Short Review Vol. 7 No. 2 (2023): International J Health Systems and Implementation Research

Midterm Review of SDG-3 in the State of Himachal Pradesh in India: Challenges, Opportunities and the Way Forward

SDG-3 in the State of Himachal Pradesh

Authors

  • Dr. Gopal Chauhan National Health Mission, Himachal Pradesh

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Keywords:

  • Sustainable Development Goals, SDG-3, Health and well-being

Abstract

The UN General Assembly replaced the Millennium Development Goals (MDGs) with 17 Sustainable Development Goals (SDGs) on 25th September 2015. 193 UN member States adopted the SDGs agenda with the commitment to achieve it by 2030. SDG-3 aims to ensure healthy lives and promote well-being for all at all ages. World Health Organization is the custodian agency for global monitoring of SDG-3. National Institution for Transforming India (NITI), has the overall responsibility of SDGs implementation in India. NITI is releasing annual Health index to see the overall ranking and incremental progress in all states. The Planning department is the nodal agency to facilitate the implementation of SDG framework in the State of Himachal Pradesh in India. Department of health is the nodal department for implementation of SDG-3. As per the Drishti Himachal Pradesh 2030 (SDG document) the timelines has been fixed to achieve the targets by 2022 and 2030. In midway of SDGs, it is an opportunity to review the progress of SDG -3 in Himachal Pradesh so that the appropriate actions can be taken accordingly.

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Introduction

The United Nations Millennium Declaration was signed during the Global Summit in New York in September 2000. As a result, the eight Millennium Development Goals (MDGs) were established to address key global issues like poverty, hunger, gender inequality, diseases, illiteracy, and environmental degradation[1]. A period of 15 years was set to achieve these ambitious goals. After progress review of MDGs, the UN General Assembly replaced the MDGs with a new framework of 17 universal goals and 169 targets known as the Sustainable Development Goals (SDGs) on 25th September 2015. SDGs agenda was adopted by 193 UN member States, and all of them committed to achieve the bold and transformative universal goals by 2030 [2]. Health is placed higher on the agenda, having a crucial linkage with the other 16 SDGs. Goal 3 specifically aims to “Ensure healthy lives and promote well-being for all at all ages.” SDG-3 includes 13 targets covering all major health priorities, including unfinished targets of the MDG agenda, non-communicable diseases (NCDs), Communicable diseases, Injuries, Substance abuse, and Universal Health Coverage (UHC)[3]. To track the progress of SDGs, the Inter-agency and Expert Group on SDG Indicators (IAEG-SDGs) created by the UN Statistical Commission defined 232 indicators, including 28 indicators for SDG-3. These indicators were adopted by the General Assembly in July 2017[4]. The High-Level Political Forum (HLPF) is the apex UN platform for the follow-up and review of the 2030 Agenda for Sustainable Development at the global level[5]. World Health Organization and other UN bodies are custodian agencies for global monitoring of health-related indicators. Despite overall health progress, the World Health Statistics Report 2023 shows signs of stagnation in the annual rate of reduction (ARR) for many health indicators across the world[6].

SDG-3 in India

The Ministry of Statistics and Programme Implementation (MoSPI), in consultation with various other Ministries and departments, developed a “National Indicator Framework” (NIF) consisting of 306 indicators based on National priorities and needs in India. For periodic review and refining of NIF, a High-Level Steering Committee (HLSC) has been constituted under the Chairmanship of Chief Statistician of India (CSI) and Secretary, MoSPI[7]. National Institution for Transforming India (NITI) Aayog, a premier policy think tank of the Government has the overall responsibility of SDGs implementation and align Government schemes/ programs to SDGs. NITI Aayog developed the “SDG India Index” in 2018 with the aim to measure the progress of States towards the 62 priority indicators covering 13 SDGs[8]. Therainid edition of the index, covering all 17 goals and 54 targets, was launched in December 2019 with 100 indicators. The third edition (Index 3.0) marks an improvement over the second edition with a wider coverage of targets[9]. The Ministry of Health and Family Welfare (MoHFW) is responsible for coordinating the overall implementation and monitoring of SDG-3 in India. Therefore, the ministry has developed a National Monitoring Framework for health-related SDG[10]. India also developed the National Health Policy in 2017 with the aim to inform, clarify, strengthen, and prioritize the role of the Government in shaping health systems in all its dimensions and to achieve SDG -3. Since Universal Health Coverage (UHC) is a crucial component of SDG-3, the Government of India started the Ayushman Bharat Scheme in 2018 with the aim of reducing the catastrophic expenditure for hospitalization[11]. NITI Aayog is also releasing an annual Health index to see the overall ranking and incremental progress across all states in India.

