KOHIMA, SEPTEMBER 1: Amid the challenge of widespread absenteeism amongst medical staff hindering effective healthcare access to the people, the Nagaland Government envisions healthy lives and promoting well-being for all ages, reducing maternal mortality and ending infant deaths in the State by 2030.
These are part of the 17 goals of the Nagaland Sustainable Development Goals (SDG) Vision 2030 goal released by Chief Minister Neiphiu Rio recently in the State capital. The goal is “Good Health and Well-Being”.
Nagaland’s current Maternal Mortality Rate (MMR) per lakh live births is 97 while Infant Mortality Rate (IMR) per thousand live births is 30 and Under-5 mortality rate (U5MR) per thousand live births is 37.
Children immunization coverage stands at around 35.4% and HIV prevalence rate of 0.76% among adults is 3rd highest in the country.
The Vision document has set the target of reducing MMR to less than 70 per lakh live births and ending preventable deaths of new-borns and children under-5 years of age while also reducing by one-third premature mortality due to non-communicable diseases through prevention and treatment and promoting mental health and well-being.
The Government also proposes to end the epidemic of HIV/AIDS, tuberculosis, eliminate malaria and other neglected tropical diseases.
Providing equitable, affordable and quality healthcare services to the people of the State is one of the core responsibilities of the State Government with a focus on preventive and promotional healthcare services to its citizens, it said.
Maintaining that the ultimate objective would be to provide equitable, affordable and quality healthcare services to the people of the State, the document has observed 9 challenges as follows:
Lack of Health Financing: Norms for allocation of funds are based on population and not on requirements or gaps faced in certain locations/among vulnerable populations.
There is also low utilisation of funds due to delays in the release of funds, difficulty in observing the complicated implementation guidelines and negligible private investors in health.
Lack of Response to Contractual Recruitment: There is adequate provision under the National Health Mission (NHM) to supplement Human Resource (HR) requirements. However, while the majority of the doctors, nurses and other technical manpower have availed the state quota/sponsorship to undergo their studies, only a few respond to contractual employment creating an apparent scarcity of technical manpower.
Lack of support for Integration of Traditional/Indigenous Systems of Medicine: Traditional health providers function in parallel or sometimes in conflict with modern systems and there is lack of coordination/collaboration between the Government agencies and such practitioners to support and promote indigenous systems of medicine.
Absenteeism: Widespread absenteeism amongst medical staff is a hindering factor to provide effective healthcare access to the people of the State.
Lack of Access to Health Care: In addition to lack of awareness and poor health seeking behaviour, shortage of health facilities, poor communication and difficult terrain are factors contributing to lack of access to healthcare. Another reason for inaccessibility is the poor referral transport network. This is mainly due to poor road connectivity, shortage of ambulances, lack of proper ambulance network management system and lack of skilled personnel in emergency care.
Lack of Proper Infrastructure to Deliver Quality Care: Consequent to financial constraints, there is still a wide gap in terms of health infrastructure: hospital buildings and quarters, equipment, Nagaland SDG Vision 2030: Healthy lives, reducing maternal mortality & ending infant death instruments, diagnostics and drugs, power supply, water supply, approach roads to hospitals, etc. On the other hand, many assets are not being effectively utilised. For instance, quarters are lying unoccupied due to want of maintenance or due to their isolated location; equipment is lying idle due to want of repair and replacement of parts, materials such as drugs and consumables are wasted due to improper storage and inefficient supply chain management.
High Out of Pocket (OOP) Expenditures: People with the least means have less access to healthcare and have to bear the brunt of high OOP expenditure for care which continues to be one of the important causes of poverty in India as per the report of the National Sample Survey Organisation (NSSO) and which also acts as a financial barrier to healthcare. The cost of hospitalisation is still very high, leading to OOP expenditure and bankruptcy in many families as there is a lack of protection from financial liabilities arising out of health events. Except for the Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) for vulnerable families and medical reimbursement for Government employees and their dependents, there is no proper financial protection system or social security net to protect families from financial hardship and impoverishment arising out of health problems. As development and strengthening of the health system is time consuming and resource intensive, in order to promote accessibility and affordability of quality healthcare services there is a need to develop a strong social security net.
Strengthening Communitisation: Presently, community participation is limited only to the extent of contributions towards infrastructure development of the institutions. This needs to be further strengthened to help achieve Universal Health coverage in a holistic manner.
Capitalising on Information Technology (IT) Services: Due to poor network connectivity, it is difficult to reap the benefits of IT services such as telemedicine, e-Governance, etc.
On the other hand, the measures and strategies for success of the visions are:
Reduce Maternal Mortality Rate (MMR): Promotion of quality antenatal care (including 4 or more antenatal check-ups or Antenatal Care (ANCs), 100 iron folic acid (IFA) tablets, 2 TT/Booster, monitoring foetal growth, first trimester registration, screening and tracking for complications such as anaemia, preeclampsia, and counselling for birth and emergency preparedness, neonatal care, breast feeding, etc.
