LIMITATIONS OF THE INDEX

NITI Aayog States Technical Mentor Agencies5 Independent Validation

3.2 PROCESS FLOW

Table 3.2 - Timeline for development of Health Index

Sr No. Step/Activity 2016 2017-18

3.2.2 Regional workshops with States

Region Venue Date States/UTs

3.2.3 Submission of data on the portal

Centre for Innovation in Public Systems (CIPS) Andhra Pradesh, Telangana

The Energy Research Institute (TERI) Delhi

3.2.4 Independent validation of data

DESK REVIEW Interaction with Documenting Field Visits to

FLV - First level verification, SLV - Second level verification

3.2.5 Index and rank generation

Performance of Larger States