SDG in the State of Himachal Pradesh

Himachal Pradesh, a hilly state with a population of about 7 million, is situated in north India. The Planning Department is the nodal agency to facilitate the implementation of the SDG framework and to coordinate with NITI Aayog for mapping and monitoring of State-level schemes to align with SDGs. In 2019, a state vision document, “Drishti Himachal Pradesh-2030; Sustainable Development Goals,” was prepared to provide a roadmap for implementation and monitoring the progress of SDGs in the State in consultation with the key stakeholder departments and experts[12]. The Economics and Statistics Department is the State-level nodal agency for coordination of all statistical activities. The planning department initiated the capacity building/training program for related departments in the State Apex Training Institute (HIPA) [13]. The Department of Health and Family Welfare is responsible for the overall implementation of SDG-3 in the State. As per the Drishti Himachal Pradesh 2030, the timelines have been fixed as 2022 and 2030 to monitor the progress of SDGs in the State. The midpoint of the SDGs' time period in 2022 is an opportunity to review the progress of SDG-3 in Himachal Pradesh so that the gaps can be identified and appropriate actions can be taken to achieve the SDGs targets by 2030.

Progress of SDG-3 in Himachal Pradesh till 2022

All the SDG-3 indicators as per “Drishti Himachal Pradesh 2030” are described in the table below with progress till 2022. However, the State has adopted selected indicators and modified a few others as per the needs of the State. The achievements on various indicators till 2022 have been graded into 3 tracks as below in Table 1. However, the categorization is based on the inputs of experts.

  1. Achieved =100% achievement
  2. On track > 75 to 99 % achievement
  3. Off track <75 % achievement
Table 1: Progress of SDG-3 in Himachal Pradesh till 2022
SDGState IndicatorBaseline data as per Drishti document 2019Target to be achieved by 2022Target to be achieved by 2030Achievement till 2022Track
3.13.1.1: Maternal Mortality in absolute numbers*63<45<2546[14]On track
3.1.3: Percentage of births attended by skilled health personnelInstitutional deliveries-84.21%90% of births are attended by Skill birth attendants or Institutional deliveries100%95.68 [14]Achieved
3.2Under-five mortality rate4230<1023[15]Achieved
Neonatal mortality rate25155-1013[15]Achieved
Infant Mortality Rate28225-1017[15]Achieved
3.3Number of new HIV infections per 1,000 populationThe HIV prevalence rate is 0.12 % in HP (2015)90% coverage under ART, Zero transmission from mother to child to sustain prevention activities100% coverage under ART, zero transmission from mother to child, to sustain prevention activities>90 % ART coverage, Zero transmission from mother to child, and the efforts are sustained[14,16]Achieved
Tuberculosis incidence per 100,000 population209 in 2016<100 /l00 thousand<20/100 thousand211/100 thousand [17]Off track
Annual Parasite Rate (APR) per 1,000 populationAPI Rate (Positive slides per 1000) <0.1Sustain the efforts and ensure zero transmissionSustain the efforts and ensure zero transmissionAPI is <0.1, and efforts are sustained [18]Achieved
3.4Mortality rate attributed to non-communicable diseasesState-level data is not availableImplementation of the comprehensive NCD prevention program as per GOI guidelines and to reduce the prevalence of NCD risk factors by a thirdTo reduce the prevalence of NCD risk factors by a third, To achieve a proportional reduction in NCD mortality by a thirdThe State Is implementing a comprehensive plan for NCD prevention and control as per GOI guidelines [19]On track
3.5Coverage of treatment interventions (pharmacological, psychosocial, and rehabilitation after-care services) for substance use disordersSubstance use disorder in Himachal Pradesh is about 20-25% Alcohol use is 39.7% (men in the age group of 15 -49 years )Ensure the De -addiction facility up to CHCs and PHCs level and ensure the quality of services at all levelsTo ensure awareness and enforcement of the existing regulations. To access the impact of innovations. To develop strategies to minimize the use of harmful alcoholThe de-addiction facilities are available to selected CHCs only. Toll-free number 104 is available 24x7 for counseling and de-addiction services[14].Off track
3.6The death rate due to road traffic injuriesThere are 1000 death per year (3 -4 deaths per dayTo ensure dedicated Trauma care services up to CHC level and quality services in all centresDedicated Trauma care services up to PHC level by 2024 and quality services in all health facilitiesDedicated Trauma care services are not available up to CHC level and quality of services in all centres is to be ascertained[14]Off track
3.7Proportion of women of reproductive age (15-49 years) who have their need for family planning satisfied with modern methodsTFR in HP is 1.7 ,unmet need is 15.7 and prevalence of adolescent pregnancies is 1.1 %Reduction in unmet need by 10% , To ensure 3 years gap between birth of two children to reduce sibling rivalry and strengthening of the existing ARSH clinicsReduction in unmet need to less to <5% by 2025 . To expand the ARSH clinics to all PHC level by 2024. To ensure optimum use and quality servicesThe unmet need Is 7.90 % [20] The use of birth spacing methods has increased. The ARSH clinics have been strengthened [14]Achieved
3.8Percentage of children aged 12-23 months who received the three doses of pentavalent vaccine before their first birthdayFull immunization (9 months ) is 99.5% in HP >76% population protected under Health insurance (against OOP expenditure) whereas national level it is <20%.100% immunization and 100% coverage under Health insurance schemeTo achieve 100% protection of public against catastrophic expenditure on HealthImmunization coverage is 96.4 [20] 100 % coverage under UHC has been ensured through Ayushman for BPL and Himcare for APL in addition to free drugs and free diagnostics services [14]On track
3.9Households using polluting fuel / non-polluting fuels for cookingThere have been 3383 deaths due to water contamination (diarrhea and typhoid), and 1,17,01755 diarrhea cases were reported in the country in 2012There is no data available on deaths and illnesses from hazardous chemicals, air, water, and soil pollution and contamination. Therefore, the targets cannot be fixed. The state may plan to conduct a survey /study to retrieve the data to fix the targetNo survey has been conducted in this context so far[14]Off track
3.aAge-standardized prevalence of current tobacco use among persons aged 15+ yearsThe prevalence of tobacco uses among the population aged 15 years and older is 22%Bring down tobacco use among those aged 15 years and older from 22% to 17%Bring down tobacco use among those aged 15 years and older to <5%As per the GATS -2 (2016 -17) the prevalence of tobacco use among adults was 16.1%. As per the state E Health Card surveillance (cohort) it has come down to 11.6% in 2022 [21,19]Achieved
3.bTotal net official development assistance to medical research and basic health sectorsNHM has funding small research projects like ( Acute Coronary Syndrome (ACS) registry, TB, Hepatitis-B and Immunization related studiesSDG-3 indicator will be reviewed periodicallySDG-3 indicator will be reviewed periodicallySDG-3 indicators are reviewed periodically [14]On track

