In Nagaland, Missing Health Services Are a Matter of Life and Death

Massive central funding for health and development goes missing on the ground, leaving residents of remote districts to fend for themselves.

Tuensang (Nagaland): “There’s a rumour that people die there,” said Nokying Chang, about the hospital in Tuensang, in eastern Nagaland. Chang, 45, is a farmer from Momching, a village about 36 km away. He is a first-generation learner and said he didn’t know much about healthcare, but he was sure of one thing – his wife, a mother of seven, would not be treated at the government-run district hospital.

In 2014, when Chang’s wife first had severe vaginal bleeding, they went to the Public Health Centre in Longpong, which functions in a public-private partnership between the National Health Mission (NHM) and the NGO Eleutheros Christian Society (ECS). She was treated during an annual surgical camp conducted there.

In late 2016, her health deteriorated again. This time, Chang consulted a doctor in Tuensang town, who told him there were complications in the uterus which would require a blood transfusion and then an operation costing Rs 30,000. But Tuensang, the largest district in Nagaland, has no blood bank – and Chang was not taking his wife to the hospital.

“We haven’t looked for blood yet. Where will we get it from? We won’t be able to arrange for it,” Chang said, matter-of-fact. All seven of his children were delivered at home. “So we decided it’s fine, we’ll give her medicines in the village and she’ll be alright,” he said quietly.

In Momching, as in most of eastern Nagaland, citizens rely almost entirely on the government for healthcare – but usually go without. Data shows large amounts being spent on health, but on the ground, health centres lie ill-equipped or defunct. NHM employees are unpaid and have no incentive to do their duties and district officials are rendered helpless by corruption at the top.

Already enduring the isolation caused by geography and terrain and decades of conflict, locals are helpless and suffer silently in the absence of basic state support.

For the 113 households of Momching and two other neighbouring villages, the nearest health facility is a sub-centre where a nurse is only available ten days in a month. The other twenty days it is shut. When open, it seldom has a stock of medicines.

Four shared taxis ply from Momching to Tuensang, the district headquarters each day. They take two hours and charge Rs 200 each way; unaffordable for most villagers, who have to walk instead. Unable to easily access a health facility and the distrust in the system meant that most villagers did not receive any medical care.

Two of his neighbours in Momching had asked Chang to buy medicines for them on his way back from Tuensang town. “So many people have made a business of selling medicines because the sub-centre seldom provides them and there is no doctor around to prescribe anything,” Chang said. Paan shops and some village households have begun to stock Fanceta, a painkiller, and Panloc (pantoprazole), which they sell at higher rates – for instance, a pill of Panloc is sold for Rs 5, double the market price. “Children in the village keep falling sick these days, mainly vomiting and stomach upset,” Chang added. “But none of them have received any treatment or gotten better. They just take these painkillers.”

Decades in the waiting room

Since the 1950s, forces within Nagaland have rebelled with arms against the Indian state, demanding sovereignty and seeking to preserve their identity. Four major and at least five minor separatist groups remain, each running a parallel government of its own and levying taxes.

During search operations last October and earlier in January, the National Investigative Agency (NIA) found evidence that state funds were being transferred to separatist groups, including the banned National Socialist Council of Nagaland-Khaplang (NSCN-K). Three government officials were recently arrested over these charges of extortion and illegal tax collection.

Meanwhile, the massive funding offered to the state for development does not find its way into schemes and projects – and is often pocketed by state officials and politicians.

According to the National Health Profile 2016, published by Central Bureau of Health Intelligence, Nagaland had the seventh-highest per capita health expenditure (Rs 1,707) and fifth-highest health expenditure as a percentage of gross state domestic product (2.23%) among all states in 2013-14. The state spent a total of 395 crore on health. According to staff at the Directorate of Health and Family Welfare, however, more than 90% of this amount was spent on staff salaries. Only a small amount of the state health expenditure was available for service delivery. The state was largely dependent on central schemes, the NHM and its flagship programmes to provide healthcare.

This discrepancy between expenditure on health and access to healthcare was evident in the recent National Health Family Survey, 2015-16 (NFHS-4), which showed Nagaland below national average in almost all indicators of maternal care and child immunisation. The districts in eastern Nagaland scored the lowest – with only 3% of mothers in Mon district receiving at least four ante-natal check-ups, for instance.

In 2015, Human Rights Law Network (HRLN) Nagaland filed 20 public-interest litigations against the health department, including on the misappropriation of 62 crores under the NHM, non-functioning anganwadi pre-schools and the absence of infrastructure at health centres.

Addressing local media in 2016, director of NHM (Finance), Kavita Singh said that the state treasury was not releasing funds sent by the Centre for the scheme. This meant that health programmes in the state were making no progress and NHM staff was often unpaid for months at a stretch. The state was also failing to match its share of funding-pattern due to a budget deficit. State employees continued to be paid on time, but crucial central schemes suffered.

The report of the comptroller and auditor general of India (CAG) on Nagaland state finances for 2014-15 clearly states that funds from the Centre go unmonitored. Misappropriation and non-payment of salaries occurs specifically with those schemes. “As long as these funds remain outside the state budget,” the CAG report stated, “there is no single agency monitoring its use, and there is no readily available data on how much is actually spent in any particular year on flagship schemes and other important schemes which are being implemented by state implementing agencies but are funded directly by the GoI.”

