SDGs: big agenda, big opportunities for India
The year 2016 marks an end of the era of Millennium Development Goals (MDGs), which drove the global development agenda since the new millennium. The MDGs have paved the way for Sustainable Development Goals (SDGs) that the world will strive to achieve over the next fifteen years. It is an opportune moment to reflect on the successes and the lessons learnt from the MDG era and the possible way forward for achieving the ambitious and inclusive agenda of SDGs in the health sector.
Lessons learnt
First, high-level political commitment globally and nationally drove much of the progress towards MDGs. We need nothing less for the SDGs.
Second, while MDGs helped improve the overall health of nations, the focus was on the aggregate targets ignoring inequities within countries. To understand the real progress and challenges there is a need to disaggregate data by gender, economic status and geographical area.
Thirdly, neither the economic benefits of good health nor the direct financial consequences of ill-health were sufficiently captured by MDGs. We know that nations require a healthy population to prosper. When people do fall sick, high out-of-pocket expenditures on healthcare lead to financial hardship and diminish the ability of the population to contribute to the economy. In India, nearly 60 million people fall into poverty just paying for healthcare, while many more abstain or delay seeking healthcare due to financial difficulties.
Fourthly, MDGs did not capture the importance of prevention, early detection and response to disease threats. The growing noncommunicable disease (NCD) epidemic and consequent premature deaths could be prevented by reducing lifestyle risk factors, specifically tobacco use, food intake, inactivity, and alcohol consumption. In addition, diseases like SARS, Ebola, MERS and Zika pose threats to global health security and have the potential to cripple countries. MDGs missed this important issue.
Lastly, it is not only about ‘more money for health, but also more health for money’; the MDGs focused on addressing specific disease and symptoms, which led to fragmentation, duplication and inefficiencies in the health systems. WHO estimates that nearly 20-40 per cent of all health resources are wasted.
The way forward
Unlike MDGs, which had three dedicated health goals, the SDG agenda has only one health goal (SDG-3) which aims to ‘ensure healthy lives and promote well-being for all in all ages’. The 13 broad targets under health goal are in-tune with current global epidemiological reality. Besides the unfinished MDG agenda of reducing maternal and child mortality and tackling the communicable disease, the SDG-3 also aims to tackle the epidemic of NCDs, substance abuse and ill-effects of environmental hazards. Health is also interlinked to several other SDGs related to poverty, gender equality, education, food security, water sanitation etc.
The unprecedented scope of SDGs provides immense opportunity to bring health at the centre of economic growth agenda, which is PM Modi’s topmost priority. Universal Health Coverage (UHC), which is an explicit target under SDG-3, can act as the anchor to guide and inform SDG goals in health.
It is interesting that these thoughts have their roots in what was envisioned by Mahatma Gandhi. He said, “Recall the face of the poorest and weakest man you have seen, and ask yourself if this step you contemplate is going to be any use to him.” It is this thinking, which was reflected in the MDGs and is now even more central in the SDGs.
Towards sustainable development
India can progress towards sustainable development in health if it follows the following five steps.
First, health must be high on the national and state agenda, as it is the cornerstone for economic growth of the nation. This requires high political commitment and collective long-term efforts by ministries beyond the Ministry of Health to invest in health. The proposal in India’s draft National Health Policy 2015 to raise public to health expenditure to 2.5 per cent of the GDP by 2020 is commendable.
Second, India should invest in public health and finish the MDG agenda through further improvements in maternal and child health, confronting neglected tropical diseases, eliminating malaria, and increasing the fight against tuberculosis. For all these challenges, it is clear what needs to be done; programmes and interventions need to be taken to scale, with a central emphasis on equity and quality of services.
Third, accelerate the implementation of universal health coverage. UHC is important to prevent people slipping into poverty due to ill health and to ensure everyone in need has access to good quality health services. To complement tax revenue based health financing, incremental expansion of prepayment and risk pooling mechanisms such as Social Health Insurance are worth considering. UHC is at the core of SDGs and in the interest of people and governments.
