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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