Indian Institute of Management scholars find huge gaps in Gujarat’s health performance indicators vis-a-vis other states

performanceBy Counterview Desk

A new working paper by two Indian Institute of Management-Ahmedabad (IIM-A) scholars, Shreekant Iyengar and Ravindra H. Dholakia, “What Determines Performance Gap Index (PGI) of Healthcare in Gujarat?” has found that huge “performance gaps” existing in several of the health indicators in Gujarat, which has long been projected as “model state” for others to follow. Attempting “a comparison of the health performance of Gujarat relative to the best and the worst performers over time by constructing a PGI”, the scholars seek to do this “by measuring a gap of performance on each of the health indicators to show the relative standing of the state”. Suggesting how the gap is measures, they underline, “The gap would indicate the distance that Gujarat has to cover to reach the best performance in the country in each indicator. A higher value of this index indicates more gap from the best and thereby a relatively poorer performance of Gujarat.”

The scholars find that PGI of Gujarat for expectancy of life at birth for males and females show a “gap of respectively 44 per cent and 41 per cent from the top performer”, but is much higher when it comes to infant mortality rate (IMR) and neo-natal mortality (NN) and under five mortality (U5MR) — 63 per cent, 56 per cent and 59 per cent, respectively. These gaps are “far more than the gaps for the total fertility rate (36 per cent), and the birth and the death rates (52 per cent and 27 per cent)”, they point out, adding, “It is only the maternal mortality (MMR) where the performance gap is low at 22 per cent putting Gujarat relatively near to the top performer.”

The scholars also find huge gaps in malnourishment and coverage of children under immunization. “The gap for stunted and underweight children is 84 per cent and 62 per cent respectively which is very high considering that Gujarat is income wise among the better off states in the country… The gaps for wasted children and children born with low birth weights are relatively low but still substantial. It has been observed that Gujarat was one of the eight major states that account for 77 per cent of the undernourished children in the country”, they say.

Then, “A substantial performance gap (36 per cent) also exists in terms of percentage children born with low birth weight (< 2.5 Kg). Low birth weight could increase the risk of neo-natal deaths, which contribute significantly to IMR and U5MR. Moreover, it also points to the nutritional deficiencies existing among pregnant women. It is also believed that children of mothers suffering from undernourishment and energy deficiency tend to have greater risk of being malnourished. Thus, improving the nourishment levels not only among children but also among mothers through significant nutrition interventions could be instrumental in reducing the gaps in the mortality indicator of the state.”

As for the immunization indicators, the scholars say, these “also show wide gaps in coverage under DPT and Measles at 52 per cent and 49 per cent respectively.” They underline, “The coverage under polio immunization is extremely poor with almost a 100 per cent gap putting Gujarat at par with the poorest performer. Such a situation despite nationwide polio eradication drives in the country places formidable challenge to the state’s healthcare performance. It is also found that the gap in terms of the percentage children received all vaccinations (i.e. complete vaccination) is relatively greater than the gap for all individual vaccines except polio.”

According to the scholars, “The percentage of children received none of vaccinations in Gujarat is only 4.5 per cent; however, its performance gap as compared to top performer Tamil Nadu (with 0 per cent children with no vaccination) is 39 per cent.” This implies that “a significant effort in improving immunization indicators in the state is required not just in individual vaccines but also for improving coverage of children under complete vaccination. One of the aspects that could be related to better immunization coverage is the existence of the vaccination cards. Gujarat faces a gap of 71 per cent in this aspect with only about one third of the children with vaccination cards in the state. The vaccination cards can provide more accurate information regarding the immunization record than the memory of the parents for individual vaccines.”

Coming to performance gap in the infrastructure availability in Gujarat, the scholars say, it “is relatively less for the number community health centres or CHCs (33 per cent), but is relatively wide for the number of sub-centre or SCs (55 per cent) and primary health centres or PHCs (62 per cent).” According to the scholars, “These gaps could partly be attributed to the norms regarding the required numbers of SCs, PHCs and CHCs as per the Indian Public Health Standards (IPHS). According to these norms Gujarat would require 20 SCs, 3.33 PHCs and 0.83 CHC for every 1,00,000 population. Gujarat already has about 21 SCs, 3.13 PHCs and 0.81 CHCs per 1,00,000 population, which is almost same as required by the norms. However, the gaps exist due to the fact that the best performers in terms these health facilities, Kerala and Chhattisgarh, have relatively higher number of existing infrastructure than required by them as per the average norms.”

Coming to performance gaps in terms of manpower availability (numbers per hundred thousand of population) in the public health system of the state, these are “quite wide in case of paramedical staff and very high in case of the medical professionals”, the scholars say.”The number of ANMs, HAs, LHVs, and staff nurses show large performance gaps ranging from 52 per cent to 83 per cent. The gap for the number of general doctors at PHC is 90 per cent and for the specialist doctors at CHC it is as high as 95 per cent. Moreover, considering the total number of doctors and nurses in the state, we find that the performance gaps are relatively lower at 50 per cent and 45 per cent respectively.” They add, “In fact for the auxiliary nurse midwives (ANMs) the performance gap has more than doubled from 32 per cent during 1998-01 to 83 per cent during 2008-10.”

All this suggests, the scholars say, that the rate of improvement in effectiveness of converting health inputs to health outputs was lower in Gujarat than the average of all major states.” In fact, they point out, “Some of the poor performing states than Gujarat in terms of the actual indicator value and the performance indices have greater effectiveness in conversion of inputs to outputs and outputs to outcomes. For instance Bihar, which is a poor performer absolutely, has above average effectiveness in converting its outputs to outcomes. West Bengal and Maharashtra performed above average and relatively better than Gujarat in converting outputs to outcomes. A relatively poor performer UP had below average effectiveness in converting inputs to outputs during 1998-01 and it reached the average level by 2005-06. Moreover, Haryana and West Bengal which have poorer input indexes have above average effectiveness in converting its inputs to outputs for both the mentioned time periods.”

It also suggests, according to the scholars say, that “the health status of Gujarat has not been very satisfactory in comparison to the other states in the nation. The indicators such as life expectancy and IMR for Gujarat do indicate improvement over time at the absolute level, but the relative standing among other states remained much lower. The life expectancy rose from 57 years in 1981 to about 67 years during 2008-10 and IMR reduced from 115 per thousand live births in 1981 to 44 in 2010 (Government of India, 2002), (RHS – MoHFW, 2012) and (Government of India, 2011). Gujarat’s ranks for these indicators during 2008-10 among 20 major states in the nation, however, were seven and 11 for life expectancy and IMR respectively which meant that other states had done better than Gujarat.”

The scholars say, “Among the other vital indicators such MMR, NN and U5MR Gujarat ranked 6, 13 and 10 respectively during 2008-10, and for birth rate and death rate the ranks were 12 and six respectively (SRS Bulletin, 2011, Government of India, 2011 and Vital Statistics-Indiastat, 2010). Although Gujarat experienced an improvement in these indicators over time, other major states did much better than Gujarat during the same period. “

Coming to health infrastructure, the scholars say, “the number of community health centres (CHCs) per hundred thousand population grew during 1990-93 to 1998-01 but has remained more or less the same in the period after that. The number of total government hospitals (rural +urban) has not changed at all between 1998-01 and 2008-10”, even though “there has been an increase in the number of beds in these hospitals per hundred thousand population.”

performance gap index


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