Where do Indian states stand in ensuring access to education and healthcare?

By: Deepanshu Mohan, Richa Sekhani, Latika Sharma, Vanshika Mittal & Advaita Singh

A recent study attempts to create a new index to measure and study the inequality of opportunities across the country.

In a recent study undertaken by the Centre for New Economics Studies, OP Jindal Global University, we have attempted to conceptualise the creation of a new index envisioning to measure and study differential inequality of access in terms of access to basic social and economic services and opportunities in states and the Union Territories.

The Access (In)equality Index consists of five “access” pillars that are crucial for households across India. Before we get into the details of our index’s findings, it is first important to clarify what we mean by access here.

We have conceptualised “access” in our index’s framework in derivation from the set of theoretical inferences developed by scholars like Penchansky and Thomas (1981) amongst others (Levesque et al 2013, Haddad & Mohindra, 2002, Peters et al 2008) based on the established discourse present in the healthcare policy literature.

Though “access” in general means a way of approaching, reaching or entering a place, as the right or opportunity to reach, use or visit, it is here broadly conceptualised to encompass the “4As”: affordability, approachability, appropriateness and availability (provided in the figure above).

These four dimensions are not only critical in addressing inequalities in accessing healthcare services but can be expanded to cover various other sectors including basic amenities, education, justice and for addressing socio-economic inequalities.

The index in its analytical framework includes five fundamental pillars of assessment (illustrated in the figure below) for states and Union Territories across India:

In the methodological design of the index, we measure overall access, using geometric mean in order to ensure partial compensability, ie poor performance in one sub-index is not fully compensated by good performance in another.

It also balances the uneven performance in the dimensions and encourages improvements in the weaker dimensions. Other prominent indices like the Human Development Index and Sustainable Society Index use the geometric mean for aggregation as well.

Based on the score range of 0.67-0.23, states are grouped into three categories – “aspirants” (below 0.33), “achievers” (0.42-0.33) and “front runners” (above 0.42).

Bihar, Uttar Pradesh, Jharkhand, Assam, Odisha and Madhya Pradesh fall under the aspirants category, requiring sustained efforts to improve access to basic socio-economic opportunities (across all identified pillars). Jharkhand in particular needs special attention as it ranks in the bottom few ranks across all pillars.

States like Maharashtra, Arunachal Pradesh, Gujarat, Uttarakhand, Chhattisgarh, Rajasthan, Tripura, West Bengal, Manipur and Meghalaya are categorised as the “achievers”. These states have good provisions of access to (basic) socio-economic opportunities and must sustain their efforts to advance to the next category.

Lastly, states such as Goa, Sikkim, Tamil Nadu, Kerala, Himachal Pradesh, Telangana, Punjab, Mizoram and Karnataka are observed as “front runners” in ensuring better access to basic socio-economic opportunities for their respective state-populations.

Goa has the highest average score, seeing a better geographical coverage of services and implementation of Sustainable Development Goals.

On comparing the highest and lowest index scores, we realise that high inequality exists within the different states. Access to basic amenities determined by drinking water, sanitation, housing, nutrition, cooking fuel and digital infrastructure has the largest range, indicating the poor condition of those placed at the bottom of the state-population pyramid.

Let us break down the performance of states based on two of the pillars of assessment.

1. Access to education

As universal turnout of elementary education has been achieved by India, we focus on secondary education as the next fundamental level of access and study the performance of states. The sub-indicators include net enrolment ratio, net attendance ratio, average annual dropout rate, average household expenditure per child, pupil-teacher ratio, secondary schools at a distance of 2 km, availability of girls toilets, schools offering vocational education, per capita spending by state governments and digital infrastructure such as functional computer and internet facilities.

The top five front runner states are Punjab (0.47), Goa (0.45), Himachal Pradesh (0.43), Sikkim (.41) and Kerala (0.37). Meanwhile, the aspirants are Arunachal Pradesh (0.22), Jharkhand (0.21), Bihar (.20), Uttar Pradesh (0.19) and Meghalaya (0.13).

Punjab has done remarkably well in improving the access to secondary schooling and implementing good infrastructure facilities which are reflected in various indicators such as low dropout rate and high enrolment. It registered a zero-dropout rate for girls at the secondary level which is highly correlated with a high percentage of schools with girls’ toilets in this state.

The better implementation of the Right of Children to Free and Compulsory Education Act, 2009 has resulted in improved enrolment rates with Punjab and Kerala at 81.5% and 74.1% respectively. However, 24.3% of males and 17.7% females of age 3 years to 35 years ever enrolled who are currently not attending education report financial constraints as the major challenge.

To understand the government’s priorities in providing affordable access, we computed the per capita spending by state governments on secondary education in 2018-’19. This is highest for Sikkim followed by Uttarakhand and Goa and lowest for Jharkhand, Bihar and Uttar Pradesh.

Furthermore, social factors like pre-defined patriarchal roles of men and women prevent about 30% of adolescent girls, from attending school as girls are engaged in domestic activities instead of schooling. Female attendance is the highest in Telangana (77.5) and lowest in Uttarakhand (36.4).

Apart from this, smaller states have lower average dropout rates (Punjab at 1.6, Himachal Pradesh at 7.2 and Uttarakhand at 8.4) while north-eastern states have higher average dropout rates (Tripura at 26.3, Assam at 32.3 and Arunachal Pradesh at 34.3).

