To the new government on health care in Nagaland
Since the liberalization of the
Indian economy in the early 1990’s, government spending on the social sector
has been cut in the name of Structural Adjustment Policy. Government spending
on health dropped to as low as 0.9% of GDP in 2005. The State Human Development
Report 2004, Nagaland showed similar decline in state government’s allocation
to health sector as percent of its total expenditure. When government spending
on health decreases; private out-of-pocket expenditure increases (which
increased to about 80%). This trend results in people falling into debt crisis
due to paying of medical bills. Health expenditure is said to be the commonest
reason for people falling into indebtedness in India. About 2% of population
fall below the poverty line due to spending on health care. There is a partial
renewal of government’s commitment to health care. Public spending rose to 1.2%
of GDP during 2011-12 and private out of pocket spending stood at 67%. But it
is still far from adequate. A High Level Expert Group was formed by the
Planning Commission to advice on what should be done to achieve universal
health coverage. One of its recommendations is to double government spending by
the end of the 12th Plan (2017).
Health is a State subject and
there are wide variations in commitment and health outcome indicators across
the States. Some States fare much better and are able to achieve standards of
health comparable to that of advanced countries while others fall behind. Looking
at the experience of other States, one cannot say that the Nagaland government
has been committed to improve health care. Being a poor state and dependant on
central grants, the purse isn’t big. But it isn’t just the size. It is how much
(proportion) of that will be committed to health care and how much to, say,
Youths and Sports.
One of the reasons for lower
allocation in health and family welfare is the arrival of National Rural Health
Mission (NRHM). However, one must remember that NRHM has not come to take over
the medical department, but only to act as a supportive arm. The flagship
programs under NRHM look huge but the fact is that the major portion of the
general health services still lies under the State government. For example, TB
control program is a big program but looks only after TB. Likewise, Leprosy
program is for one disease, Vector Borne program for three diseases and so on.
Each program is limited in scope and specified in interventions. But for the
common ailments that our people suffer from, for example, common cold, ARI,
peptic ulcer, urinary infection, diarrhea, typhoid, hepatitis, cholecystitis,
kidney stone, hypertension, stroke, diabetes, burns, tonsillitis, skin
infections; NRHM does not cover! And almost all types of minor and major
operations. So, if a TB patient getting free medicine from the program happens
to suffer gastritis due to the medication, she has to buy medicine for her
stomach on her own. The performance of the NRHM is also dependant on the State
contributing its share on a timely manner. The NRHM is a time bound mission and
procedural delays affect the functioning adversely. When the State does not
give its share on time, central releases get delayed, staff salaries are not
paid, works are not done, and the next year’s fund is minimized due to unspent
balance.
Below are six suggestions to
improve health services that I request the new government to consider:
1. Increase
state budget allocation on Health
Good health is a basic human need
and health care should be given more importance. Health is not something
optional that you can choose to buy or not to buy from the market, like your car,
or cold drink. Even for basic need like clothing, there are options to choose
from based on your income. But health care is a matter of life and death. A
poor father would do all he can to give the best treatment if that can save the
life of his son. So, farmers would sell their paddy fields, and women would die
as they cannot afford to come to treatment in Kohima, or Guwahati. The current
spending is inadequate to buy essential medicines, hospital equipments,
laboratory reagents, cottons and syringes, etc. Since the early 1980s, state
government’s spending on health as a proportion of its total expenditure has
been decreasing. In 1980-81, Nagaland was spending 9.57% of its total
expenditure on health, which dropped to 6.30% in 1990-91 and further reduced to
5.39% in 1998-99. For 2011-12, the figure stood at 3.5%. The Expert Group
recommends that the ‘state should
be primarily and
principally responsible for ensuring
and guaranteeing Universal Health Coverage for its
citizens’. It clearly mentions that increase in central fund through
NRHM should not be an excuse for not raising the state budget on health. ‘States should not only continue to
contribute as much as
they do now
on health care,
but also proportionately increase
their budget allocations
for health over the years. In
other words, the
transfers received from the Central
government along with the matching contribution by the states should
constitute additional public spending on health – and should not be used
to substitute spending
from own resources by the states. This is all the more important because,
as noted earlier,
the existing pattern
of resource allocation by
India’s State and
Central governments, collectively
result in one of the lowest priorities given to health of any country in the
world’.
