Health care system in hill districts of Manipur
Issues, challenges and strategies for improvement

Grace Kamei *

Mother and child bear the pain of lack of primary health care in hill areas in December 2010 :: Pix - TSE

In his address to the nation on Independence Day, 2014 Prime Minister Narendra Modi spoke about inclusive development, with food security, safe housing and sanitation being the rights of every citizen of the country. Health is intimately linked to these essentials of living. The health status in hill districts of Manipur namely Senapati, Churachanpur, Tamenglong, Chandel and Ukhrul is in need of special attention. Among these five hill districts of Manipur, Tamenglong District is considered to be the most backward districts with low economic, education and health facilities. Tribal are the poorest and most marginalized groups in India, they experience extreme levels of health deprivation. The tribal community lags behind the national average on several vital public health indicators, with women and children being the most vulnerable.

Several studies on maternal health show very poor nutritional status, higher levels of morbidity and mortality, and lower utilization of antenatal and postnatal services among tribal. Health problems prevalent in tribal areas include endemic infectious diseases like malaria, tuberculosis, and seasonal diseases like diarrhea, fever, HIV/AIDS apart from malnutrition and anemia. What is worrying is that the prevalence of chronic diseases such as hypertension and diabetes mellitus, hitherto rare in these populations, is rising, and stroke and heart disease are now the leading causes of death.

The health status of Indian tribal women is extremely low. Likewise, tribal women face various health issues from early childhood to motherhood life. Tribal women living in hilly region of Manipur face numerous types of health problems due to different factors. Some of the factors are poor health care system and delivery system; lack of required funds allotted in tribal areas, lack of professional health practitioner, nurse and staff, and misuse of health schemes provided for hill district, inadequate health infrastructure (hospital, dispensaries, PHC and others), low quality medical equipments, lack of health awareness programs cum free distribution of medicines in remote villages and lack of concern from responsible health department.

Reasons of poor health

Many researchers have shown that 75 per cent of India’s tribal population defecates in the open and 33 per cent does not have access to a clean source of drinking water. Insanitary conditions, ignorance, lack of health education and poor access to healthcare facilities are the main factors responsible for the poor health of tribals. Further, displacement from their traditional forest homes and natural source of food and lack of livelihoods makes them dependent on the Public Distribution System (PDS) and other government handouts for survival. Most tribal groups are traditionally hunter-gatherers and not accustomed to agriculture their diets, therefore, are now severely limited in fruits and vegetables as well as good sources of protein (including fish and meat). Polished rice and cereals available through the PDS have replaced diverse dietary food baskets.

Although the government has provided for the establishment of Primary Health Centres (PHCs) in tribal areas for every 20,000 population and sub-centres for every 3,000 population, quality healthcare is not available to the majority of tribals. Posts of doctors and paramedical are often vacant not fill up by the concerned department. Additionally, the non-availability of essential drugs and equipment, inadequate infrastructure, difficult terrain and constraints of distance and time, and the poor of transport and communication facilities further hinder healthcare delivery. The geographical and infrastructural challenges to public health and the lack of health-related knowledge among tribals are exploited by quacks (unqualified medical practitioners), who are often available at the doorstep. Though some traditional practices and superstitions persist, acceptance of modern medicine has increased in recent years, but access to good care is the major issue. Levels of illiteracy are high, better educated tribal communities will be better aware of their healthcare needs (and rights) as well as of better care-seeking practices.

Under the Chief Medical Officer (CMO), 20 health camps for each district should conduct along with free distribution of medicines in a year. These privileges of health care system have not been implementing in all the hill districts of Manipur. There is no such evident of 20 Health Camps conducting in each hill district of Manipur. Due to lack of awareness on health programs and scheme, tribal people living in remotes or interior villages have no knowledge in seeking their rights to good health care. It is very important to make aware of their rights to approach to any health department or health centre for the betterment of tribal people living in hill districts.

Though successive Five Year Plans have provided for the needs of tribal populations within different schemes, and a large amount of funds are allocated, little improvement has been noted on the ground. The poor health of tribal populations cannot be overcome by mere establishment of more PHCs and sub-centers. Scarcity of trained manpower for health sector is a major problem and an obstacle to the extension of health services to rural and tribal areas.

