Sunday, January 31, 2010

Health for All and All for Health: Sorry Condition of Health Sector in Manipur

The photograph carried in the Sangai Express (English edition) (dated January 30, 2010) of special room/isolation room for treatment of swine flu patients tells the sorry tale of government hospitals/health centres in Manipur. The slogan Health for all and All for Health does not seem to carry any significance in this State. News items involving treatment of trauma patients and others are filled with phrases like "referred to Shija Hospital", that’s too from leading hospitals such as Regional Institute of Medical Science (RIMS) and Jawaharlal Nehru Hospital (JNH). The pitiable condition must be read at a time when JNH is aspiring to be upgraded to the Jawaharlal Nehru Institute of Medical Sciences (JNIMS).
Good health is an integral component of human wellbeing. It is a fundamental human capacity that enables every individual to achieve her/his potential to actively participate in social, economic and political processes. In particular, a growing body of evidence highlights the importance of the early years in the development of individual potential. Overall, improving the health of its large population, especially among the most economically and socially vulnerable sections of the society, is central to the achievement of human development of any state or nation.
Despite the low level of material well-being and health infrastructure, the state has an impressive record on select public health indicators. According to the National Human Development Report 2001, Manipur had the lowest infant mortality rate in the country from as early as 1981. But this is a concomitant of the unique socio-cultural context, wherein child birth and child rearing is regarded as a community duty (for example, culture of care given to pregnant women by the relatives and community as well as the culture of shared breast feeding). Therefore, it is not solely a contribution of health facilities that have given such a record to Manipur.
Health infrastructure
The Health and Family Welfare Department of the State provides services such as public health, control of communicable diseases, health education, family welfare and maternal and child health care through a network of 14 Civil Hospitals, 72 Primary Health Centres, 420 Primary Health Sub-Centres, 16 Community Health Centres, 20 Dispensaries and 7 Drug De-addiction Centres as in March 2002. JN. Hospital also known as State Hospital is being developed into a super-speciality hospital. It is a 200 bedded hospital providing services in 11 clinical disciplines. Regional Institute of Medical Sciences (RIMS) was established on 14th Sept. 1972. This Institute is a joint venture of the north eastern states viz. Manipur, Meghalaya, Mizoram, Nagaland, Tripura and Arunachal Pradesh. It is fully funded by the Government of India through the North Eastern Council (NEC) and the six beneficiary states, later transferred under the supervision of the Ministry of Health, Government of India. The campus of the institute occupies 192 acres of land and comprises of one 881 bedded hospital and a medical college having 25 major departments including super specialities with an extensive area of residential campus for the staff and adequate hostel accommodation for the students.
Churachandpur District Hospital is the biggest district hospital having 100 beds. There are seven District Hospitals. District hospitals in the State other than Churachandpur district hospital have beds ranging from 25 to 50. These hospitals are handicapped due to absence of blood bank. As a result of which major operations are not performed regularly.
Only consolation with the people of Manipur is the huge number of private hospitals, nursing homes and clinics but mostly confine in the urban areas. These private health institutions are registered under the State Health Department. Some of the notable registered nursing homes and clinics under the Department include Shija Hospital & Research Centre, Babina Diagnostic Centre, Catholic Medical Centre etc.
The mere existence of health infrastructure has no necessary correlation with the accessibility and quality of services provided and the changes in the existing health situation and/or the current morbidity, burden of the population. Most doctors in Manipur are trained in the allopathic system of medicine. Sixty per cent of doctors are located in rural areas. However, as compared with other districts, there are disproportionately more doctors in urban and rural areas of Imphal district. No district had even one doctor per 10,000 population. There are no data available on other health care personnel in the state, such as nurses, auxiliary nurse, midwives and traditional birth attendants. Another interesting aspect is that as per Manipur Development Report, since 1971, more patients received treatment from nurses, midwives and dais than from doctors. The same Report observes, majority of the patients have been treated outdoors than as in-patients.
Policy guidelines
At present there is no framework guiding the development of Health sector. Accountability for well-being and regulatory mechanisms for private sector in Health is almost missing. Most importantly there is no leadership which could show the appropriate direction for health sector growth. The enlightened advice and guidance for channelzing the investment in health sector is missing. Government negligence and apathy and absence of guiding framework has given opportunity for the mushrooming of private hospitals and clinics in Manipur. It is only recently that the Government has come out with the notice demanding registration of the private health institutions.
Dakshina Piba Culture in Government hospitals
Today, we witness in Manipur replication of a form of exchange relations in the Government health institutions, popularized by colonial ethnography in the Indian sub-continent popularly known as the Jajmani system. In its classical construct, different caste groups specialized in specific occupations and exchanged their services through an elaborate system of division of labor. Though asymmetry in position of various caste groups was recognized, what it emphasized was not inequality in rights over land but the spirit of community. Each served the other and each in turn was master. Each in turn was servant. This system of inter relatedness in service within Hindu community was called the Jajmani system. Central to such a construction of exchange is the idea of reciprocity with the assumption that it was a non-exploitative system where mutual gratification was supposed to be the outcome of the reciprocal exchange. Permanent informal bond is made between the giver and taker to meet each other’s need for good and services.
Key features of the Jajmani system included hereditary relationship in which Jajmani rights are enjoyed hereditarily. After the death of a man, his son is entitled to work for the same jajman (patron) family or families. Second relates to barter exchange, in which the payments are made mainly in terms of goods and commodities. These are two key areas which have attracted attention of Indian sociologists and explicate examples, such as presentation of gifts during times of festivals by the jajman to kameen (person providing the service) as token of thanks and love, which later on become a jajmani right. In such cases, the notion of mutual exchange becomes invalid, but rather demanded as a right.
The replication can be observed in the relationship between the doctors and pharmacists, on one hand in which patients who do not buy from particular pharmacies referred to by the doctors or use laboratory facilities of an indicated clinic faces ire from the doctors. On the other hand, the culture of Dakshina Piba is most heard chanting, especially, in the gynae-wards. While Dakshinas are offered as a means of thanksgiving, very often these are demanded by doctors/nurses, the moment an expected mother hits the ward. These are the cultures, which medical professional needs to shed.
Do we have a way forward?
Do we have a way forward? This is a question disturbing Yenning. Particularly in Manipur and North Eastern part of India, where the Government of India have neglected since the beginning till date, what will the Government do to improve the heath services? There is a not single health care facility, valley or hilly area, run by the State. The implementation of health care programmes are the must in our state. The upgradation of two district hospitals in Manipur, the Churachandpur and Bishnupur district hospitals to Indian Public Health Centre under the National Rural Health Mission (NRHM) must similarly be spread to other parts of the districts especially in the hilly districts where common people can really utilize the facilities in a worthy manner. The process of these programmes cannot take it into serious account until and unless they spread the seed of health care service messages. Verbally anyone or all of us can claim that the programmes have been launched, building construction of sub-centres are on or completed and the initiatives are operating under the guidance of the experts. The concerned authorities should not try but should make it sure to implement the objectives of the Health for All and All for Health in all the nine districts and 36 blocks. The movement cannot be sustained if the authorities do not work with a will.
This article was posted on The Sangai Express on Sunday, January 31, 2010

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