India faces formidable challenges not only in implementing national health and nutrition goals, but also in tracking its progress towards those targets.
Abstract
India has made it clear that its development goals will be in alignment with the Sustainable Development Goals (SDGs), as NITI Aayog prepares the vision document for the country’s development for the 15 years beyond the Twelfth Five-Year Plan. The global success of SDGs over the next 15 years will depend, to a large extent, on India’s performance. However, India is faced with formidable challenges not only in implementing its national health and nutrition goals, but also in tracking its progress towards those targets. In July 2016 the Observer Research Foundation organised a panel discussion on the subject, titled, “Better Data for Better Health: Developing an Indian Approach on Indicators to Achieve SDGs”. This Special Report draws policy lessons built around the key themes shared during the event. A longer paper is in progress.
As India prepares to implement its national targets informed by the SDGs, there are apprehensions that the reporting burden — which already appears heavier than that during the previous MDG era — might take away from implementation capacity, which is weak to begin with. India’s diverse statistical system needs a transformation based on cross-coordination, rationalisation, and technological innovation.
In early 2016, around 200 countries agreed in principle on a global indicator framework as a starting point for the 2030 Agenda and the Sustainable Development Goals (SDG). The 17 goals and 169 targets of the SDG framework are complemented by 230 indicators, representing a five-fold increase from the 48 indicators of the Millennium Development Goals (MDG).
As India joins the global community in the pursuit of the SDGs, it faces the twin burden of implementation and official data capture. Since the 1970s, various studies of India’s health sector have shown that a third of field workers’ valuable time is often eaten up by the task of maintaining registers and records. Over the years, these trade-offs have had a negative impact on the quality of data captured by the health system.
This systemic weakness has been acknowledged by a succession of Indian governments. The National Health Policy of 2002 recognised the dire need for systematic and scientific population health statistics. Initial assessments have identified several key issues such as lack of information on non-communicable diseases and injuries, dearth of primary data on causes of death, lack of private health sector numbers, and insufficient district-level data.
Another issue is the policy relevance of the numbers that are produced. Current data on health workers, for example, are inadequate: while information is available on those employed in public health facilities, there is insufficient data on the large numbers in private practice. Professional registries are of limited use, as they do not reflect retirement, death or migration of health professionals. In this context, the Census remains a highly useful but underutilised resource. In 2016, the World Health Organization published the first definitive report on state-level health workforce in India. As it is based on Census 2001 data, however, it has lost its policy relevance, other than to function as a useful baseline. There are no known plans so far to analyse the 2011 Census data.
The MDG framework of vertical goals has contributed to a fragmented approach. This time, the SDG framework attempts to overcome this anomaly with a broader set of goals. To understand the huge regional, inter- and intra-state disparities and remedy them, large amounts of new information will be required. Given existing constraints within the system, a ‘data revolution’ is needed in terms of making disaggregated data publicly available, if India is to achieve—or get anywhere near—the ambitious SDG targets related to health and nutrition. The following are specific recommendations to streamline and build on the existing national statistical infrastructure to facilitate such a revolution.
1. Transform Civil Registration and Vital Statistics (CRVS) systems
The World Health Organization (2015) has observed that unlike other data sources such as censuses and household surveys, the Civil Registration and Vital Statistics (CRVS) systems permit continuous production of statistics even for local administrative subdivisions. It therefore provides more accurate information, and in turn, clearer ‘denominators’ for assessing progress across sectors.
India relies on sample registration and surveys to track mortality-related goals because of the inadequate coverage of its Civil Registration System (CRS). The National Population Policy 2000 had set the goal of achieving universal birth registration by the year 2010. While the country has made considerable improvement, the nationwide coverage is inadequate for informing decision-making. There are 28 States/UTs where the coverage of birth registration is more than 90 percent and 17 States/UTs where the coverage of death registration is more than 90 percent, according to official estimates (See Figure 1).
Figure 1: Coverage of Birth and Death Registration in India (2013)
Only eight States/UTs have achieved the target of 90 percent in both birth and death registration, with 17 having reached 100-percent birth registration and 11, 100-percent death registration. Overall, birth and death registrations in India stood at 85.5 percent and 70.7 percent, respectively, in 2013. Inter-state differences are sharp: For example, if Bihar and Uttar Pradesh are excluded from the analysis, the national coverage of registration of births is at 96.8 percent and that of deaths, 85.2 percent.
The proportion of female birth registration is 47 percent and death registration, just 42 percent. Barring certain states, there is no evidence of selective under-registration of female births in CRS. Still, more research is necessary in the case of mortality—after all, the proportion of infant deaths registered in rural areas is a low 33.1 percent. A reason could be that deaths are registered at the place of death rather than at the place of residence. There is strong evidence of poor registration of infant deaths; 22.48 million births were registered in 2013 and the registered number of infant deaths was 188 thousand (187,689)—or less than nine infant deaths per 1000 births, which is quite low given India’s IMR, which is 40 according to SRS 2013. Research should be conducted to find the extent to which gender or regional variance represent a relatively low probability of registration for women or those from rural areas.
NFHS rounds have reiterated rural-urban differences in birth registration, while gender-based differences are not seen across the country, barring exceptions like Rajasthan. Studies show that inequities based on income are a major constraint in achieving universal registration. Further, there is a need to standardise actual registration processes to facilitate cross-coordination. As things are, registration is done by officials from different state departments—ranging from police to health, to revenue.
In 2014, India announced a “Vision 2020” plan, aiming to achieve universal registration of births and deaths by the year 2020. Given current trends in the low-performing states, this goal appears farfetched. However, the initiative to integrate the National Population Register (NPR) – which is set to be completed in December 2016 – with CRS offers transformative possibilities. Efforts to universalise birth and death registration, as well as integrate existing databases like the Census, NPR and CRS systems at the sub-district levels, can help track at-risk population in small areas.
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