By Phrangsngi Pyrtuh
In 1978, at the Alma-Ata Conference, ministers from 134 countries in association with WHO and UNICEF declared “Health for All by the Year 2000” with the onus on primary health care to achieve the target. For most developing countries including India the declaration remained a distant dream. Even after 35 years of the Declaration India’s primary health care indicators remained grim and among the lowest. Progress in primary health care is essential for countries struggling to achieve the 2015 targets of health related Millennium Development Goals (MDG) such as infant and maternal mortality rate. On both counts, India’s infant and maternal mortality rate remained below the world’s average. Current figures on infant mortality rate ( as per SRS of 2013) is 40 per 1000 live births. India was supposed to achieve 39 per 1000 live births in 2015 as stipulated by the MDGs.
The Indian state had initiated extensive steps for improving infant and maternal mortality rate especially through the National Rural Health Mission (NRHM). Under the “Janani Suraksha Yojna” cash incentives were provided to pregnant women and those who choose the option of institutional delivery. The policy initiative is to encourage pregnant mothers to visit a healthcare center for safe delivery of the new born baby. The JSY is specifically targeted towards ST/SC and BPL population whose primary health indicators leave a lot to be desired. The JSY is a well thought out scheme to bring changes in delivery preferences and improving the immediate health care requirements for the mother and the child. Though there are signs of improvement yet there are variation in states, region and target groups. Generally urban areas have lower maternal and infant mortality due to availability of adequate health care services. Moreover, states with higher literacy levels tend to have lower maternal and infant mortality rates.
It cannot be denied that institutional delivery is a significant parameter for healthcare services. It is a good practice to have a child within the premises of a health care center where the safety and security of both the mother and the child is assured. The probability for the mother and the child remaining healthy is higher if the delivery occurs within the premises of a health care facility.
Institutional delivery can resolve the problem of both maternal and infant mortality rate. India’s institutional delivery stands at around 49 %. Among all South Asian countries, Sri Lanka has 99% hospital delivery. Its success in achieving low maternal and neo-natal death rates is attributed to the introduction of selective primary healthcare and investing a substantial amount of GDP on health. On this count India lags behind in terms of absolute spending on health.
The PHC at the community level was a novel concept for making health care services accessible. Primary healthcare is a core component for enhancing institutional delivery rates. Institutional deliveries along with good health care services at the PHC level, the presence of doctors and associated paraphernalia are basic requirements to make a PHC functional. In Meghalaya there are reports of resource constraints both structural and human in PHCs across the state. The situation is worse in the rural areas. There are reports of non-functioning PHCs or CHCs due to absence of doctors and basic health infrastructure. The people complain against the apathy of the city based doctors who have no passion to serve the rural folks. Doctors complain that quarters are inhabitable. General complaints are the lack of medical provision for newborn, inadequate medicines, negligible ambulances services to cater to emergencies etc.
It is no wonder that institutional delivery in Meghalaya is unsatisfactory. The situation is similar in other north eastern states. Despite the various programmes implemented to augment institutional delivery, the response in the region is low. Barring Mizoram and Sikkim all the other north eastern states are outliers and way below the national average of around 49% as per the National Family Health Survey-3. Meghalaya’s institutional delivery rate stands at 30% with Nagaland occupying the bottom of the table at 12%. Institutional delivery for the rural areas of Meghalaya would be even less than 30%. Not much would have changed with the new NHFW-4. The lack of response in the North East has frustrated policy makers. Recently JP Nadda the Union Minister of Health and Family Welfare raised the issue and asked for new approaches to tackle the problem.
Different states are coming up with different schemes to promote health services. The Meghalaya Health Insurance Scheme (MHIS) was launched with an objective to provide financial aid at the time of hospitalization and reduce out-of-pockets expenses for residents. Many pregnant mothers have availed the insurance for hospital delivery since the scheme would cover all expenses. An audit exercise is prudent to find out how many have utilized the MHIS specifically for hospital deliveries. Has it increased over the years or remained stagnant? And importantly how many of those deliveries involved caesarean operations? Since the Caesarian section is expensive (than natural births) all expenses would accrue to the government via the MHIS. It would be interesting to see if Caesarean operations have increased after the MHIS was launched in Meghalaya. How can MHIS improve the low malnutrition count of the state as revealed by the NFHS-4? These are important questions as they would bring out the quality of health care services being provided through insurance which is increasingly considered superior than traditional health care provision via the PHCs/CHCs.
It is time to have a holistic approach to health care services. There are complaints of malpractices, incorrect diagnosis, discrimination by doctors etc compelling NGOs to intervene and aggravate the situation. Patients’ grievances against a doctor or a health care facility must also be addressed with proper compensation for any wrongdoing. The health care system needs to be comprehensively revised to bring in transparency and accountability. This would also bring to an end the blame game and NGOs interference in the working and functioning of a health care institution. The benefits of such an exercise would accrue to those who need basic health care the most.