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Comparative Analysis of Health Systems: Through the trans Himalayan States of Himachal Pradesh and Uttarakhand – IMPRI Impact and Policy Research Institute

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Comparative Analysis of Health Systems: Through the trans Himalayan States of Himachal Pradesh and Uttarakhand - IMPRI Impact and Policy Research Institute

Saurabh Bisht

Abstract

The trans Himalayan states of Uttarakhand and Himachal Pradesh often face multiple challenges of, and in, the healthcare systems. While the challenges in accessing and delivering healthcare services through the healthcare systems are largely similar for both the states, the outcomes of their individual healthcare systems are different. For 2021-22, Uttarakhand allocated 5.12% of its budget to the health sector, while Himachal Pradesh allocated 6.7% to it. In terms of overall health index score, Uttarakhand, with a total of 44.21, lags much behind Himachal Pradesh, with 63.17. 

A larger share of voids in healthcare systems often inordinately affects women and children. As per latest data, Maternal Mortality Rate (MMR) was recorded at 101 for Uttarakhand and 55 for Himachal Pradesh. Further, the Neonatal Mortality Rate (NMR) and Under Five Mortality Rate (UFMR) were recorded at 22 and 33 for Uttarakhand and 13 and 23 for Himachal Pradesh respectively. The inordinate burden can also be seen as the Sex Ratio at Birth (SRB), being 840 for Uttarakhand and 930 for Himachal. It can be said that the healthcare system is more disproportionate for the women and children of Uttarakhand.

This research analyzes and compares how the difference in the healthcare systems of the two Himalayan states have an impact on population health, focusing on women and children.

Introduction

Himachal Pradesh and Uttarakhand, the two Himalayan states of India, seldom find spaces beyond tourism. With the rugged terrain and geographical challenges, delivering quality and accessible healthcare has been an ordeal for the two states. Since India, at large, is a patriarchal society, the inefficiencies and/or ineffectiveness of the healthcare system more often affects women and children. 

The issues pertaining to maternal health in Uttarakhand were highlighted by the National Family Health Survey – III (2005-06). With a high proportion of high-risk pregnancies, high percentage of child births outside the health systems, majorly attended by untrained midwives, it resulted in a high maternal mortality and morbidity in the state (Chimankar & Sahoo, 2017). Though the MMR for Himachal Pradesh is not calculated because of an insufficient denominator, due to less than 100,000 childbirths annually, the 2015 Himachal Health Commission Report estimated it to be only a little less than the national average (Chauhan & Suryavanshi, 2021).

The MMR and NMR are two of the key indicators that can be used to assess the health of a state. As per the latest report by the Registrar General of India, the national MMR stands at 103. While the MMR for Uttarakhand has been categorized ‘high’, the state has made some progress in improving it over the years. The state also has the third highest Infant Mortality Rate (IMR) in all the ten Himalayan states (Tyagi, 2021). Compared to Uttarakhand, both the MMR and IMR are lower for Himachal Pradesh.

Most of the pregnancy related deaths, for both, mother and child, are avoidable with an accessible and quality healthcare system. However, access to healthcare in both the trans Himalayan states is often hurdled by a difficult connectivity/transportation, dearth of doctors and paramedical staff and out of order healthcare services. Pregnant women often have to cover long odd distances just to reach the understaffed hospitals.

The burden more often falls upon the rural women and children as a large number of doctors are concentrated at the urban settlements. This is especially worrying as about four-fifths of the population in Himachal and more than two-third population in Uttarakhand live in rural areas.

The inadequacy of the healthcare services in the states result in healthcare inefficiencies and translates as deteriorating healthcare indicators, such as higher MMR, NMR and IMR. Further, the underfunded and underutilized healthcare budgets result in inadequate, insufficient and inefficient healthcare systems and services. The dearth of quality and fully operational healthcare systems results in non achievement of their intended outcomes and the resulting inefficiencies get further fuelled by low budget allocation and administrative hurdles.

As per the Health Index Round IV report by the NITI Aayog, while Uttarakhand has a positive incremental change, with respect to the base year of 2018-19, the change has been low at 0.58, giving it an incremental rank 13 and overall rank 15. On other hand, Himachal Pradesh fared even low in terms of the incremental change, at -0.06, with incremental rank 15 but had a higher overall rank at 7.