Traditional healers, who are often the first point of care, can be sensitized and trained to deliver simple interventions like ORS for diarrhea and anti-malarias as well as to refer patients to the PHC in a timely manner. Tribal boys and girls (who complete school but often have no further opportunities) could be trained as community health workers or nurses and incentivized to stay and work in their own communities. A successful example is the ASHWINI Gudalur Adivasi hospital in the Nilgiris, where the management and most staff (except the doctors) are tribal. Nutritional counseling and education, establishment of kitchen gardens and provision of a more diverse range of food items through the PDS would help in curtailing macro and micronutrient deficiencies. More research needs to be done on the traditional herbal medicines used by tribal people and their use encouraged, wherever beneficial.

Scaling up models for improvement of health care system

The theme of this year’s International Day of the World’s Indigenous Peoples is “Bridging the gap implementing the rights of indigenous people”, tribals’ right to good healthcare must be addressed using modern technology and innovative approaches and most importantly, by involving the community in developing solutions for their problems. Health is intimately linked to food and nutrition security, safe housing and availability of sanitation and clean drinking water. There are many successful examples of good healthcare delivery in remote tribal areas in our country (almost all involving dedicated NGOs working with the people). These models need to be scaled up in order to improve the lives of the most vulnerable and marginalized tribal communities.

Today, almost every tribal people living in hill areas are suffering from various diseases. The existing health care centers in the villages are defunct in many places where the villagers are supposed to get health care and attention. Because of the poverty and the problem of money, low income people cannot afford the expenses of medical in the better hospitals. Government should first improve the systems of existing health care centers in the villages and extend the GDP expenses in health sector, second it should provide incentives to doctors who work in rural areas, and third it should make the state government to submit the report regarding the improvement in their states.

The government needs to revise the infrastructure in the state especially in the tribal areas on availability of Medical Professionals in the rural segment for this the Central Government needs to review the recruitment and posting of Medicos initially at least for five years with zero tolerance on absenteeism. It is true that Central Government has come up with about 50 medicines for free distribution but need to put a check on quality control and distribution of these medicines. Need for working on the network of dispensaries and medical Health centres and health facilities are made to be available for all.

It is necessary to train and educate all the quacks, who are already had the soft skills and let them too provide a quality service under the government supervision. The government should train the local people for treating all the minor ailments and a good transportation should be made in remote areas of hilly region so that all the serious ailments can be treated to the nearby secondary care centre.

Welfare programs of government should protect the economic and social well-being of its citizens by providing good education, health, assured employment etc. at affordable cost. It is based on the principles of equality of opportunity, equitable distribution of wealth and public responsibility for those who lack the minimal provisions for a good life. We have to achieve this goal in a time-bound Plan of Action.

Scarcity of trained manpower for health care is a major problem and an obstacle of health services to rural and tribal areas. No doctor is interested to work in remote area, connecting to the nearest town is very difficult and working in this climate is a daunting task. When an individual is not interested to work in this environment what the government will do. It’s a time to inclusive development for Tribal People; at least some innovative measure can boost morale of doctors’ staffs to work in this kind of environment.

It may be mentioned that health related studies among the tribal population is found to be limited. Most of the available studies are without an adequate sample size and standard methodology. The government and the health department of the state should encourage professional researchers to study the various health related issue in the tribal areas of Manipur. In order to improve health issue in hill district of Manipur, studies of different health problems and the health management system would help in modifying the health program based on the research studies and its statistical data.

Voluntary organization like NGOs plays a vital role in delivering health care services to various communities through innovative approaches, strategic health plan and modules. They focus more in most deserve area or people who needs special attention in health problems. The government should support and encourage those NGOs working in health program or project by providing necessary fund so that the health service can expand to unreached area particularly the interior villages of hill districts in Manipur. Thus, tribal living in hilly region of Manipur needs special health care by following the relevant strategy of health care methods and system for bringing solution to various health issues, challenges and for the betterment of health status.