Is national health care enough? Infant mortality data suggests a growing disparity amongst states

In 2005, India launched the National Rural Health Mission, a ground breaking government scheme intended to improve access to basic healthcare. Comparing one progress on one crucial indicator [What does this mean?]—infant mortality rate—from 2006 to 2012 reveals a troubling picture. Far from being a national initiative that brought health care to all, the Swaniti Initiative’s analysis shows that none of the poorly performing states were able to achieve a rate ofsaw a decline in infant mortality close to what the best performing states achieved. In other words, the interstate inequity grew between 2006 and 2012, despite the fact that NRHM provides additional funding to states with poorer outcomes. This data raises the question: what is required to reduce the disparity in infant health amongst states?

Reducing infant mortality is an critical priority, one that India committed to achieving when it signed the UN’s Millennium Development Goals in 2000 and which the NRHM’s special focus on maternal and child health is intended to address. Data from the national government’s Planning Commission shows that the infant mortality rate (IMR), or the rate at which children under the age of one die, declined nationally from 57 per 1000 live births in 2006 to 42 per live births in 2012. Even in 2012, one out of twenty four infants died before the age of one.  A close analysis reveals a growing interstate bifurcation in progress towards a reduced IMR.

The graph below shows data from the seven states with the highest IMR in 2006. All of these states saw consistent declines over the past six years, though the declines were insufficient to put these states on track to reach international targets, set when India signed the UN’s Millennium Development Goals. Moreover, none of the rates of decline below matched the speed of decrease achieved by the seven highest performing states.

Trends in IMR from 2006-2012:

Progress of the seven states with the highest IMR in 2006

State

2006 IMR

2012 IMR

% Decrease in IMR from 2006-2012

Bihar

60

43

-28%

Odisha

73

53

-27%

Rajasthan

67

49

-27%

Uttar Pradesh

71

53

-25%

Madhya Pradesh

74

56

-24%

Chhattisgarh

61

47

-23%

Assam

67

55

-18%

Data taken from the Planning Commission

*States and union territories with a population below 5 million were not included.

Assam continues to lag far behind the other six states with the highest IMR in 2006 and the smallest decrease, of 18 percent between 2006 and 2012. Every other state decreased its IMR between 23 and 28 percent over the six year period.


Progress of the seven states with the lowest IMR in 2006
Trends in IMR from 2006-2012:

State

2006 IMR

2012 IMR

% Decrease in IMR from 2006-2012

Tamil Nadu

37

21

-43%

Punjab

44

28

-36%

Delhi

37

25

-32%

Maharashtra

35

25

-29%

Uttarakhand

43

34

-21%

West Bengal

38

32

-16%

Kerala

15

12

-13%

Data taken from the Planning Commission

*States and union territories with a population below 5 million were not included.

The contrast between these two groups becomes starker when looking at the progress the states with the lowest IMR in 2006 achieved in the past 6 years. Out of the seven states with the lowest IMR in 2006, four achieved a decrease of 29% or more of their IMR. None of the seven states with the highest IMR in 2006 were able to achieve a decrease this rapid. The data itself is grim: the current infant mortality rate in Assam is over two times as high as the rate in Delhi, Tamil Nadu, Maharashtra, and Kerala.

Swaniti Initiative’s analysis of state-level IMR data from 2006-2012 suggests a growing national inequality in infant health. While the best-performing states are improving their already-superior health

outcomes rapidly,  poorer-performing states are improving their poor health outcomes slowly, ever-widening the gulf between both groups of states.

Why did the NRHM fail to deliver on its promise of making health outcomes equitable in India? Infant mortality is impacted by a host of factors, including access to nutritional food, sanitation, or good housing. In other words, simply improving healthcare is insufficient to address the structural causes of high infant mortality. Presumably, in 2006 high performing states were already better at addressing the structural causes of infant mortality and continued to improve over these six years. In contrast, poorly performing states received insubstantial support under NRHM to tackle structural causes of infant mortality. Moreover, the institutional causes of poor health outcomes in the states with high IMR—such as poorly run district-level health facilities or a shortage of qualified doctors—likely persisted under NRHM.

When it was implemented, NRHM was hailed as an ambitious initiative that had the potential to end national health disparities. In retrospect, the question must be asked: was it ambitious enough?  As the new government moves towards implementing a national health insurance scheme, the National Health Assurance Mission, for all Indians, it is critical to examine whether a national health policy alone is sufficient to address the troubling health gap amongst states.