Both the states have deteriorated their rank from the base year of 2018-19, Uttarakhand slipping from 14 to 15 and Himachal Pradesh slipping to 7 from 6. Therefore, it is important to not just analyze and understand the health system based health outcomes of both the states but also to compare them.

Comparative Analysis

  1. Inputs
  • Governance & Health Information Indicators

Table 1 shows that the healthcare governance and information indicators in Uttarakhand are poor, compared to Himachal Pradesh. The poor healthcare governance gets translated as inefficiencies of the implementing healthcare systems. It was also found that amongst the larger states, Uttarakhand witnessed the maximum shortage of specialists in its district hospitals. 

Table 1

Governance & Information Domain Indicator

Governance and Information Indicator Overall Indicator Performance
Himachal Pradesh Uttarakhand
Data Integrity Measure – Institutional deliveries  13.35 8.15
Average occupancy of an officer (in months), combined for three keyposts at state level for last three years 13.01 11.99
Average occupancy of a full time Chief Medical Officer (in months) inlast three years for all districts  19.68 8.39
Source: Health Index Round IV, 2019-20, NITI Aayog
  • Healthcare Workforce and Pharmacies

Table 2 shows that Himachal has a better pharmacist coverage at its PHCs in rural areas than Uttarakhand.

Table 2

Pharmacists at Primary Health Centers (PHCs) in Rural Areas

State Pharmacist
Required Sanctioned In Position Vacant Shortfall
Himachal Pradesh 651 694 521 165 122
Uttarakhand 298 341 310 31
Source: Rural Health Statistics, 2020-21

Table 3 shows the poor percentage of availability of gynecologists and child specialists in Tehri. The shortage of gynecologists is not just limited to Tehri but is spread across the state overall. It was also found that Uttarakhand has 64% positions for gynecologists vacant and only 41% child specialists, against the approved capacity, are available. The availability of healthcare workforce, pharmacies and medicines, healthcare budget, health information systems, governance and regulation indicators act as important inputs for the healthcare systems. 

Table 3

Specialist Doctors at Tehri

Specialist Approved Working Vacant (Working/Approved) in percentage
Gynecologist 15 2 13 13
Child Specialist 12 1 13 7
Source: RTI filed by SDC Foundation

The issue of shortage of doctors and medical staff is not just limited to Uttarakhand but also extends to Himachal Pradesh. While, at 5 beds for every 10,000 people, Himachal Pradesh has the highest number of hospital beds compared to all other Himalayan states of India, it too suffers from a shortage of specialists in the public healthcare systems. In some rural districts, there is a shortage of about 50% of healthcare workers in the government healthcare units. (Kashyap, 2022). 

For fiscal year 2021-22, while Uttarakhand allocated INR 3,438.84 crores, 5.12% of its total budget, on healthcare, Himachal Pradesh allocated INR 2,976 crores, 6.7% of its total budget. Both the Himalayan states have a common significantly high concentration of healthcare services at their respective capitals. There is a stark difference in healthcare services in rural and urban settlements. In Himachal, despite the urban areas only accounting for 10% of the state population, they account for around 40% of the total healthcare spending. A similar story comes from Uttarakhand where of the total 2021-22 budget for health and family welfare, only 23% was exclusively allocated for rural healthcare services. 

  1. Organization
  • Public Healthcare Centres

In terms of absolute numbers, Himachal’s health infrastructure is better compared to Uttarakhand given the difference in population between the two states. While Uttarakhand’s NMR is marginally better than Himachal’s, its UFMR is very high. The high UFMR can be explained due to the lack of child specialists in Uttarakhand. The lower UFMR of Himachal can be credited to its overall larger healthcare system.

Owing to the challenging terrain, almost all private hospitals, for both the Himalayan states, are concentrated in their major cities which are home to a very small population. Since the majority of their population lives in the rural regions, access to private hospitals is very challenging, physically and financially. 

The healthcare organizations of the states can be understood through the distribution of the healthcare facilities across their population. Table 4 summarizes the distribution of the public health facilities across Himachal Pradesh and Uttarakhand.

Table 4

Available Public Health Facilities

State Number of Government Facilities per 100,000 People
Primary Health Centers (PHCs) Community Health Centers (CHCs) Sub District/ Divisional Hospitals (SDHs) District Hospitals (DHs) Total Beds Available in Government Hospitals
Himachal Pradesh 7.5 1.2 0.9 0.2 9.8 127
Uttarakhand 2.7 0.7 0.2 0.2 3.8 67
Sources: Ministry of Health and Family Welfare & Census 2011. 

