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Nagaland has 500 doctors for 2 million people

By Rahul Goswami

Patients from Nagaland often travel to Assam for medical attention. Meghalaya has set up permanent accommodation in Vellore, Tamil Nadu, for patients travelling there for treatment. A severe shortage of medical personnel and facilities is the major problem in the northeast

* When TW, a teacher in the northern district of Mon in Nagaland, needed treatment for an infected leg she painfully made the trip from her village to the district headquarters, and from there bore a seven-hour bus ride over a road that's a little better than a bullock-cart track to the town of Sonari in Assam. Like many who need medical attention and care in the remote district, she has no confidence in the government hospital and would rather undergo the hardship of travelling to the next state in order to be treated.

* VA, a senior member of a village council in Nagaland's Kohima district, was left with little option but to travel first to Dimapur, and then to Guwahati, to seek treatment for a kidney ailment. Although the state capital Kohima is a little over an hour away by road from his village, VA's condition could be diagnosed only outside the state. Through 2004, at great cost to his family, he has had to be treated far away from his home village.

* Two years ago PS, who runs a small grocery shop in Shillong, Meghalaya, was advised a CT scan of the head. She was told this could be done only at a private hospital in Guwahati, which is three-and-a-half hours by road. The scan cost her about Rs 1,500 and she was able to pay for it only by borrowing money from friends and family. Yet she counts herself more fortunate than other people she knows who have been forced to sell their assets to pay for medical diagnosis and treatment.

The major problems of the health sector in the northeast are severe shortages of personnel and facilities. The northeastern states have a combined population of around 39 million (about 3.7% of the country's total population). In Arunachal Pradesh, Manipur, Meghalaya, Mizoram and Nagaland, scheduled tribes comprise about two-thirds of the population. The number of indigenous communities in this patchwork of states is probably as great as the number of dialects, but it is generally reckoned that there are over 200.

Examples such as those cited above help explain why the Nagaland state government has been running up a bill of around Rs 20 crore a year as reimbursements for those from the state who are forced to seek medical treatment outside it. "The lack of adequate specialty services means people have to go outside the state to seek healthcare. Laboratories and other associated ancillary diagnostic facilities are at a premium -- few and outdated. There is only one CT scan machine in the whole state, at a private hospital in Kohima. Patients requiring high-end investigations and immunology are sent to Mumbai, Kolkata and Guwahati," says the Nagaland State Human Development Report 2004, the state's first.

In Meghalaya, the dependence on external medical diagnosis and healthcare is even more pronounced. Late in 2004, the Meghalaya state government announced, with some fanfare, the inauguration of a 'Meghalaya House' in Vellore , Tamil Nadu, to "provide accommodation to Meghalaya people going for treatment at the Christian Medical College " there. Reportedly, the state government has so far paid Rs 6,500,000 to the Tamil Nadu Housing Board for the 10 houses purchased solely to accommodate those from the state who travel to Vellore -- this is a high-traffic route -- seeking medical diagnosis and healthcare.

The wrangling between the state governments of Meghalaya and Assam and the central government over the planned "super-specialty" hospital -- the North East Indira Gandhi Regional Institute for Medical Sciences (NEIGRIMS) -- has not helped. The institute was originally approved by the central government in May 1986 and would have then cost Rs 72 crore if completed on schedule in March 1999. In February 2001 the project was re-opened with a new deadline of March 2005 and a project cost of Rs 422 crore. The 500-bed NEIGRIMS is now being monitored by the ministry of statistics and programme implementation and is expected to be completed in May 2005.

While the government in Shillong is understandably upbeat about the regional institute being set up there, Assam's government has been voluble in its disappointment at the Guwahati Medical College not yet being "upgraded" to the status of an All India Institute of Medical Science, and has tended to view the nascent institute in Shillong as having diverted much-needed funds and central attention away from the state.

Although the condition of health infrastructure in the northeast region ranges from basic to abysmal -- the Guwahati Medical College does not have a fully equipped emergency ward -- such one-upmanship does little to provide desperately needed regional solutions. If the college at Guwahati needs to be upgraded, a popular argument in Assam points out, what about the Assam Medical College in Dibrugarh, which at one time was reputed to be the premier medical education institution and hospital in the entire region? Students at the Dibrugarh college have been led to agitate at the lack of facilities in their institute, which has the potential of attending to the healthcare needs of Arunachal Pradesh, the northern districts of Nagaland, and of course the upper Assam region -- the tea and oil belt of the northeast.

Yet Assam 's own Human Development Report of 2003 had cautioned: "People do not necessarily visit the facilities, even if they are available. While this may be due to a variety of reasons -- credibility loss, poor care and attention, amount of time taken, absence of medicines and sometimes absence of doctors -- it has important policy implications." It is indeed the absence of enough doctors and trained medical personnel that drags down health indicators all across the region.

Nagaland has less than 500 doctors, including 98 specialists, to serve a population of 2 million. The indications are that Naga students want to enter medicine, but with no institute for medical education in the state Nagaland exports a human resource it simply cannot afford to. Meghalaya is short of at least 100 doctors, which the state government has said "severely affects" healthcare in rural areas of the state, with most primary health centres and community health centres insufficiently staffed, complained state Health Minister Sayeedullah Nongrum. Manipur's Health and Family Welfare Minister Laishram Nandakumar has pointed out in the state assembly that the state is short of around 160 doctors (including 120 specialists) and that there are only 150 doctors in the state health department who are very thinly deployed over 420 public health sub-centres, 72 public health centres and 16 community health centres.

