On health care in Nagaland

When Delhi tells us to sit down, we sit down. When we are told to stand, we stand. Why, because Delhi has money and we don’t. So, we implement what Delhi sanctions for, unquestionably. The State government’s allocation to health (which again is from Delhi, but which can be used for State specific needs) is so low that it can barely manage the salary of the regular employees and build a few health centre buildings each year. There’s neither political commitment nor the knowledge of what’s going on (except how to recruit grade IV staffs that we don't need, and where supply orders are).

But what Delhi plans for us may not be the best for Nagaland. Each political ministry wants to achieve quick and popular results during its time, in order to return to power in the next election. In health care, the present ministry is more interested in projects and programs than in general health services. Likewise, donor agencies like Gates Foundation, World Bank, Global Fund, etc. are more interested in vertical health programs. But just as we cannot survive on fast food like coca cola and Bingo, we need to think beyond quick fixes. We can pay honorarium/incentive to a volunteer and orientate him to get a job done for us (a lot of that is going on). But without structures and processes, that may not be sustainable. In health care, we cannot get a task done, pack our bags and leave.

A time has come for us to put our thinking caps on our heads and put shoes on our feet. As doctors, administrators and managers, we need to go beyond biology to understand the social and political factors which determine health. We need to study the cause of the cause of ill health. First, we need to arm ourselves with the knowledge of what works and what wouldn’t work. Maybe a lot of health programs today are planned and designed in front of the computer screen. The experience gained in the field cannot be bought with money or gained from a university. We need to gather that resource into a common think tank. Next, we need to analyse, debate, and discuss. We will thereby get a clear picture learning how to make head and tail of the health care system; and have a clear vision and goal for the future. Next, we need to lobby, argue, and persuade; armed with evidence and elaborate plans.

Two examples to wind up. In implementing JSSK, as there is constraint in delivering services, paying of money directly was finally approved. Not about the initiative itself, but this is an example that negotiations can be done based on local conditions. Captain Jack Sparrow said in the Pirates of the Caribbean that the code of the pirates is not a sacred text that pirates need to obey. It is more of a guideline, he said. Most of the health activities in the State are program based and each program has guidelines. But they are not sacred books, and we must constantly see how far we can negotiate or adapt them to our context.

Second example. If we have these four things together, I believe our health services (in availability of medicines) will be much improved:  State Essential Drugs List, State Treatment Protocol (which we already have), State Drug Procurement Policy, and state of the art State Drug Testing Laboratory. We can make all essential medicines available in adequate quantity, procured without much corruption, and cheaply but constantly quality tested, and used rationally as per treatment protocol.

In a book recently published by London School of Public Health and Hygiene called ‘Good Health at Low Cost’, 3 major observations from countries and states which have good health services are that they have ‘continuity’, ‘leadership’, and ‘political will’. We have continuity unlike the politicians and can give sustained effort for long term endeavours. It takes just one or a handful of strong leaders for those countries, e.g. Bangladesh. And we need to generate political will.

I wrote this on the morning of quarterly review meeting of Chief Medical Officers and Medical Superintendants of all Districts and District Hospitals...as I was preparing my presentation on monitoring and supervision reports. I read it out to the Principal Director and he likes it and asked me to publish it in the local newspapers...I couldn’t get time to present it during the review meeting. Before publishing, it will require editing, for which I don’t have the time now.



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