Strengthening public health delivery in North East

Dr Priscilla C Ngaihte, Public Health  Specialist, Public Health Foundation of India and SumMinLun Vualnam, Independent Researcher, Developmental Studies, Tata Institute of Social Sciences, give an idea on public health scenario in the region which has lacked not only in world class infrastructures, but also basic facilities

Right to health is fundamental to human being, states the World Health Organisation. It further states that the right to health consists of two components viz. freedom and entitlements. Freedom as in the right to control one’s health and body and to be free for interference and entitlement includes the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health. The constitution of India under Article 21 provides the right to life and personal liberty. The Supreme Court on its various court rulings has interpreted Article 21 as not just the act of physical breathing or animalistic existence but the right to a dignified life. This interpretation includes the right to proper healthcare and thus makes the government legally responsible for the health care of its citizen.

The North-East region of India has always been one of the most under-developed regions of India. Despite the availability of natural resources, the region has lacked the infrastructure needed to fully utilise these resources. Apart from the hilly terrain, the insurgency infested nature of the region has kept private investors away from the region. The local businessmen have also chosen to stay out of large business venture due to the uncertainty of the region and the risk involved in such uncertain conditions. It has become the sole task of the government to cater to the development needs of the region until it is able to solve the political problems that has clouded the region since independence. A striking observation to all economist and other academicians, however, is that despite its low GDP and its economy mostly dependent on agriculture and its allied activities, the area has performed comparatively well in its Human Development Index (HDI). Most academicians have attributed this to the tribal cultural and traditions as the region is predominantly occupied by tribals. Nonetheless, this does not mean that the region has achieved the desired standard of human development. It still has a long way to go, especially in public health which has lacked not only in world class infrastructures, but also basic facilities of healthcare.

The recently concluded ‘North-East Health Care Summit’ organised by Public Health Foundation of India (PHFI) and Federation of Indian Chambers of Commerce and Industry (FICCI) at Guwahati highlighted the status of healthcare sector in North East region. The summit was attended by leading healthcare professionals, government health departments and other stakeholders as well as academicians and over 200 doctors. The main highlight of the summit is the lack of infrastructures and the shorthanded nature of the available infrastructure in the region. There are shortages of reputed medical, paramedic and nursing institutions as well as equipment to treat advanced diseases such as cancer. The requirement of health facilities exceeds the sanctioned post.  In Sikkim and Assam, the Community Health Centres available fell 50 per cent and 37 per cent short of the required needs respectively. Also, Tripura fell 17 per cent short of the required needs of primary health centres. Apart from the lack of world class infrastructure, the summit also highlighted the shortage of skilled manpower such as supervisors, doctors, specialist, female health workers, HRH professionals etc. in the region. A 100 per cent shortage in Lady Health Visitor (LHV) and health assistant in Tripura and Assam respectively is notable. Other basic reinforcing facilities such as electricity, proper connectivity, clean drinking water which are required for healthcare services are also lagging behind.

Another added problem to infrastructure and manpower shortage is the problem of access to the sparsely available healthcare facilities. The geographical terrain is one such hindrance to access. The north eastern states being mostly hilly area and majority of the population living in the rural areas access to healthcare facilities most of which are made available in the cities, thus a majority of the population are cut off from accessing quality healthcare. For example, as highlighted in the summit report, the highest cancer mortality in India is seen in the North Eastern states while 40 per cent of the cancer centres are in the metros, 85 per cent are in the private sector (inherently out of the reach of the poor patients) and 50-60 per cent trained oncologist reside in the metros. To add to this problem of concentration of medical facilities at the metros and cities, the connectivity to rural areas is in a very bad shape. Most of the rural corners are cut off from the towns and cities during monsoon due to landslide and other natural calamities thus further worsening the situation. It is during the monsoon season that various communicable diseases are more prevalent. Thus, the life and death of the rural populace are sometimes kept at the mercy of the climatic condition. The summit also highlighted lack of funding from the government leading to financial crunch as one of the major setbacks to healthcare in the region.