Strengthening outreach services through Integrated Village Health Nutrition Day (VHND) as a community-led intervention focusing on communitisation and the strong social capital of the State.
Implementation of Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) for comprehensive ANC services on the 9th of every month.
Convergence with ICDS during Poshan Abhiyaan with focus on ANC and nutrition and raising awareness on the importance of the first 1000 Days and Pradhan Mantri Matritva Vandana Yojana (PMMVY).
Collaboration with Nagaland Health Project with focused activities like community-led interventions, outreach sessions, Reproductive and Child Health (RCH) camps in selected villages focusing on ANC, immunisation and institutional deliveries through incentive-based financing.
Identification of High Risk Pregnancy Tracking during ANCs and ensuring all high-risk pregnancies reach an institution for hospital delivery.
Promotion of Institutional Deliveries and Care around Birth/Respectful Maternity Care: To improve the quality of care in labour rooms and operation theatres, National Laqshya Certification is being implemented at district hospitals and other high case load facilities.
To improve the quality of maternal and newborn care during intra and immediate postpartum periods through providers who are competent and confident, ‘Dakshata’ training will be expanded to all healthcare personnel involved in maternal and newborn care.
Operationalisation of High Dependency Units (HDU) at district hospitals and other high case load facilities.
Providing Blood Services along with appropriate skilled HR for Caesarean Sections in all district hospitals and CHC-First Referral Unit (FRUs).
Promoting Institutional Deliveries through Laqshya implementation and Dakshata training along with SBA.
To operationalise SCs and PHCs to Health and Wellness Centre (HWCs) for delivery of comprehensive primary health care.
Training of Health Personnel for Home Delivery: For home deliveries, the State will ensure one auxiliary nurse midwife (ANM)/General Nursing and Midwifery (GNM)/Community Health Officers (CHO) attend each delivery with use of misoprostol tablet and proper birth planning. The State will saturate all facilities with Skilled Birth Attendance (SBA) and Dakshata trained staff, line listing of all pregnant women by ASHAs, and consequent follow-up to ensure safe delivery.
Implementation of Maternal Death Surveillance and Response (MDSR): The State will strengthen community death reporting through ASHAs and monthly review of all deaths (maternal and child deaths including stillbirths) will be done at facilities and at the district level. State-level review meetings will be held under the Principal Secretary on a quarterly basis and action points will be implemented accordingly.
Reduce Newborn and Children Mortality: Strengthen Home Based Newborn Care (HBNC) for provision of essential newborn care to all newborns up to 42 days of life including counselling of mothers on exclusive breastfeeding, appropriate infant and young child feeding practices and hygiene by ASHAs so as to ensure that there is a continuum of care from health facility to home during the most vulnerable period. Follow-up of newborns discharged from the Special Newborn Care Units (SNCUS) is also to be undertaken by frontline workers through home visits.
Facility Based Care of the Sick Newborns by operationalisation of Newborn Stabilisation Units (NBSUs) at CHCs or first referral units (FRUs) for providing first level of care to sick newborns and establishment of SNCUs at district hospitals to provide secondary level of care to sick newborns for neonatal sepsis, premature and low birth weight newborns. Newborn Care Corners (NBCCs) in all labour rooms for initial resuscitation and care of newborns are operationalised.
Child Nutrition and Essential Micronutrients Supplementation through key interventions to improve overall nutrition status of children by promotion of Infant and Young Child Feeding (IYCF) practices for early and exclusive breastfeeding and complementary feeding including growth monitoring; Line Listing of Babies Born with Low Birth Weight by frontline workers (ANMs and ASHAs) and follow-up for early detection of growth faltering.
Establishment of Nutritional Rehabilitation Centres (NRC) for providing medical and nutritional care lo children with severe Acute Malnutrition (SAM) at district hospitals with priority in districts with high prevalence of wasting. NRCs are to be linked to community based programmes and to ICDS for identification, referral and long-term nutritional rehabilitation of severely undernourished children.
Deworming will be done for the children once in 6 months with albendazole covering all schools, Anganwadi centres and health facilities.
Implementation of Anemia Mukt Bharat (AMB) in all districts including Weekly Iron and Folic Acid Supplementation (WIFS) for all children.
Integrated Management of Common Childhood illnesses: Implementation of Integrated Management of Neonatal and Childhood illnesses (IMNCI); Intensified Diarrhoea Control Fortnight (IDCF) campaign in all blocks for prevention and management of diarrhea; Integrated Action Plan for Pneumonia and Diarrhoea (IAPPD) with high case load and mortality Management of Pneumonia through frontline workers (ASHA, ANM) and at all levels of health facilities and National Vector Borne Diseases Control Programme for prevention, early detection and prompt treatment of malaria among children.