There are a host of plans and initiatives aimed at improving health services in the northeast. The region's nodal development agency, the North Eastern Council, is supporting a tele-medicine network for the northeast in association with the Indian Space Research Organisation. Tele-medicine facilities are planned for all the medical colleges in the region: the Guwahati Medical College and Hospital, Silchar Medical College , Assam Medical College and the Regional Institute of Medical Sciences in Imphal. Simultaneously, a North East Health Care Mission is likely to be launched this year, with an act establishing the mission to be brought before parliament soon. Under this, Rs 88 crore a year will be used to take healthcare to every village.

Finally, a region-wide health insurance programme is being promoted. Without the healthcare basics being addressed, however, and urgently, such programmes are only likely to widen the disparities within medical care in the region.

Manipur has the lowest infant mortality rate in India

"Even in 1981, Manipur had the distinction of having the lowest infant mortality rate in the country, even lower than Kerala. Both Kerala and Manipur have better availability and a more equitable distribution of health services in comparison to the rest of the country. What is striking is that, unlike Kerala, the level of female literacy in Manipur is not significantly high, it is in fact around the national average. Women's empowerment brought about by its unique socio-cultural context, and not so much by female literacy, explains the impressive health attainments of the state. Greater women's freedom; increased political consciousness and participation facilitated, in part, by the matrilineal structure of the society; higher levels of maternal advancement; stronger social organisations and, perhaps, overall system of entitlement protection and relative equality reinforce each other to lower the infant mortality rate in Manipur. Work participation rates for women in Manipur, in different categories of work, are much better than the national average as per Census 1981 and 1991. In Manipur, the mean age of women at marriage, 23.3 years in 1981, is even higher than in Kerala."

-- National Human Development Report 2001


Nagaland's communitisation of health experiment

The Nagaland Communitisation of Public Institutions and Services Act, 2002, was designed to take advantage of the traditional social capital of Naga communities for the state's development. In the health sector, it means turning over the management and maintenance of health institutions to the community. All primary healthcare institutions have been transferred to village communities.

Under communitisation, each village has a village health committee whose responsibility it is to manage, coordinate and monitor its health services. Expenditure on health is routed through these committees, which are responsible for buying medicines, paying salaries, maintaining accounts, planning expenses and focusing on public health issues. The committee consists of members from key stakeholder groups like the village council and village development board, but the participation of women in such societies remains extremely low and, as a result, women's health concerns have tended to be inadequately represented -- their views on sanitation for example are dealt with cosmetically by organising 'village cleanliness drives' but without addressing the very conspicuous attitudinal and infrastructural difficulties that exist.

The Nagaland State Human Development Report 2004, the state's first, observes that, "the quality of existing infrastructure needs to be improved", that there are not enough health personnel and specialists which "restricts the coverage of health services in rural areas", and, finally, that "the chasm between reality and vision is enormous". While the report has been generous in praising Nagaland's communitisation experiment (which includes education, power, roads, forest management and other aspects of community development), little has been said about the abysmal condition of the state's delivery mechanisms -- which is the government's promise in the communitisation partnership.

When essential medicines are not available, when they cannot be stored as required because of lack of equipment, when medicines available in the market are suspected to be fake -- often with dangerous consequences -- and secure channels of distribution of essential drugs are not protected there is little the village health communities can do to ensure that their families, clanspeople and neighbours have access to basic and reliable healthcare.


Only 2% of children are immunised in some parts of Assam

Some vignettes of the state of healthcare in Assam and other northeastern states

* In the outskirts of Assam 's fourth biggest town, Bongaigaon, the complete immunisation rate of children is barely 2%. Several men and women ask me if I can arrange for pulse polio immunisation for their children since they have heard so much about it from their friends and relatives elsewhere. This when the central government in its limited wisdom has given so many pulses of polio that we have no idea what the long-term effect of so many doses is on children, or whether this repeated drowning in polio drops will work.

 

This state of public healthcare in Assam is scarcely surprising, with over 30% of PHCs and CHCs occupied by the security forces even today. Even surrendered militants are put up at PHCs and CHCs pending rehabilitation. Although militants have only rarely targeted medical personnel, health department officials do not dare travel into the hinterland.

* The central norm of two health workers per 3,000 tribal population in the hills is completely inadequate. Small hamlets are located at great distances, so nurses and health workers can never cover them all even if they wanted to. While the auxiliary nurse midwife (ANM) is still conscientious and does at least half her work, the male health workers don't bother to visit any villages. So Meghalaya innovates by replacing male health workers with chowkidars to 'guard' the sub-centre. The chowkidar is paid more or less the same salary as that of an ANM. Other hill states simply do not see the need to ask their male workers to report for duty. Others innovate by not appointing them in the first place. Hence the malaria work, for which the Centre offers 100% assistance here in the northeast, can never be implemented because only male health workers are expected to carry out that part of the health work. Who hasn't heard of malaria in the northeast? Now you know why!

* Governments here buy Albendazole, the drug used to treat children for intestinal worms, at Rs 12-14 while the government of Tamil Nadu buys it for less than 30 paise. Most governments here buy medicines at 500-3,000% more than the cost at which the Delhi or Tamil Nadu governments buy them.

* Most anganwadis of the ICDS programme in Assam get their meal rations only once in three months or so and are content with calling children only on that day to distribute the dry rations to them -- that too discounted heavily. Some years ago, newspapers reported that Nagaon cows and pigs had access to this supplementary feed through illegal sales outlets.

-- Sunil Kaul

(Rahul Goswami is a writer and analyst based in Goa. Email: This email address is being protected from spambots. You need JavaScript enabled to view it. )

InfoChange News & Features, June 2005