To tackle these institutional, infrastructural, access and human resource shortage problems, the summit proposed various policies for strengthening public health and healthcare facilities in the region. The summit has its eye on modernising the health infrastructure in the region and making available world class infrastructure at its disposal. It has discussed the need for formulating policies that will suit to the needs and resources available in the region, to overcome bureaucratic red tapeism in getting clearances in the healthcare sector. The main suggestion to the problems while not forgetting the need for setting up more PHCs, training more health personnel and penetrating the rural and border areas was the introduction of PPP model in the healthcare sector. The need to create a more viable environment for the entry of private players in healthcare sector in the region and inviting more investment from them for setting up world class hospitals, institutions and other healthcare facilities were some of the other suggestions.

It is no doubt that the aim of achieving a world class medical infrastructure and facilities can be done in no time with the involvement of private players in the arena. The summit has rightly identified the bottlenecks in the region but the policy suggested to tackle the problem has been a concern. The entry of private players will only create a market condition while the only aim of these capitalists is profit making. As David Harvey said, the first objective of capitalism is profit making and not serving the needs of the public. Capitalist only create needs and they thrive from making profits from the needs of the people and not providing the need of the people. It can be argued that most of the developed countries have handed over the health sector to the private companies and in the hands of market while various players compete. One thing to be noted is that the foundation has been set in those countries for such competition such that they are able to avail healthcare facilities as they have enough income to do so. The condition is not the same in India and especially in the North East where more than 30 per cent of its population is under poverty and more than 75 per cent are employed in the unorganised sector. Leaving such an important sector in the hands of the market will only create more problems to the question of access. While the infrastructure and facilities might be improving, it will only be accessible to a few high income groups excluding the poor and low income groups from the system. Rural and border areas will be left out by these players due to the question of profitability. It thus defeats its purpose of making healthcare more easily accessible. The government must ensure that private healthcare institutions and facilities are made available to the masses. The government will need an iron arm in regulating such institutions and not fall to corporate pressures. An alternative to this problem and which I think that India as a welfare state should be doing is to increase its expenditure in the healthcare sector. Health as mentioned earlier is a basic human right and it should be the obliged duty of the government that an individual is entitled to this right. In providing basic healthcare to its citizen, the government not only fulfills its duty but also build up its economy in the long run by providing itself with a healthy workforce. This would be a great advantage to the country in trying to achieve its millennium development goals and will push the country in its strive for a global economic power. There might be argument that India have spent enough of its resources on the healthcare sector and that it is unable to spend more of its resources. It is however seen that India’s expenditure on healthcare as a proportion to GDP is one of the lowest amongst the middle income countries. Also, there are countries which have a lower GDP than India but performed much better than India in terms of providing healthcare.

With minimal investment by the government in such a crucial sector, healthcare facilities and infrastructure will be sub-standard. To boost this sector, more government attention in terms of increased flow of monetary assistance, is required. And the first and prior focus should be in terms of penetrating healthcare facilities in the rural areas. This can be done by setting up more healthcare centres in  rural areas and making sure that healthcare professionals are available in these areas. A development from the grass root is necessary so that the objective of greater access can be achieved. Modern and advanced equipment which are out of the reach of majority of the population will not help in improving the health condition of the region. To actually strengthen public health and healthcare facilities in the region, it needs to be ensured that the facilities are made available to the intended beneficiaries. Another step to make healthcare accessible to the people is to improve the available hospitals and healthcare centres. When hospitals face shortage of healthcare professionals such doctors, specialists, nurses and other basic equipment, patients have no choice but to approach other private hospitals where in many cases, the poor are unable to afford such expenditure. This can be addressed though setting up of more government hospitals, medical institution and medical research centres to address the specific medical needs of the region.

Public hospitals should be equipped with the latest equipment, have adequate healthcare professionals and managers etc. A sector as crucial as this cannot be left in the hands of the private sector and it should be the duty of the government to ensure that its citizens are entitled to this basic right of health. A private sector which aims of squeezing out maximum profit from the people thought its primitive system of exploitation cannot be trusted with the life and death of the people. Strengthening of healthcare in India and in the North Eastern region is dependent on how far the government is ready to extend its arms for the welfare of the people.