Vaccination Coverage: Ensure all infants receive vaccines against 7 vaccine preventable diseases (tuberculosis, polio, diphtheria, pertussis, tetanus, measles and hepatitis B).
Still Birth, Neonatal and Child Death Reviews: Reporting and reviews of all stillbirths, deaths of neonates and children in both communities and facilities with appropriate action points at all levels of healthcare.
Collaboration with Government Departments: Department of Social Security and Welfare (SSW) for supplementary feeding and nutrition activities of children during VHNDs and Poshan Abhiyaan activities and School Education Department (Village Education Committee) for regular check-up of the children, deworming, hygiene and sanitation and other WASH activities.
Social and Behaviour Change Communication (SBCC) Activities: Intense SBCC activities on breastfeeding, immunisation and complementary feeding through involvement of churches, civil bodies, SHGs and other stakeholders.
Implementation of Janani Shishu Suraksha Karyakaram (JSSK)/Referral Transport: JSSK should cover all newborns with reference to transport so that everyone has free services to the right facilities in a timely manner.
Reduce the Burden of HIV/AIDS: Intensifying and consolidating prevention services with a focus on key populations at higher risk and increasing access and promoting comprehensive care, support and treatment for them. Expanding information, education and communication (IEC) services for the general population and key populations with higher risks with a focus on behaviour change and demand generation as well as strengthening strategic information management systems.
Eliminate Tuberculosis (TB) by 2025: For this the Government proposes to launch Integrated Patient-centred Care and Prevention for early diagnosis including universal drug-susceptibility testing and systematic screening of contacts and high-risk groups through Active Case Finding (ACF), notification of all cases from the private and public sectors and robust sputum collection and transportation.
Political commitment and engagement of communities, civil society organisations and public and private care providers with adequate resources for TB care and prevention. A Universal Health Coverage policy and regulatory frameworks to be created for case notification while also intensifying research and innovation:
Eliminate Malaria by 2022: Early diagnosis, prompt and complete treatment through screening of all fever cases and timely referral of severe malaria cases. Case-based surveillance and rapid response through scaling of existing disease management and preventive approaches through Integrated Vector Management (IVM) and behaviour change communication and community mobilization through IEC.
Reduce the Burden of Non-Communicable Diseases (NCDs): Population Based Screening (PBS) for NCDs for all persons 30 years of age and above for early detection and management of common NCDs such as oral cancer, hypertension and diabetes mellitus and all women over 30 years for cervical and breast cancer. Ensure timely referral of suspicious cases to the PHC/CHC/DH for further examination and confirmation by a medical officer, physician, surgeon, gynaecologist or dental surgeon as appropriate.
Reducing Substance Abuse, including Narcotic Drug Abuse & Harmful Use of Alcohol: Extensive IEC activities, Monitoring of Tobacco Control laws, setting up and strengthening cessation facilities including provision of pharmacological treatment facilities at district level. Ensure universal access to sexual and reproductive healthcare services including family planning. Integration of reproductive health into present Government strategies and programmes.
Universal Access to Sexual and Reproductive Health Services: Ensure availability of pregnancy test kits with ASHAs and doorstep distribution of condoms, Combined Oral Contraceptive (COC) pills and Emergency Contraceptive Pills (ECPs) by ASHAs. Promotion of spacing methods such as injectable contraceptives (Antara programme), Intra Uterine Contraceptive Device (IUCD), Postpartum Intra Uterine Contraceptive Device (PPIUCD) and Post Abortion Intra Uterine Contraceptive Device (PAIUCD) in all HWCs and higher hospitals. Provide comprehensive abortion care or Medical Termination of Pregnancy (MTP) services. Management of sexually transmitted and reproductive tract infections.
Strengthen Adolescent Health Services: Setting up of Adolescent Friendly Health Clinics (AFHC) with a focus on sexual health, nutrition, teenage pregnancy and mental ailments.
Universal Health Coverage and Access to Quality Essential Healthcare Services: The average OOP expenditure per delivery in public health facilities is INR 5,83442, which is one of the highest in the country. Out of pocket expenditure is directly linked to the public expenditure on health. Under AB-PMAY, 2.33 lakh economically weak families are covered for health insurance of INR 5 lakh per annum for various medical treatments. The State will expand the beneficiary coverage to other vulnerable sections – women, children, old age and differently abled etc., of the society.
Telemedicine: Using telecommunication and IT to provide clinical healthcare from a distance will be initiated. Remote rural communities without medical services will be covered by this method.
Strengthen Health Systems and Promote Access to Services: Health infrastructure facilities in the State are currently inadequate. Better procurement and distribution systems need to be created, adequate health workers with the right skills and motivation need to be engaged and a financing system which covers the most marginalised is essential.
(Page News Service)