India’s Poorest States Need Special Healthcare Focus – One Size Won't Fit All

There is a wide gap between the top-performer, Kerala, and the states at the bottom of the list, Bihar and UP.

Good health is vital for human life and the development of society. This interlinkage was explained by Michael Grossman (1972) in a model, which shows that an individual consumes healthcare to improve their stock of health, which, in turn, is translated into a productive resource. A World Bank report (1993), Investing in Health, considered public health as a public good and warned against the deleterious effect of poor health on individuals and households; it also stated that better health translates to economic progress at a national level.

The World Health Organization (WHO) has also established the causality between health and economic development, which was observed by Amrtya Sen (2002) as the core element of social justice. The United Nations (UN) prioritised health in its ambitious international agenda of Millennium Development Goals (2000-2015) and Sustainable Development Goals (SDGs)-2030.

Kerala vs Bihar and UP

Health is at the heart of SDGs. But the success of SDGs also, to some extent, relies on India’s performance, where 27.9 per cent of people live under multidimensional poverty (MPI). In turn, India’s triumph depends on the performance of its states. The dismal health indicators of most populous states like Uttar Pradesh and Bihar hamper the progress of human development and are a big hurdle in the attainment of SDGs at the national level.

There is a wide gap between the top-performing state, Kerala, and the states at the bottom of the list, ie, Bihar and Uttar Pradesh. Three consecutive reports published by NITI Ayog – Best Practices in the performance of District Hospitals, MPI Report (2021) and Health Index Report (2021) – highlight the unequal public health infrastructure across the country. The objective of the reports is to measure states’ performance vis-à-vis the UN mandate of SDGs.

The first report examines health infrastructure at the district level. Functional hospital beds are a significant indicator of health infrastructure. WHO guidelines suggest that there should be two to five beds for 1,000 people; the Indian Public Health Standard (IPHS) recommends 22 beds against a population of 1 lakh. Bihar and Uttar Pradesh, with six and 10 functional beds, respectively, are far below the national average of 24 functional beds; the availability of functional beds in Kerala is 22, satisfying the IPHS recommendation.

The IPHS also assessed district hospitals in states and UTs. Uttar Pradesh accounted for 150 district hospitals, which is 21 per cent of the total district hospitals that exist in India. An estimated 28.57 districts hospitals in Kerala met the IPHS norms of position doctors, ie, per bed more than or equal to one doctor, against 8.33 per cent in Bihar and 16 per cent in Uttar Pradesh districts hospitals.

Hospitals in Bihar and Uttar Pradesh are struggling with a shortage of nurses and paramedical staff. Only 10.1 per cent of hospitals have all-support services in Uttar Pradesh.

Why Health Is in the State List

The third report, the Health Index of Indian State, repeats the same story. States with sound health infrastructure have been able to reduce the Neonatal Mortality Rate (NMR), Under-five Mortality Rate (U5MR), and improve Sex Ratio and full immunisation. The SDG3 has set a target of reducing the NMR below 12 per 1,000 live births.

In 2018, Kerala, with 5 NMR and 10 U5MR, was far ahead of Uttar Pradesh and Bihar with 32 and 25 NMR, respectively, and 47 and 37 U5MR, respectively.

The skewed sex ratio at birth also raises concern for gender parity. This lopsided trend of NMR, U5MR and sex ratio has continued up to 2021. Uttar Pradesh and Bihar need some serious catching-up to meet SDG3 targets.

Weak health infrastructure has also led to human deprivation in several forms. Good health fuels the development process. A healthy worker can work for longer hours, lives long, saves more and invests in asset creation. The argument is justified in the MPI report: in Bihar and Uttar Pradesh, 51.92 per cent and 37.79 per cent of the population, respectively, still lives under multidimensional poverty, against the 0.73 per cent in Kerala.

However, mere equal distribution of healthcare may not help in raising the well-being of the poor if income distribution is uneven. The health requirement of an individual differs from one state to another, depending on the environment, source of livelihood, and so on. The architects of the Indian Constitution understood that every state of India has a unique set of problems and potential. Consequently, they made arrangements for power distribution between the Union and states under the seventh schedule (Article 246). Public health and sanitation, hospitals and dispensaries, come under the State List. States are responsible for making programmes and policies related to health and well-being.

The Aspirational Districts Programme Hasn't Yielded Results

The functioning of a state’s health programmes depends on its financial health. The Union government is expected to work cooperatively to generate coherence between the Union and states. The erstwhile Planning Commission and the National Development Council (NDC) were founded to look after the development initiative of India. Now, the Planning Commission has been replaced with NITI Ayog to facilitate cooperative federalism, and the NDC has become defunct after the abolition of the Planning Commission. Therefore, the chances of backward states getting special treatment through special status have dwindled.

Unlike the earlier arrangement, in 2018, the government of India launched the Aspirational District Programme, a centralised approach towards mainstreaming the development process of backward districts. The scheme covers backward regions in states such as Bihar and Uttar Pradesh, along with Odisha, Jharkhand and Chhattisgarh. The experiment has not yielded the expected results so far.

The UNDP (2020) report suggests that since most of the selected districts lack human resources and technical capacity, such disparities among districts restrict fair competition.

Inequitable but efficient distribution of resources may not be desirable, or even sustainable, politically. Recognising the asymmetric structure of the Indian Union, the government should think about decentralisation and providing special treatment to backward states so that they can mainstream development policies.

(Utsav Kumar Singh is assistant professor of Economics at Shaheed Bhagat Singh College, University of Delhi. This is an opinion article and the views expressed are the author's own. The Quint neither endorses nor is responsible for them.)