The appropriateness of this pillar is assessed by the pupil-teacher ratio and schools offering vocational training at a secondary level. The required student-teacher ratio in government secondary schools, according to Rashtriya Madhyamik Shiksha Abhiyan framework, should be 30:1.

Bihar, Jharkhand and Gujarat are the only states which do not meet this threshold. When it comes to vocational education, in absolute terms, Uttar Pradesh, Rajasthan and Maharashtra have the highest number of schools having vocational courses under the National Skill Qualification Framework.

Lastly, accessibility to education through digital means reflects on gaps in remote and digital learning infrastructure across states in India. For the academic year of 2019-2020, United Information System for Education Plus revealed that only 22% of all schools had internet and 37% had computer facilities. This low penetration of digital education formed the base for the increased inequalities in distance learning induced by the pandemic. To add to the inequality, India has been slower than other countries in reopening schools – an observation made by Abhijeet Banerjee earlier.

2. ‘Access to healthcare’

India’s healthcare system, just like any other nation’s, was put to test with the onset of the Covid-19 pandemic. Despite healthcare being one of the largest sectors in terms of employment and revenue generation, health outcomes for the majority of the population have not improved (see here for previous analysis).

It is important to understand that health outcomes such as life expectancy and mortality rate depend on the available means in health facilities. To capture state-level performance on access to healthcare, we identified the following sub-indicators: reproductive health, health insurance, immunisation, government hospitals and beds, population and area covered by sub-centres, teleconsultation funds and public expenditure.

As can be seen above, the Front runners (index value greater than 0.57) are Goa, Tamil Nadu, Sikkim, Kerala, Himachal Pradesh, Mizoram, Andhra Pradesh, Punjab and Karnataka. Nagaland, Assam, Jharkhand, Bihar and Uttar Pradesh are some of the Aspirant states (below 0.45).

The disparities across states are quite visible and reflect the priorities of the state governments in making services and provisions available to its existing and potential voters. Public spending on health by the Centre (appropriateness) has been stuck at around 1% of GDP for close to 15 years and is one of the lowest in the world.

The public health expenditure per 1,000 population is particularly low in Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand and West Bengal. On the other hand, the average public expenditure allocated per 1,000 population is highest in Arunachal Pradesh, followed by Goa, Sikkim and Himachal Pradesh.

On average, the top five states have 0.054 hospitals available for their population, however, this is far below the global standard. Similarly, the availability of government hospital beds per 1,000 population is as low as 0.009 in Uttar Pradesh and as high as 2.2 in Sikkim.

While these figures reflect on the availability of healthcare facilities, its approachability is measured from the average radial distance covered by sub-centres that act as the most peripheral healthcare contact for outreach communities.

The all-India average distance covered is 2.6 km with state differences ranging from 4.26 km in Mizoram to 1.4 km in Kerala. Even the proportion of household members covered under health insurance is very low in India (Assam is the lowest with only 10.4% of the households covered).

Reproductive and child healthcare indicators have improved over the years yet remain unsatisfactory. Only 65% of the children in India receive full immunisation during the first year of their life. UP, Bihar, Jharkhand, West Bengal, Nagaland, Assam and Arunachal Pradesh have the least immunisation coverage.

In 2015-’16, on average 57% of mothers had received postnatal care from a healthcare personnel within two days of delivery and 63% received at least four antenatal care visits. All the factors combined lead to north-eastern states ranking really poorly in this pillar.

Key takeaways

Our report also delves into the existing gaps in “access” performance observed between the different segments of the population, based on: the area of residence (the divide between the urban and rural), caste groups and gender.

In healthcare, we see how the dominance of the private sector in the urban healthcare system has resulted in rural India being at a disadvantage in terms of access to affordable and approachable healthcare services. It has made its “access” exclusive to the upper caste and dominant class groups.

Furthermore, low insurance coverage (and public awareness) have driven the costs of healthcare asymmetrically in urban-rural areas. Out of pocket healthcare expenses show this disparity. States with the lowest case fatality rates as of April 2020 are Kerala (0.68), Tamil Nadu (1.1) and Haryana (1.15), of which Kerala and Tamil Nadu are front runners and Haryana is an aspirant in our sub-index.

Under education, rural areas witness higher levels of dropout rates especially for females. These gender gaps increase with progressive levels of education. Though enrolment of marginalised groups such as the Scheduled Caste, Scheduled Tribe and Other Backward Classes is higher than the all-India average, their actual attendance is low.

This also reflects on how accessible tools of distance/remote learning – a key indicator to understand how the digital gulf impacted communities’ access to education during the pandemic-is so different across states (with states like Assam scoring the worst).

This is the first in a two-part series disseminating the observed findings of state-level performances from the Access (In)Equality Index, 2021. Our next part in the series will showcase findings from the index made across the remaining three pillars: access to basic amenities, access to socio-economic security and access to justice for states-UTs across India.

Deepanshu Mohan is Associate Professor of Economics and Director, Centre for New Economics Studies, Jindal School of Liberal Arts and Humanities, OP Jindal Global University. Richa Sekhani is a Research Associate at ICRIER and a Senior Research Analyst with CNES.

Latika Sharma is a Public Sector Consultant. Advaita Singh and Vanshika Mittal are students at Ashoka University and Senior Research Analysts with CNES.