Last week, The Lancet published a report entitled ‘Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals (SDG) in 188 countries‘. This is an analysis from the Global Burden of Disease (GBD) Study 2016, which measured 37 health-related indicators from 1990 to 2016. The researchers then transformed each indicator on a scale of 0-100 (with higher values indicating good progress), and computed an overall index representing all 37 indicators. These were then used to rank all 188 countries in the analysis.
The results showed that, globally, the median health-related SDG index was 56·7 in 2016 and country-level performance markedly varied, with Singapore (86·8), Iceland (86·0) and Sweden (85·6) having the highest levels in 2016, and Afghanistan (10·9), the Central African Republic (11·0) and Somalia (11·3) recording the lowest.
On the global rankings, Singapore, Iceland, Sweden, Norway and the Netherlands got the top ranks (1 through 5), while Chad, South Sudan, Somalia, Central African Republic and Afghanistan ranked 184 through 188.
India did very poorly in this analysis, ranking 127, with a SDG index value of 39. The graphic below displays India’s data on each indicator. Countries making good progress toward SDG goals will have most bars reaching the end of the ring (i.e. index values reaching 100).
Any interested reader can visit the GBD data visualisation tool, select India from the drop-down menu, and re-create this graphic and get more information by clicking on each indicator.
The graphic shows that India scored well on indicators like mortality due to conflict and terrorism (index value of 100), prevalence of alcohol consumption (index 86.8), overweight prevalence in young children (index 84.5), proportion of women who had their family planning needs met (index 80.7) and coverage of eight vaccines (index 76.5).
But for a majority of the 37 health indicators, India scored very poorly. India did particularly badly on the following indicators: hepatitis B incidence (index 10.5), deaths attributable to unsafe water, sanitation and hygiene (index 10.9), air pollution due to fine particulate matter (index 11.4), prevalence of sexual violence (index 13.6), mortality due to air pollution (index 15), prevalence of wasting among children under the age of five (index 16.7) and maternal mortality (index 22.4). India also scored poorly on incidence of tuberculosis, malaria and self-harm.
How did India fare in comparison to other BRICS countries? Every single BRICS country ranked ahead of India. Brazil ranked 67 (SDG index 63), China 74 (SDG index of 61), Russia 103 (SDG index 54) and South Africa 122 (SDG index 43). The graphics below compare Brazil with India, side by side. Brazil performs poorly in very few indicators, namely homicides, adolescent births and road injuries.
There are many limitations to the GBD study, including poor quality of data that goes into the complex modeling exercise. This is especially true for India, where surveillance systems are poorly developed and high-quality data are not easy to come by on a variety of indicators (for instance, prevalence of sexual violence or suicides). Even tuberculosis estimates are not precise, given the lack of a nationwide prevalence survey, and because large numbers of TB patients are managed in the private sector.
So it is important that future GBD estimates for India are strengthened by better quality primary data from the country, including nationally representative prevalence surveys for key conditions. This requires India to strengthen its chronically underfunded research agencies, especially the Indian Council of Medical Research, and invest in disease surveillance systems, building on the experience of the successful National Polio Surveillance Programme. Improved cause of death data are also critical.
Even without this new GBD rankings on SDG index, it is abundantly clear that India underperforms in health. There is a huge and widening gap between India’s economic progress and the ground realities in health. The prevalence of under-weight children in India is among the highest in the world. TB kills nearly half a million Indians each year, with India leading the world in TB burden. India has more people living in rural areas without access to clean water than any other country. Nearly half of India’s rural population lacks access to toilets, and 240 million people live without electricity. None of these statistics add up to good health, and the recent Gorakhpur tragedy merely underscores the gravity of the situation.
The fact that India spends less than 1.5% of its GDP on health, as compared to the global average of about 6%, is one of the biggest reasons for India’s atrociously low ranking on the SDG index. India’s National Health Policy, approved this year, proposes to increase health expenditure by the government from the existing 1.15% to 2.5% of the GDP, by 2025. Along similar lines, India has made several other ambitious commitments, including elimination of kala-azar and filariasis by 2017, leprosy by 2018, measles by 2020 and TB by 2025.
The $64,000 question is: Will India put money behind these ambitious goals and increase its spend on health? Perhaps anticipating this, the 2017 National Health Policy concludes by stating that “a policy is only as good as its implementation.” It is time for India to fully fund and implement its ambitious health policies and translate them into better health outcomes for its millions. Without health, little else matters.
Madhukar Pai is a Professor and Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. He is the Director of McGill Global Health Programs and Associate Director of the McGill International TB Centre. He is also a member of the Royal Society of Canada, and a Fellow of the Canadian Academy of Health Sciences. He can be followed on Twitter @paimadhu.