Fourth, build robust health system in all aspects and strengthen both the rural and urban components, with comprehensive primary health care at its centre. Given the magnitude of the private sector in India, more effective engagement with private healthcare providers is vital. Appropriate contracting modality, which is an important feature under the Social Health Insurance or RSSY, can be worked out and private sector can be instrumental in complementing the public sector as demonstrated by different country experiences, including Thailand and Philippines.
Finally, develop a strong system for monitoring, evaluation and accountability. It is absolutely essential to regularly review and analyse the progress made for feeding into policy decisions and revising strategies based on the challenges.
In conclusion, the SDGs have the potential to create a world where no one is left behind.
The SDGS also make it possible to achieve what the WHO constitution mandates: attainment by all peoples of the highest possible level of health.
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- In the Large States category (overall), Chhattisgarh ranks 1st, followed by Odisha and Telangana, whereas, towards the bottom are Maharashtra at 16th, Assam at 17th and Gujarat at 18th. Gujarat is one State that has seen startling performance ranking 5th in the PAI 2021 Index outperforming traditionally good performing States like Andhra Pradesh and Karnataka, but ranks last in terms of Delta
- In the Small States category (overall), Nagaland tops, followed by Mizoram and Tripura. Towards the tail end of the overall Delta ranking is Uttarakhand (9th), Arunachal Pradesh (10th) and Meghalaya (11th). Nagaland despite being a poor performer in the PAI 2021 Index has come out to be the top performer in Delta, similarly, Mizoram’s performance in Delta is also reflected in it’s ranking in the PAI 2021 Index
- In terms of Equity, in the Large States category, Chhattisgarh has the best Delta rate on Equity indicators, this is also reflected in the performance of Chhattisgarh in the Equity Pillar where it ranks 4th. Following Chhattisgarh is Odisha ranking 2nd in Delta-Equity ranking, but ranks 17th in the Equity Pillar of PAI 2021. Telangana ranks 3rd in Delta-Equity ranking even though it is not a top performer in this Pillar in the overall PAI 2021 Index. Jharkhand (16th), Uttar Pradesh (17th) and Assam (18th) rank at the bottom with Uttar Pradesh’s performance in line with the PAI 2021 Index
- Odisha and Nagaland have shown the best year-on-year improvement under 12 Key Development indicators.
- In the 60:40 division States, the top three performers are Kerala, Goa and Tamil Nadu and, the bottom three performers are Uttar Pradesh, Jharkhand and Bihar.
- In the 90:10 division States, the top three performers were Himachal Pradesh, Sikkim and Mizoram; and, the bottom three performers are Manipur, Assam and Meghalaya.
- Among the 60:40 division States, Orissa, Chhattisgarh and Madhya Pradesh are the top three performers and Tamil Nadu, Telangana and Delhi appear as the bottom three performers.
- Among the 90:10 division States, the top three performers are Manipur, Arunachal Pradesh and Nagaland; and, the bottom three performers are Jammu and Kashmir, Uttarakhand and Himachal Pradesh
- Among the 60:40 division States, Goa, West Bengal and Delhi appear as the top three performers and Andhra Pradesh, Telangana and Bihar appear as the bottom three performers.
- Among the 90:10 division States, Mizoram, Himachal Pradesh and Tripura were the top three performers and Jammu & Kashmir, Nagaland and Arunachal Pradesh were the bottom three performers
- West Bengal, Bihar and Tamil Nadu were the top three States amongst the 60:40 division States; while Haryana, Punjab and Rajasthan appeared as the bottom three performers
- In the case of 90:10 division States, Mizoram, Assam and Tripura were the top three performers and Nagaland, Jammu & Kashmir and Uttarakhand featured as the bottom three
- Among the 60:40 division States, the top three performers are Kerala, Andhra Pradesh and Orissa and the bottom three performers are Madhya Pradesh, Jharkhand and Goa
- In the 90:10 division States, the top three performers are Mizoram, Sikkim and Nagaland and the bottom three performers are Manipur and Assam
In a diverse country like India, where each State is socially, culturally, economically, and politically distinct, measuring Governance becomes increasingly tricky. The Public Affairs Index (PAI 2021) is a scientifically rigorous, data-based framework that measures the quality of governance at the Sub-national level and ranks the States and Union Territories (UTs) of India on a Composite Index (CI).
