The release of the 'Healthy States, Progressive India' report by Niti Aayog recently is a welcome step towards developing a comprehensive annual systematic tool to measure, monitor and understand the country's performance in healthcare. It promises that this health index report would act as a reference point to monitor future progress in health and as a tool to monitor and guide healthcare intervention at the national level to achieve National Health Mission goals as well as the United Nations' Sustainable Development Goals. In this context, it would be interesting to cautiously and critically study the report, and the indices generated for the states and Union Territories.

The report ranks Kerala, Punjab and Tamil Nadu on top in terms of overall performance, and Jharkhand, Jammu and Kashmir and Uttar Pradesh as the top three states in terms of annual incremental performance, although admittedly from a lower base than at which the top performing states are. The policymakers and health planners also believe that this health index will not only act as an indicator of performance but also motivate states to compete and improve health outcomes. In this direction, Niti Aayog is also in the process of ranking all 730 district hospitals in the country based on their performance  with an avowed "name and shame strategy", which may be linked to hospital personnel's career growth and promotion, which is a good sign.

However, it would be interesting to see the response and strategies of health administrators, particularly in states like Bihar, Jharkhand, Uttar Pradesh and others, where the health system is struggling with lack of human resources, health infrastructure, supplies, and corruption, poor leadership and lack of political will. In this scenario, there is all likelihood of false and fudged data reporting by the district and state officials to meet the pressure on them to perform. Thus, a continuous reality check on data provided by the states will be an important issue.

It would be interesting to study the case of Jharkhand, which tops the list with a score of 6.87 with respect to incremental improvement in its key health indicators during 2014-15 (base year) and 2015-16 (reference year). According to the Rural Health Statistics reports of 2014, 2015 and 2016, there were significant and constant shortfalls of health infrastructure and human resources in Jharkhand. The same report also shows infrastructure shortfalls of 35% in Sub-Centres, 66% in Primary Health Centres, and 22% in Community Health Centres, which remained constant during 2014-2016.

Besides, one can also observe a significant lack of health personnel during the base year (2014-15) and reference year (2015-16), when the human resources shortfall over the two years was almost the same for Health Workers (male) at Sub-Centres (90.2% and 88.5%), Health Assistants (female) at PHCs (95.1% and 94.2%), Health Assistants (male) at PHCs (91.7% and 94.2%), Specialists at CHCs (83% and 83.8%), Radiologists at CHCs (69.1% and 79.3%).

In such a scenario, where, the state is struggling with the issues of supply, corruption, lack of health infrastructure and human resources, it would be interesting to examine and study the circumstances, strategies and steps taken by the state government which led to this incremental change in the Niti Aayog's health index. One of the possible reasons for this performance may be false reporting under pressure, where the district teams and health personnel were told to show enhanced performance numbers in their districts, even at the threat of termination in some cases. Thus, a reality check of the health index prepared by NITI Aayog with technical support from the World Bank, and in consultation with the Ministry of health and Family Welfare, is needed.

Besides, poor incremental performance of states also needs examination. Particularly, the factors responsible for their low performance on selected indicators. These state-specific studies and reflections will help states to improve their performance and design targeted interventions.

The report shows that the states with better literacy, nutrition and primary health care system have achieved the best scores and ranks. Thus, there is a need to focus on holistic and inter-sectoral convergence between the line departments such as health, education, social welfare, etc., to enhance its ranking. Besides this, to achieve the desired results, both the Centre and the state governments have to increase budgetary allocations and invest more on healthcare in accordance with their performance and required domain-specific targeted interventions. Especially, when health is a state subject, the efficiency of the state administration will reflect on what results are achieved.

This initiative is a beginning and will have some positive impact in the future. Nevertheless, we also need to understand and address intra-state inequalities in healthcare, which is crucial if we are to meet the National Health Mission and Sustainable Development Goals in the coming years.

(The writer is Associate Professor, Xavier Institute of Social Service, Ranchi, and Adjunct Additional Professor at the Global Institute of Public Health, Thiruvananthapuram, Kerala)