2. Concentrate
on function over structure
There is shortage of health
centres. But the more pressing need is to make the existing ones function
optimally. There are several reasons why they are functioning sub-optimally or
not at all. One is site selection. There are population norms, referral set-up,
and connectivity concerns in choosing a site to set up a health centre. But often
our health centres are set up through political decision and personal
connection. An influential person would like to have a primary health centre in
his village, in his land, with a doctor placed there. So, we have many health
centres which flout every norm and logic. Then so many Sub Centres are built
away from the village which are not accessible. As Chief Minister has rightly
said that roads need maintenance fund, buildings cannot deliver services. There
need to be a continuous supply of water, electricity, medicines, laboratory
reagents and consumables, etc. Therefore rather than setting up structures which
wouldn’t work, resources need to be put to make the present ones work. The
district hospitals need special attention, so that even if the length and
breadth of Nagaland cannot be given comprehensive health coverage, there is one
good hospital in each district. Human resource management also needs a thorough
recheck, which is discussed in the next point.
3. Improve
the human resource management system
Salary of Grade III and IV staffs
is draining a huge chunk of the state budget. Staffs are appointed for the sake
of employment and not for need of service. A district hospital may have almost
a 100 employees and you’ll see only a handful of them on any day of visit. On
the other hand, there is shortage of technical manpower for which there is no
post creation. Another important issue is the rational deployment of technical
manpower. A Sub Centre covering a single village of about 600 population has 3
ANMs while some covering several villages has only one. Technical guidance is
not sought for transfers and they are done at the top for other motives. As a
consequence, service delivery suffers. Transfer and posting policy needs to be
looked into that all employees are treated fairly and that transfers are based
on need assessment. Such policy document for doctors is in place. The doctors’
association has also submitted a very well written proposal for restructuring
of district hospitals in Nagaland which has addressed this issue in detail.
Political will is needed to implement it. Among others, reasons for staff
absenteeism and low performance are the lack of rationality in posting of
health personnel and victimization of some in order to help others.
4. Strengthen
drug procurement and supply chain management system
Nagaland has a state essential
drugs list and a standard treatment protocol. A procurement system is in place
and is functioning. The most pressing need is funding. State needs to increase
budget for buying essential medicines which is very inadequate at present. On
procurement system, let me humbly put this suggestion. We need to strengthen
the drug procurement system by having a procurement policy passed by the
government. Variations in medicine prices are so wide that a brand can be a
hundred times costlier than another for the same medicine. Actor Amir Khan was
right in saying that a one rupee medicine is sold at Rs. 20. Opting for cheap
but quality tested generic medicines will tide over the financial constrain.
So, if the state commits 10 crores for buying medicine, opting for generic
medicines will procure as much as spending over a hundred crores. That has to
be a government policy decision to protect the interest of the people’s health.
It will meet with objections from various interest groups but it needs to be done,
and other states have drawn up such drug procurement policy. Drug testing laboratory
needs to be beefed up to test that the medicines procured are of acceptable
quality. Cheaper than branded medicines is a category called ‘branded generic
drugs’ which can be explored for greater acceptability. To check leakage and
rationality of supply and use, a digitalized supply chain management system
need to be put in place and standard treatment protocol duly followed. The new
medical minister can take this proposal for generic medicines, quality testing
facility and supply chain management as a pet project and show that during his
tenure, the people of Nagaland received affordable, adequate, and quality
medicine supply.
5. Need
for a State Health Policy
Besides the Five Year Plans of
the planning commission, the country has a national health policy which acts as
a vision document for the long term. During the period, the planning commission
and the ministry of health and family welfare design programs and interventions
to meet those goals set in the policy. Short term targets are set to achieve
step by step to achieve the long term goals. A similar state health policy is
needed as some other states also have. The health needs are not uniform
throughout the country. We might have achieved very low infant mortality rate
but poor in institutional delivery. The pattern of disease burden in Nagaland
is also different. Therefore, there is a need to tackle state specific issues
and set goals of our own. A committee may be formed to draft a state health
policy and have it passed by the government to function as a vision document
for health care delivery in our state.
6. Improve
Inter-sectoral coordination
It is not possible to achieve
good health care in isolation. Many of the health challenges are beyond the
purview of the health and family welfare department. So, inter-sectoral
coordination needs to be strengthened and joint ventures of line departments
need to increase. If the Roads and Bridges department does a shabby job,
transportation of patients and vaccines become a problem. If ICDS of Social
Welfare functions smoothly, fewer children get sick, and so on. We have the
‘year of entrepreneur’ and similar themes that government adopts. Emphasis on a
particular theme may be important but each and every sector is interrelated and
one cannot progress at the expense of the other. But if some things in life are
more basic and we are to prioritize, those which we can’t do without; they are
food, housing, good health, education, communication. They are more essential
than, say, music and dance.
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