*The state has a low denominator (<100000 live births per year ), so the actual number of maternal deaths are considered.

Discussion

In view of the low denominator, i.e. <100000 live births per year, it is not possible to calculate the Maternal Mortality Ratio (MMR) in the State, so the target has been mentioned in an absolute number of maternal deaths. The reported maternal deaths in the State were 63 in 2015-16, and it has reduced to 46 in 2022 against the SDG target of 45[14]. The Percentage of births attended by skilled health personnel has increased from 84.21% to 95.68 %[20,22]. Due to the lack of MMR indicators, each maternal death needs to be reviewed to find out the exact cause so that such instances can be avoided in the future. The quality of services needs to be improved in the State. There is a substantial improvement in child health indicators, especially in Under 5 mortality rate (U5MR), Neonatal mortality rate (NMR), and Infant mortality rate (IMR). As per SRS 2022, U5MR, NMR, and IMR have been reduced to 23, 13, and 17, respectively[15]. Since 10 out of 29 states in India have lower IMR than Himachal Pradesh, there is a huge scope for improvement because 6 States have already brought the IMR to single digits (SRS 2022)[15,23]. The state has progressed well in the prevention and control of infectious diseases. In 2015, HIV prevalence in HP was 0.12 percent as compared to 0.26 percent in India. The current HIV prevalence is 0.11 (NACO 2022), and more than 90% of persons living with HIV are on ART, and no transmission from mother to child has been reported [16]. The annual parasite rate (API) in HP is <0.1/1000, and zero transmission has been reported (NCVBDC Report 2023)[18]. The Tuberculosis (TB) incidence in the State was 209 in 2016, whereas it was 217 in India. As per the current India TB Report 2023, the incidence of TB has increased to 211, which has caused a concern[17].

To reduce the prevalence of non-communicable diseases, the state has developed a comprehensive strategy (Integrated digital approach for NCD prevention and control) called Mukhya mantri Nirog Yojna since 2019. The scheme envisages risk assessment NCD screening of the entire +18 population for all common NCDs, including management and referral linkages as a continuum of care[24]. More than 65% of the entire 18+ population has been enrolled under digital surveillance. However, the impact of this strategy is yet to be assessed. To address the rising trends of drug abuse, the IEC activities and de-addiction services have been strengthened. In addition to the 104 toll-free helpline, 101 Nyi Disha Kendras has been started, where trained doctors and counselors are providing drug de-addiction services. However, the de-addiction facilities are not available to CHCs, and the quality of services is to be ascertained. The increase in the use of alcohol from 29 to 41% from 2010 to 2015, as per NFHS-5, is also a matter of concern[20]. Moreover, the economic argument of revenue collection from alcohol is prevailing over the adverse health outcomes.

