By Bhogtoram Mawroh
On December 11, 2022 it was widely reported that Meghalaya has been awarded at the national level for achieving the target of operationalising 448 Health and Wellness Centres (HWCs) under the Ayushman Bharat Comprehensive Primary Health Coverage programme. A visit to the Ayushman Bharat – Health and Wellness Centre page housed under website of the Ministry of Health and Family Welfare, Government of India touts the Ayushman Bharat (AB) program to be an attempt to move away the selective approach to health care to deliver comprehensive range of services spanning preventive, promotive, curative, rehabilitative and palliative care. This, it is claimed, will be achieved by creating Health & Wellness Centres (HWCs) to deliver Comprehensive Primary Health Care, which is universal and free to users, with a focus on wellness and the delivery of an expanded range of services closer to the community. In simple words the scope of the existing Primary Health Centres and Sub-centres will be expanded to include more services apart from “Maternal and Child Health Care Services to include care for non-communicable diseases, palliative and rehabilitative care, oral, eye and ENT care, mental health and first-level care for emergencies and trauma, including free essential drugs and diagnostic services”. As for those whose needs are beyond the scope of these HWCs the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the second component of the program, intends to provide health insurance cover of Rs. 5 lakhs per year to over 10 crore poor and vulnerable families for seeking secondary and tertiary care. On its part, Meghalaya received the award for upgrading 18 Urban Health Centres, 114 Public Health Centres, and 318 sub-centres into HWCs. On the surface, the intention of the Ayushman Bharat (AB) program is praiseworthy and the award received by Meghalaya is especially very opportune coming at a time when multiple reports have revealed the health indicators in the State to be in very bad condition.
One of the important reports that highlighted the dire position of Meghalaya regarding health is the ‘North Eastern Region District SDG Index: Report & Dashboard 2021-22’. The report ranked the districts of all the states in the North East Region (NER) in terms of achievement of the Sustainable Development Goals (SDGs). Overall, Meghalaya was second from last in those rankings. Among the SDGs, the performance of the State under SDG 3, Good Health and Well-Being: Ensure healthy lives and promote well-being was especially very depressing. In terms of ranking, none of the districts from Meghalaya have performed well enough to be even in the Front Runner category (the second highest ranked after the Performer category). Instead majority of the districts (7 out of 11) are in the Aspirant category, i.e., the lowest category. Only West Garo Hills, East Garo Hills, West Khasi Hills and Ri Bhoi are in the Front Runner category (just above the Aspirant category) but are ranked in the mid 70’s from among the 103 districts (entire NER) which have been included in the report. Altogether 11 indicators were used to score the performance of each district. As reflected by its ranking the State has done very badly on all those indicators.
Another report, the National Family and Health Survey (NFHS-5) also reiterated the deplorable condition of the health sector in Meghalaya. Two of three indicators under Sanitation and seven out of the eight indicators under the Maternal and Child Health have figures lower than the national average. Under Child Feeding Practices and Nutritional Status of children two indicators out of five again have figures worse than the national average. This includes the finding that 46% of the Children under 5 years in the State are stunted. Even though the figures for the remaining three indicators, viz., Breastfeeding children age 6-23 months receiving an adequate diet, Non-breastfeeding children age 6-23 months receiving an adequate diet and Total children age 6-23 months receiving an adequate diet, are higher than that of the national average, just only around 30% or less of the children consume an adequate diet, i.e., the situation elsewhere is worse. Similarly, though the performance of the State when it comes to Anaemia among Children and Adults is better than the national average, still around half or more of them are anaemic. To be fair it is not only Meghalaya but India itself whose performance under health and nutrition has been very poor. In the recently published and much debated Global Hunger Index 2022 India has been ranked 107th out of 121 countries. The only country in South Asia that has performed worse than India is Afghanistan which has been plagued by political turmoil for many decades. In this context, Meghalaya’s performance under health becomes even more glaring. It is here where the Ayushman Bharat (AB) program has to be a little circumspect. Upgrading to Health and Wellness Centre is a good move but it will be important to see how the implementation of the program pans out over time. Additional services will require increased funding and manpower, something which is always the issue with any government program, especially when spending on social sectors is the prime target for budget cuts.
A very good example of the poor implementation of the health initiatives in Meghalaya has been brought out very starkly by the “State ranking Index for NFSA” report published in June 2022 by the Ministry of Consumer Affairs, Food & Public Distribution. The Index attempted to document the status and progress of implementation of NFSA (National Food Security Act) and various reform initiatives across the country and has ranked the states accordingly based on their performance. The Index for ranking the states and UTs is built on three key pillars which covers the end-to-end implementation of NFSA through TPDS (Targeted Public Distribution System). These pillars are: i) NFSA— Coverage, targeting and provisions of the Act, ii) Delivery platform, and iii) Nutrition initiatives. The National Food Security Act (NFSA), which is the focus of this Index, is a law passed on July 5, 2013 which brought about a rights based approach when it comes to food security in the country. Schemes such as the Mid-Day Meal Scheme (MDMS), the Public Distribution System (PDS), and the Integrated Child Development Services (ICDS) are included under the Act. The current version of the Index, however, measures the effectiveness of NFSA implementation majorly through operations and initiatives under TPDS. It does not cover programs and schemes implemented by other Ministries and Departments under NFSA. Here again, Meghalaya is second from the bottom in the country highlighting poor implementation as being one of the main factors for poor health outcomes in the State. The Ayushman Bharat (AB) program will have to learn from this experience.
Apart from the state of health infrastructure there are other factors which need to be taken into consideration when discussing about health. Good health is not only important for a good quality of life but it is also important for raising productivity and bringing about good economic returns. At the same time, financial capacity, both at the state and the household level, is crucial for promoting good health outcomes; hence the focus on Pradhan Mantri Jan Arogya Yojana (PM-JAY) in the Ayushman Bharat (AB) program as well. With Reserve Bank of India data for the 2021 FY (Financial Year) revealing Meghalaya as being one of the slowest growing states in India, the challenges facing the State are immense. How these issues are tackled will determine if it will continue to remain at the bottom of the rungs of socio-economic indicators (including health) or try to come out of this morass. Delay on the part of the State to address the problems will only exacerbate the situation and lead to more hardships for the citizens.
(The views expressed in the article are those of the author and do not reflect in any way his affiliation to any organization or institution)