Posted by Press Information Bureau on July 24, 2018

  1. Outputs

The output of the healthcare systems can be assessed via the provision of the healthcare services, overall medical and social measures. There is a huge void in the healthcare system of Uttarakhand because of the unavailability of doctors and medical staff. Of the 13 districts of Uttarakhand, it was found that 9 districts had less than 50% availability of specialist doctors. The state’s worst affected district, Tehri, had only 13% available specialist doctors.

The grim condition of low availability of gynecologists and child specialists extends to Himachal Pradesh too. As per the 2019-20 rural health statistics, it was found that out of the required 80 gynecologists and obstetricians and 85 child specialists, only 4, against each category, were available in the Community Health Centers (CHCs) in Himachal’s rural areas.

Table 5

Health Facility in Rural Areas

State Sub Centres PHCs CHCs Rural Population(in million) Total Health Centres per 100,000 Population 
Himachal Pradesh 2114 553 98 6.2 45
Uttarakhand 1823 245 53 7 30
Source: Rural Health Statistics, 2020-21 and Census 2011

Table 5 shows the difference in number of Sub Centers, PHCs and CHCs for the rural regions of Himachal Pradesh and Uttarakhand. Despite a population less than that of Uttarakhand, Himachal Pradesh has a larger rural healthcare system coverage. But a mere larger number of healthcare units simply cannot function efficiently and effectively if they lack the doctors and paramedical staff. The latest National Family Health Survey 5 (NFHS-5) report reflects how the difference in healthcare system coverage of the two states yields different results for maternal and child health.

  1. Outcome
  • Postnatal and Early Childhood Care 

As per NFHS-5, the institutional delivery for Himachal stands at 88% and 83% for Uttarakhand. Table 6 below shows the postnatal healthcare behavior in mothers and Table 7 shows the early childhood mortality trends for 0-4 years preceding the NFHS-5 survey for the two states.

Table 6

Postnatal Care Status

State Mothers who had postnatal check
After their last birth Within 2 days of birth
Himachal Pradesh 93 90
Uttarakhand 86 84
Source: NFHS-5, 2019-21

Table 7

Early Childhood Mortality Rates

State NMR IMR UFMR
Himachal Pradesh 20.5 25.6 28.9
Uttarakhand 32.4 39.1 45.5
Source: NFHS-5, 2019-21

A comparison between Table 5 and 8 shows how the difference in number of healthcare units in both the states produce varying results. Himachal Pradesh, with a more elaborate healthcare system, has lower UFMR and IMR compared to Uttarakhand with fewer healthcare units. It can also be seen that a larger percentage of women in Himachal had better antenatal healthcare compared to Uttarakhand. It was also found in the NFHS-5 that the percentage of women who received antenatal care (ANC) during their first trimester was 72% for Himachal Pradesh and 69% for Uttarakhand.]

Table 8

Child and Maternal Health Indicators

State UFMR IMR Percentage of mothers who had 4 or more antenatal visits
Himachal Pradesh 29 26 70
Uttarakhand 46 39 62
Source: NFHS-5, 2019-21

Table 9 shows, despite a larger healthcare system than Uttarakhand, Himachal Pradesh surfs lower for ANC for women. 

This difference in the maternal healthcare indicator can be attributed to the internal dearth of specialists within the state’s healthcare systems. Although in terms of institutional and health personnel assisted deliveries, it surfs better than Uttarakhand. 

Table 9

Maternal Healthcare Indicators

State Region In Percentage
Received ANC Deliveries in Health Facilities Deliveries Assisted by Health Personnel
Himachal Pradesh Rural 92.8 87.5 86.6
Urban 87.2 93.3 90.5
Total 87.8 88.2 87.1
Uttarakhand Rural 90.9 80.6 82.5
Urban 93.4 89.2 86.4
Total 91.8 83.3 83.8
Source: NFHS-5, 2019-21

Table 10

Time of first health checkup post delivery

State Time between delivery and first postnatal health check of the newborn
<1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days No Postnatal Check
Himachal Pradesh 30.2 46.5 5.9 6.1 1.5 8.5
Uttarakhand 35.4 40.9 2.2 5.1 1.1 13.8
Source: NFHS-5, 2019-21

Tables 10 and 11 show how the difference of healthcare services, in Himachal and Uttarakhand, is reflected in the maternal and child health status. The indicators show that Himachal Pradesh, for the given maternal and child health care indicators, performs better than Uttarakhand. 

