In a recently released NITI Aayog health index report, titled ‘Healthy States, Progressive India’, Tamil Nadu was ranked third for its overall performance with regard to health.
However, the report also highlighted some key challenges the state faces, which need to be addressed immediately, chief of which is the drop in sex ratio in the state.
The other major problem areas the report addressed are the decline in immunisation the state is seeing and the number of functional 24X7 primary healthcare centres in the state.
The report, according to NITI Aayog, is a weighted composite index based on indicators in three domains: health outcomes (70% weightage), governance and information (12%), and key inputs and processes (18%).
The report is important as the first study that attempts to make sense of the various complex healthcare systems across Indian states and Union Territories.
Sex ratio at birth
“Keeping track of the number of girls born for every 1000 boys born during a specific year is important as it points to any sex selective abortions and female infanticide in practice,” says the report.
From the base years of 2012-2014 to 2013-2015, Tamil Nadu has seen a dip in sex ration, from 921 to 911 females to 1000 men.
However, according to Health Secretary J Radhakrishnan, the state saw an improvement in the 2016-17 period. He still admits this is a cause for concern.
“We still have to tackle pockets of challenges where there is female infanticide. It is an area of work we can link up with social welfare and anganwadis,” he says.
On the other hand, Tamil Nadu’s Total Fertility Rate or the average number of children born per woman has achieved the target of over 2.1 for the year 2015.
Primary Health Centres in TN
PHCs form the bedrock of healthcare delivery in rural areas. While cities and towns are amply provided with government hospitals, rural populations’ first point of healthcare access remain primary healthcare centres that are, ideally, equipped to handle basic emergencies, deliveries, immunization programs, etc.
While the NITI Aayog report claims that PHCs help reduce the workload at higher level facilities, Health Secretary J Radhakrishnan views this differently.
“Tamil Nadu is a state where we are seeing a transitional shift. The problem with the classification is that in northern states don’t have the concept of sub-district hospitals. Tamil Nadu is unique in having taluk and non-taluk hospitals, which run 24x7, and there are 30 bedded PHCs which also run round the clock. Even in the remaining PHCs, the doctors are there till the evening and the rest of the time the nurses take care,” he says.
When asked about a possible rural-urban divide reflected in the study, the Health Secretary says, “People generally tend to go to the nearest available higher facility, which is a welcome shift rather than a cause of worry. We should analyse if the shift is happening to the private sector or a better-performing public sector.”
According to Dr Balaji, of the Thondamuthur Block PHC in Coimbatore, “If a PHC is close to their house, the patient would choose to go there first for any emergencies, outpatient treatment or deliveries. If there is anything lacking there, then they come to us as we are better equipped with various schemes and technical facilities.”
“If we are not able to handle major cases, like cardiac surgery, we do an ECG and refer the patients to the government medical college hospital. There is a multi-level system. If not a PHC, the patient will go to another bigger government hospital,” he adds.
The report’s criterion for functional 24x7 PHCs is 10 deliveries per month (5 deliveries per month for hilly and north-eastern states, except Assam). Dr Balaji says block PHCs comfortably meet that target with at least 12 institutional deliveries a month.
He adds that even if a patient does choose to go to a private hospital, the Chief Minister’s Health Insurance program will cover their cost of treatment.
While a block PHC has five doctors, other PHCs have a provision for 2 doctors, who will generally be available between 9 am and 4 pm. The centre itself remains open with staff present round the clock – the report may have not accounted for the heterogeneity of the state’s healthcare delivery systems.
Speaking to TNM, the duty staff nurse at the Kalvarampalayam PHC says, “On average, we see 150 people a day. Because we are near the urban side of town, a lot of the low-income families in the area come to us.”
Pointing out another aspect that report failed measuring, she says, “While we are open for outpatient between 9 am and 4 pm, our delivery services alone are round the clock.”
Communicable and non-communicable diseases
According to the health index report, “non-communicable diseases (NCDs) have emerged as the leading cause of morbidity and death for adults, contributing to 55% of all disease burden and more than 62% of deaths in the country”.
While data for how each state is tackling diseases is not available, this is a priority for TN, which struggled to battle the dengue epidemic last year.
The dip in immunisation from 85.5% points to 82.7% is also a cause for alarm.
Tamil Nadu reported the highest number of dengue cases last year – 22,197.
According to the National Vector Borne Disease Control Programme (NVBDCP) of the Ministry of Health and Family Welfare, while 5 dengue deaths were recorded in 2016, it saw the number rise to 52 in 2017.
While the government admits that this is the next big challenge, it insists, however, that this cannot be tackled without the active involvement of people. “The people have to take advantage of the preventive measures available to them,” says the Health Secretary.
While releasing the report, the NITI Aayog said that the index would be linked to incentives under the National Health Mission, which underlines the importance of such an exercise.
The NITI Aayog is also set to bring out a ranking of 730 district hospitals based on their performance.