States are classified into two categories – Large and Small – using population as the criteria.
In PAI 2021, PAC defined three significant pillars that embody Governance – Growth, Equity, and Sustainability. Each of the three Pillars is circumscribed by five governance praxis Themes.
The themes include – Voice and Accountability, Government Effectiveness, Rule of Law, Regulatory Quality and Control of Corruption.
At the bottom of the pyramid, 43 component indicators are mapped to 14 Sustainable Development Goals (SDGs) that are relevant to the States and UTs.
This forms the foundation of the conceptual framework of PAI 2021. The choice of the 43 indicators that go into the calculation of the CI were dictated by the objective of uncovering the complexity and multidimensional character of development governance
The Equity Principle
The Equity Pillar of the PAI 2021 Index analyses the inclusiveness impact at the Sub-national level in the country; inclusiveness in terms of the welfare of a society that depends primarily on establishing that all people feel that they have a say in the governance and are not excluded from the mainstream policy framework.
This requires all individuals and communities, but particularly the most vulnerable, to have an opportunity to improve or maintain their wellbeing. This chapter of PAI 2021 reflects the performance of States and UTs during the pandemic and questions the governance infrastructure in the country, analysing the effectiveness of schemes and the general livelihood of the people in terms of Equity.
Growth and its Discontents
Growth in its multidimensional form encompasses the essence of access to and the availability and optimal utilisation of resources. By resources, PAI 2021 refer to human resources, infrastructure and the budgetary allocations. Capacity building of an economy cannot take place if all the key players of growth do not drive development. The multiplier effects of better health care, improved educational outcomes, increased capital accumulation and lower unemployment levels contribute magnificently in the growth and development of the States.
The Pursuit Of Sustainability
The Sustainability Pillar analyses the access to and usage of resources that has an impact on environment, economy and humankind. The Pillar subsumes two themes and uses seven indicators to measure the effectiveness of government efforts with regards to Sustainability.
The Curious Case Of The Delta
The Delta Analysis presents the results on the State performance on year-on-year improvement. The rankings are measured as the Delta value over the last five to 10 years of data available for 12 Key Development Indicators (KDI). In PAI 2021, 12 indicators across the three Pillars of Equity (five indicators), Growth (five indicators) and Sustainability (two indicators). These KDIs are the outcome indicators crucial to assess Human Development. The Performance in the Delta Analysis is then compared to the Overall PAI 2021 Index.
Key Findings:-
In the Scheme of Things
The Scheme Analysis adds an additional dimension to ranking of the States on their governance. It attempts to complement the Governance Model by trying to understand the developmental activities undertaken by State Governments in the form of schemes. It also tries to understand whether better performance of States in schemes reflect in better governance.
The Centrally Sponsored schemes that were analysed are National Health Mission (NHM), Umbrella Integrated Child Development Services scheme (ICDS), Mahatma Gandh National Rural Employment Guarantee Scheme (MGNREGS), Samagra Shiksha Abhiyan (SmSA) and MidDay Meal Scheme (MDMS).
National Health Mission (NHM)
INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
MID- DAY MEAL SCHEME (MDMS)
SAMAGRA SHIKSHA ABHIYAN (SMSA)
MAHATMA GANDHI NATIONAL RURAL EMPLOYMENT GUARANTEE SCHEME (MGNREGS)