“We have to keep raising the issue with the local media and threaten to go on strikes so our salaries are paid. It’s exhausting,” an NHM doctor in Dimapur said.

“The Centre monitors only well-performing districts so we’re kept on our toes,” another doctor pointed out. “No one knows what’s happening in the remote areas.”

While NHM doctors and other employees were overworked and unpaid in districts like Kohima and Dimapur, in remote districts like Mon and Tuensang they were largely absent. A field study conducted by HRLN in early 2016 found most sub-centres and PHCs in these districts shut. Since medical staff weren’t receiving salaries for months at a stretch, they often placed themselves in towns and visited their rural postings – like Momching – a few times a month or on monthly immunisation days.

“Villagers spend most of their time working in the fields and have no one to go to in emergencies,” said Marina Dangmei, a social activist with HRLN, who was a part of the field study. “In the absence of any effective intervention, there was a complete lack of awareness about health and well-being.”

In these districts, the NHFS-4 survey highlighted, residents were almost entirely dependent on government healthcare, which they did not receive.

Broken links in the supply chain

The rumours Nokying Chang had heard about the district hospital in Tuensang probably have do with the fact that the 100-bed facility has been functioning poorly.

During my visits, last September and this April, it had no anaesthetics, no gynaecologist on regular duty and its doctors were being transferred without being replaced. General surgeons were conducting emergency caesarean sections under pressure. In case of an obstructed labour during a delivery, a patient would be referred to the district hospital in Mokokchung – five hours away over broken roads.

In 2002, Rs 3 crore was allocated towards a regional diagnostic centre in the district hospital, but it only received a non-functional CT-scan machine. An ultrasound remains sealed and unused. Patients were referred to private clinics for these examinations. Technicians arrived from Kohima to fix the X-ray machine this April, a year after it broke down.

According to one employee, speaking on the condition of anonymity, it was futile for the storekeeper of the hospital to even make a list of required medicines to send to the Directorate of Health Services’ central store in Kohima. They only received pre-packaged cartons of medicines at random. Anti-hypertensives, which are in demand in cities and seldom in Tuensang, often come in bulk. The store-keeper has to sign vouchers that specify the quantity of medicines, but he is unable to count them there; when boxes are opened in Tuensang, they sometimes hold just 300 strips instead of the 1,000 he signed for.

The hospital has not received any medicines so far this year. “How long will 500 bottles of IV last in a district hospital?” the employee remarked.

To transport the drugs, vehicles are hired at a steep private rate. Last March, the hospital’s only ambulance had an accident. The hospital authorities, as well as local student and women’s associations, sent several letters to the health department about it, but have had no positive response.

“Those in Kohima decide what is required for Tuensang. We are not informed about funds. We have no say in what is bought and what quality is bought,” the employee said.

According to Chongsen Mongea, programme manager of ECS who earlier worked as the district programme manager for NHM in Tuensang, district level officials work on a project implementation plan every year in which they rigorously plan the required projects and funds for the district.  “But it is a futile exercise. When the approval comes from Kohima, the sanctioned plans and assigned funds are completely different from what is required. This is why things should be decentralised,” he said. “You can’t often blame the medical staff because they are asked to work while being provided insufficient resources.”

The human cost of corruption

Families across Eastern Nagaland are affected by broken supply chains and allocation of insufficient funds which keep health units from functioning efficiently.

For Bechung Konyak, a security guard and the resident of Tobu village in the far eastern district of Mon, the nearest health facility is a Community Health Centre (CHC) in the outskirts of the village, about 3 km away. His wife, Bemang delivered seven of her eight children at home. None of them have been immunised, beyond getting polio drops. “We’ve never been informed about these things,” she said.

In 2013, Bemang and Konyak lost a five-year-old daughter. They followed the advice of doctors at Tobu CHC and took her to Mon district hospital, where she was admitted for two months, but they never received any reports nor learnt the cause of her death. Konyak was unsure if her blood samples were ever sent to a laboratory. “We got her dead body home,” he said.

Last year, when their 6-year-old daughter Esang complained of severe stomach ache, they rushed her to Tuensang district hospital, where the doctors said she couldn’t be treated, and then to the district hospital in Mokokchung. The taxi to Mokokchung cost Rs 5,500, which they could only afford with the help of ECS. “She was operated an hour after we reached, and was saved only because we made it in time,” Konyak said.

Konyak’s job, guarding the additional deputy commissioner’s office, pays him

Rs 3,450 per month. He says he has not received his salary for four months now. He has debt of about a lakh, most from spending on medical expenses for his daughters.

Like the district hospital in Tuensang, Tobu CHC, too, was understaffed and underfunded. It covered more than ten villages with just two doctors. The CHC also received fewer medicines from Mon than what was signed for – they were informed that this was due to cuts made from the funds as taxation by militant groups.

Konyak is not fully aware of what has happened to Essang. When he showed her medicines to Sentimoa Tzudir of ECS, who was accompanying me, we realised that they were for Tuberculosis (TB). Tzudir advised him to consult a doctor again once the course was over. “Can she be treated here now? We won’t be able to go all the way to Mokokchung again,” Konyak said, his face creased with worry.

Sarita Santoshini is an independent journalist based in Assam, reporting on human rights, development and gender issues.