Table 11

Comparative Maternal and Child Healthcare Indicators

State Maternal Health(In Percentage) Child Health(In Percentage)
ANC during first pregnancy trimester Delivery in Healthcare Unit Postnatal Checkup After Last Birth 12-23 months old children who received all basic vaccinations Children who received any Integrated Childcare Services  (ICDS)
Himachal Pradesh 72 87 93 89 72
Uttarakhand 69 83 86 81 69
Source: NFHS-5, 2019-21

The outcomes of any healthcare system is a function of its inputs and implementation mechanisms and its coverage/universality. While Himachal’s healthcare infrastructure is comparatively large, for its population of 6.8 million, Uttarakhand’s larger population, of 10.1 million, is met with a smaller healthcare system. Fewer healthcare systems lead to difficult access to healthcare and affects the state’s population health, making the achievement of universal health coverage a difficult reality.

  1. Impact

The difference in the available number of public health facilities is reflected in the overall health performance of the states. For 2019-20, while official data on MMR of Himachal Pradesh is absent, the state’s UFMR and NMR, at 23 and 13, had a negative incremental indicator performance, at -2 and -1 respectively. For the same period for Uttarakhand, the MMR stood at 99 and the UFMR and NMR, at 33 and 22, too had a negative incremental performance at -2 each. 

The impact of the under-developed and under-utilized healthcare systems results in under-addressed healthcare challenges. The lack of healthcare infrastructure and healthcare personnel has resulted in an increased healthcare burden on the women and children. The higher concentration of healthcare services in only a select few cities makes this differential burden even more inordinate for rural women and children, thereby acting as a major impediment in achieving an equitable population health.

Further, the internal discrepancies of unavailability of medical staff and/or equipment, despite a larger healthcare system, renders the delivery and utilization of healthcare services inefficient, as can be seen in 2019, Uttarakhand registered a 100% birth registration but the same was at 82.5% for Himachal Pradesh.

Conclusion

Both, Himachal Pradesh and Uttarakhand, are nestled in the trans Himalayan belt of India. Their challenging geography affects the access to, and quality of, healthcare systems. Both the states are predominantly rural, yet most of their healthcare facilities are concentrated in their major cities which account for only a small percentage of their population. The challenging access to healthcare affects the health system deliveries and population health, where most of the healthcare burden falls on women and children. 

Though both the states lack the required healthcare infrastructure and manpower, in terms of absolute numbers and coverage, Himachal Pradesh has a better healthcare system. The results of the more expansive healthcare system of Himachal lets it surf better than its neighbor Uttarakhand. Himachal, when compared to Uttarakhand, has a lower NMR, IMR and UFMR. However, both the states fight with an understaffed healthcare system, particularly in their rural regions.

The lack of paramedical staff and unevenly distributed healthcare systems are the biggest obstacle in their universal health coverage. The internal healthcare differences and shortages inordinately affect the health of the women and children of the states. There is an ardent need to not just expand and upgrade the healthcare infrastructure of the two states, but also to provide them with sufficient manpower to grapple the healthcare issues.

Footnotes

  •  The health index scores and ranks are used for assessing the year-to-year progress of individual states and Union Territories, expecting it to pave the way for achieving the Sustainable Development Goals related to health.
  • This difference in performance makes Himachal Pradesh an achiever, with rank 7 and Uttarakhand an aspirant, with rank 15.
  • The NMR talks about the number of infants dying within the first 28 days of birth per 1000 live births in a year.
  •  The WHO defines UFMR as the probability of a child dying before reaching the age of 5 years, born in a specific year or period, subject to the period’s age-specific mortality rates.
  •  The IMR is defined as the number of infants dying before reaching the age of one for every 1000 live births.
  •  The nutrition and health services are provided via ICDS program to children under the age of 6 years along with the pregnant or breastfeeding women.

References

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Saurabh Bisht is a final year student of M.A. in Public Policy at Jindal School of Government and Public Policy, O. P. Jindal Global University. 

Read more by the author: Beti Bachao, Beti Padhao: Through the Trans-Himalayan Terrain.

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