Author : Tanoubi Ngangom

Expert Speak Health Express
Published on Jul 21, 2016
Measure to act: Tracking the health #SDG targets

India has had limited success in realising the health Millennium Development Goals (MDGs). The country missed the mark on both MDG 4 (child mortality) and MDG 5 (maternal health). According to the 2015 MDG country report, India is ‘moderately on-track’ in reducing child mortality and ‘slow or off-track’ in improving maternal health. Adequate checks and balances must be in place to ensure the timely achievement of the targets set under the sustainable development goals (SDGs) — the second-generation development goals. This requires an effective national follow-up and review apparatus that allows policy-makers to routinely track progress, and make necessary mid-course corrections. Central to this exercise is the creation of an indicator framework supported by robust statistical data.

Given India’s traditional strategy of planned development through stringent progress measurement policies, the country already has access to data on a range of socio-economic parameters. Under the Census Act 1948, Independent India has been conducting the decennial Census since 1951; the National Sample Survey Office (NSSO) has been carrying out annual sample-based surveys since 1950; initiated in the early 1990s, the National Family Health Survey (NFHS) collects demographic data with a focus on reproductive, maternal, new-born and child health (RMNCH). Demographic recording systems, such as the civil registration system (CRS), the sample registration system (SRS), and the recently introduced the Health Management Information System (HMIS), also provide a large pool of health data.

Despite the abundance of data sources, there is a dearth of data collection systems that make the cut. As the NITI Aayog and the statistics ministry (MOSPI) prepare to roll out the national SDG indicator framework, they must work towards tackling five fundamental issues that Indian statistical structure must overcome: data gaps, irregular periodicity, incomplete coverage, the lack of equity-sensitive tracking and the need for supplementary indicators.

Data on lower geographic levels is generally absent for most health indicators. For instance, sample-based data aggregations – such as the NSSO and SRS — do not provide district-level data. The NFHS, India’s largest health survey too, did not generate district-level estimates until the latest round (NFHS-IV). Even at the state-level, information on certain major indicators is still missing: MOSPI’s primary source for health statistics — the SRS — publishes MMR (maternal mortality rate) for only 15 of the 29 states. Indian states are at varied stages of economic and social development: the 2015 MDG country report shows that MMR for Assam was almost five-fold that of Kerala. Thus, overall target achievement calls for targeted intervention based on reliable geographically disaggregated data.

Second, the different rounds of the data collection systems tend to have long gaps and also suffer from irregular intervals. For example, in the case of the NFHS, the second round was conducted six years after the first; the next round with a seven-year gap; and the latest will be published after a break of at least nine years. The NSSO morbidity rounds follow a similar trend. Effective statistical tracking is contingent upon the availability of reliable data at regular junctures. The UN Office of Internal Oversight Services (OIOS) recommends evaluations to be carried out every five years, and monitoring at even smaller intervals. The Indian government recognises this challenge and is working on addressing it: the recent decision to conduct the NFHS every three years is a step in this direction.

The third point deals with the coverage of the data sources — an issue that has large implications for reliability of estimates. A Central Government Act mandates the registration of all births and deaths in India via the CRS. Registration, however, is rarely carried out and, hence, the CRS suffers from acute incomplete coverage — so much so that an interim sample-based recording system (the SRS) had to be introduced to fulfil the role of the CRS. The discrepancy between the CRS and the SRS estimates illustrates this point: calculations (made by the author) as per the latest CRS report shows that India’s infant mortality rate (IMR) in 2013 stood at 8 as opposed to the SRS estimated figure, which was 40. Certain statistics also suffer from selective coverage. For example, the absence of data for private health institutions considerably limits the usability of the HMIS.

Ensuring inclusive progress is a priority concern at the global SDG platform as well as in India’s national agenda. For a population like India — that exhibits enormous socio-economic disparity — this requires tracking of data disaggregated across geographies, social groups, religious groups, income-levels and between sexes. The Indian MDG tracking framework provided gender-wise and residence-based (rural-urban) analyses. Given the ambitious nature of the SDGs, the incorporation of even more stratifiers would definitely facilitate a more inclusive realisation of the health targets. Because most data sources, such as the NFHS and the NSSO, already collect such disaggregated information, incorporating them into the SDG framework can be carried out with relative ease.

Primary indicators for the health targets must also be accompanied by auxiliary indicators. Certain key measures, like the IMR and the MMR, present the degree of improvement or deterioration, and hence signal for policy corrections when required. The remedial measures can, however, only be carried out through a nuanced understanding of the underlying causes. For instance, rectification of the sluggish reduction of MMR calls for information on the factors leading to maternal deaths. Thus, each primary indicator must be assigned a set of supplementary indicators that help identify specific problem areas.

While these challenges may seem daunting, most of the groundwork has been laid out. The strengthened NFHS addresses many of the core issues; the existence of multiple, fairly detailed, data sets means that disaggregated tracking can be carried out easily. The remaining gaps can be plugged with a little political will: in this light, last month’s announcement regarding the introduction of a 15-year vision document for India’s achievement of the 2030 development goals is a welcome sign.

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Tanoubi Ngangom

Tanoubi Ngangom

Tanoubi Ngangom is a Chief of Staff and Deputy Director of Programmes. Tanoubi is interested in the political economy of development — the evolution of global ...

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