Another area of concern is the lack of adequate trauma care services in the State. According to the Road Safety Cell, Transport Department Himachal Pradesh, a total of 6771 deaths have been reported in the State due to road accidents during 2017-2021, which shows road injuries have claimed over 1000 lives per year. Most of the people dying in road accidents are young and in a productive age group[25]. However, road accidents and injuries are beyond the control of the Health Department but the trauma care services need to be improved. Currently the basic trauma care services are not available up to CHCs as per Government of India (GOI)/ Indian Public Health Standards (IPHS) norms.

The unmet need for family planning methods has shown substantial reduction but the continuous decline in Total Fertility Rate (TFR) can disturb the demographic profile of the state. There is a need to increase the gap between two births, which will also help in reducing sibling rivalry[20]. The state has progressed well toward universal health coverage. Apart from the Government employees and other similar categories, those getting free medical services or reimbursements, all the Above Poverty Line (APL) people are covered under the Himcare Scheme, and those Below Poverty Line (BPL) are covered under the Ayushman Health care scheme to avail the free and cashless indoor services. For all outdoor patients, the Free Drug and Free Diagnostic services are also available as per the essential /free drug and diagnostic scheme. However, the evaluation of all these schemes is required, specifically for the Himcare scheme, to see the reduction in OOPE and utilization of the health services by APL over BPL people in pro-poor public health institutions.

No study has been conducted to know the number of deaths and illnesses due to hazardous chemicals, and water and soil pollution, but it is an emerging issue in the state. Due to the cold climate in winter, there is a high burden of indoor air pollution due to fuel wood burning, and outdoor pollution is increasing due to rising industrial establishments, including vehicles. The State has shown a substantial reduction in Tobacco use, and adult tobacco use prevalence has reduced from 22% in 2010 to 16.1% in 2016-17 as per GATS-2. The prevalence of second-hand smoke exposure at home has reduced from 83% to 33%[21]. The current prevalence of tobacco use in the +18 aged populations 11.6% as per the State E-Health card surveillance system[19]. Also, tobacco use among the 13-15 age group is the lowest in the entire Country, as per GYTS[26]. There is a lack of strategy to promote research and development for appropriate interventions in the health sector. Despite better health financing (3.3% of GDP) and adequate Human resources, the unequal distribution of health institutions and HR is a big issue. There is a lack of a plan to strengthen the capacity for early warning, risk reduction, and management of health risks in the state.

The key challenges are lack of local evidence for decision making, lack of coordination among the key stakeholder departments/ institutions, and lack of proper monitoring of the SDGs-3 indicators. However, there is a huge scope for improvement, so coordinated action is required from all the key stakeholders. No study is available on the progress of SDG-3 in the State of Himachal Pradesh. However, a study titled “Progress tracking of health-related SDGs” (Rudra and Kurian) evaluated the capacity and constraints to monitor the progress of SDG-3 indicators and highlighted the several limitations of data availability within the health system[27]. A research article on the Progress and prospects of health-related SDGs measured the progress of selected health indicators in the states of India and predicted their likely progress by 2030 [28]. A systematic review, “Meta-analysis of the literature related to SDG-3 and its investment,” emphasized the need for significant financial resources to achieve the goals by 2030 [29].

Conclusion

This study shows that the progress of SDG-3 in Himachal Pradesh is mixed so far. The state has already achieved some of the targets and is on track in a few others but is also lagging in many areas. The decline in the SDG Health index ranking from 6th to 7th rank is also a matter of concern, and the incremental progress is not satisfactory. However, it is a fact that many determinants of health are beyond the scope of the Health Department, and the emergence of COVID in 2019 cannot be ignored. It is recommended to constitute an expert committee for a detailed review of the progress of SDG-3 in the state of Himachal Pradesh. However, all the key stakeholders shall be involved in the review process, and working groups shall be constituted for technical support on each indicator. Close monitoring of SDG-3 is required at all levels to achieve the targets before or by 2030.

References

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2023-12-30

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Vol. 7 No. 2 (2023): International J Health Systems and Implementation Research

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Short Review

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Midterm Review of SDG-3 in the State of Himachal Pradesh in India: Challenges, Opportunities and the Way Forward: SDG-3 in the State of Himachal Pradesh. (2023). International Journal of Health Systems and Implementation Research, 7(2), 9-16. https://ijhsir.ahsas-pgichd.org/index.php/ijhsir/article/view/187

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