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Fourth edition of state health index released by NITI Aayog

The National Institution for Transforming India, Government of India (NITI Aayog), released the 4th edition of Healthy States, Progressive India: Report on the rank of states and Union Territories on 27 December 2021.

The Vice Chairman of NITI Aayog, Dr Rajiv Kumar, released the report in the presence of the Chief Executive Officer, Mr Amitabh Kant, Additional Secretary, Dr Rakesh Sarwal, and Ms Sheena Chhabra, the Senior Health Specialist at the World Bank.

The 198-page report, whose focus is on the overall performance and year-on-year incremental improvement with regard to health outcomes of the 28 states and 8 Union Territories of the nation, is prepared by NITI Aayog in collaboration with the World Bank and the Ministry of Health and Family Welfare (MoHFW). The report categorizes the states and Union Territories as ‘Larger states’, ‘Smaller states’, and ‘Union Territories’ for better evaluation.

The State Health Index is a weighted composite index with 24 indicators grouped under three domains, namely, ‘Health Outcomes’, ‘Key Inputs/Processes’, and ‘Governance and Information’.

The Health Outcomes domain includes the following parameters—sex ratio at birth, neonatal mortality rate, and under-5 mortality rate; the Key Inputs/Processes domain contains parameters such as the deficit in healthcare providers compared to the recommended numbers, birth and death registration, and tuberculosis treatment success rates; the parameters of the Governance and Information domain include institutional deliveries and the average tenure of senior staff in key healthcare-related posts.

On the annual incremental performance yardstick, the top ranking larger states are Uttar Pradesh, Assam and Telangana. Mizoram and Meghalaya were the best ranked smaller states, and Delhi and Jammu and Kashmir the highest ranking Union Territories.

For the overall ranking for 2019–2020, based on the composite index score, Kerala and Tamil Nadu (larger states), Mizoram and Tripura (smaller states) and Dadra, Nagar Haveli, Daman, Diu and Chandigarh are the best geographical regions.

The data for the report were collected via a NITI Aayog portal, then validated by an independent agency, after which it was shared with the respective states for verification, and final resolutions of any disputes/disagreements. The final data sheets were then shared with all states and Union Territories for their approval. Subsequently, the finalized data were used for preparing the report.

This report, which has been continuously published since 2017, stimulates the 36 entities towards cross-learning, cooperative and competitive federalism, policy-making and resource allotment, enhancing their service delivery, and building a robust health system. Not only are the historical performances of the entities examined, but their incremental performances are also underscored.

The MoHFW has linked the State Health Index reports to various incentives of the National Health Mission, thus highlighting their importance.

There are some limitations in the report. These are: lack of quality data for critical areas such as infectious diseases, mental health, non-communicable diseases, governance, and financial risk protection; data for the Health Outcomes domain (neonatal mortality rate, under-5 mortality rate, sex ratio at birth, etc.) were available only for the larger states; and lack of field verification for certain indicators (e.g. Health Management Information System) as independent field surveys could not be carried out.

Doctors exhort action from government and social media for incidents of violence against doctors in Canada

There have been increasing reports of violence against doctors all over the world in recent times. China is the country where most such incidents of violence occur, and India too (Pai SA. Natl Med J India 2015;28:214–15) has had this problem. Ironically, this violence seems to have increased during and after the early months of the Covid-19 pandemic, at a time when healthcare workers have been under particular stress and have often worked well beyond their expected capacities. Canada provides the latest example of such violence. There has been verbal abuse, online abuse, incidents of violence and death threats and, in an extreme case, death. Walter Reynolds, a family physician in Alberta was bludgeoned to death by a patient in August 2021.

Violence against doctors in Canada is not new. There have been reports of minor and major abusive incidents for more than a decade. A survey done among primary care physicians in 2017 showed that about one-third of them had faced abuse in the past month. Another survey revealed that 68% of nurses and related workers in Ontario had faced violence on the job in the past one year.

A remarkable episode came to light when Ezra Levant, a conservative mediaperson, offered a reward of Canadian $5000 to anybody who filmed and sent a video of two specific doctors breaking Covid rules—merely because the doctors in question had been promoting standard Covid rules, such as avoiding holiday crowds, etc. Twitter Canada refused to see this act as stalking or harassment and defended their policy to host the tweet. (The tweet, however, was later taken down.) When Katherine Smart, President of the Canadian Medical Association criticized the tweet, she too was the target of abuse.

The Canadian Medical Association (comprising 70 000 doctors) and the Ontario Medical Association released a statement on 3 September 2021 on bullying, attacks and violence against health workers, which stated: ‘We have confronted uncertainty, exposed ourselves to risks, and worked prolonged hours, weeks and months all in support of our patients and the public we serve. We have not signed up for bullying, attacks and violence…’ Physician groups in Canada have demanded that the government introduce laws to protect healthcare workers and punish those who break such laws. They have exhorted social media sites to rein in their users and to stop online bullying.

An editorial in the Canadian Medical Association Journal in 2017 (Sibbald B. CMAJ. 2017;189:E184) had stated what is true even today: ‘Workplace violence is not a part of a doctor’s job.’

Large increase in the number of medical colleges being accorded recognition by NMC/MCI during 2019–2021

As per the data placed before Parliament during question hour, it has been stated that, during 2019–21, a total of 124 medical colleges across India were accorded recognition by the National Medical Commission (NMC). Of these, 66 medical colleges have been recognized in 2021, 26 in the year 2020 and 32 in the year 2019 (by the erstwhile Medical Council of India [MCI]). In 2021, the maximum number of medical colleges that got recognition by NMC were from Uttar Pradesh (11), followed by Karnataka and Telangana (6 each); Maharashtra and Andhra Pradesh (5 each); and Chhattisgarh, Tamil Nadu, Gujarat, Rajasthan and West Bengal (4 each). It has also been stated that there were 558 medical colleges/institutions in the country and that there has been an increase in the number of MBBS seats in India by 53.2% from 54 348 seats in 2014 to 83 275 seats in 2020.

In Andhra Pradesh, 14 new medical colleges will be established at Vizainagaram, Anakapalli, Rajahmundry, Amalapuram, Palakollu, Eluru, Bapatla, Markapuram, Madanapalli, Penukonda, Nandyal and Adoni (with intake of 150 MBBS students per year); and Pulivendula, Paderu, Machilipatnam (with intake of 100 MBBS students per year).