Community Ownership helps Improve Health Services in Nagaland

A few years ago, the Peren District Hospital in India's northeastern state of Nagaland was in a poor condition. It was dusty, had shattered floors and there were no handwashing or toilet facilities for patients. There was no operation theatre, forcing emergency services to be performed in the corridors. The labour room was so congested that Dr Dietho Koza, anaesthesiologist and critical care specialist, recalls performing Caesarean surgeries under torchlight.

Today, with World Bank support, the hospital is a changed place. It now has a well-equipped labour room and a designated corner for the care of newborn babies. An improved drainage system has reduced stagnant water and biomedical waste is now disposed of properly, making the hospital safer for the staff and patients, as well as for the environment.

As a result, in just four to five months, the hospital delivered around 56 babies, compared to just 50 babies delivered in an entire year.

Improving health services, even in the remotest regions

Bringing health services to Nagaland's people, especially to those in far-flung regions, has long been a challenge. Around two-thirds of the state's 2.2 million people live in rural areas where road connectivity is poor, electricity is unreliable, and water supply and sanitation are inadequate. The shortage of specialist physicians and skilled healthcare workers leads to few deliveries in health facilities - the lowest in the country. Immunization rates are also low, and it has been difficult to address child malnutrition and mortality.

But this is changing now. Since the Nagaland Health Project started in 2018, the functioning of 188 health centres across the state has improved, with more than 8,36,000 people now receiving some form of health service.

For instance, the Primary Health Center (PHC) at Thonoknyu - one of the state's remotest facilities, over 260 kms from the capital Kohima - was rarely visited by patients. Now, the old, dilapidated building has been refurbished, and new water and sanitation facilities installed, leading to a notable increase in patients visiting the center.

"Many changes have happened, like the labor room, rainwater harvesting reservoir, improved drainage and biomedical waste management systems," described Pehie, a pharmacist at the PHC. "Now, many more people come to us for treatment."

Promoting community ownership

An important step forward in improving Nagaland's healthcare was empowering local communities to take ownership of their health services by revitalizing the state's pioneering 2002 Communitization Act.

Under the Project, the village health committees were reconstituted, and it was made mandatory to have a woman as a co-chair, which helped in strengthening the focus on maternal and child health. Today, the 500 or so village health committees that have been formed across the state have a woman as a co-chair.

"The project taught us that health services are not only the responsibility of the government but the shared duty of villagers too," said Mrs. Zhito, co-chair of the committee in Mehuli village.

The village, which has a female population of just over 2,500, encouraged pregnant women to visit the facility for check-ups and immunizations by distributing carefully chosen gifts to them, such as flasks, eggs, and baby blankets, giving them a sense of support from the community.

Yaongyimsen village, on the other hand, adopted another innovative approach when it introduced door-to-door visits with food packages for the underprivileged and elderly.

"Taking up the role of co-chair has helped me become more empowered and aware," said Ms. Tatongkala, who introduced the idea when she was elected as co-chair. "And it has furthered my learning about women's health issues."

Improving medical education

To meet the shortfall in health specialists, the functioning of nursing and midwifery schools in five cities was improved, with faculty members being trained in modern management practices. This helped the faculty to improve their teaching methods and adopt innovative approaches to nursing education. Previously, the four nursing schools in the state operated at less than half their capacity. As a result of this initiative, seating capacity in five nursing schools has been expanded to accommodate the growing number of students, significantly boosting enrolment. Additionally, quality of services in terms of infrastructure, furniture, equipment and learning aid has also been increased in select nursing schools and paramedical institutes of Nagaland

Ensuring reliable power supply

To solve the challenge of erratic electricity supply, the project helped harness the sun as a cost-effective and reliable option, especially in the remote areas.

Now, 175 health facilities have solar installations, ensuring stable power supply for surgeries and other procedures.

"Patients now receive uninterrupted services with the help of 24x7 electricity backup from the solar plant, enabling electronic machines to run and vaccines to be stored in the refrigerator. It has been a great relief during deliveries," said Vizonuo Thaprii, Chief Health Officer at the Peren District Hospital.

"The availability of 24x7 power supply has enabled the smooth delivery of health services even when there is no grid supply," said Dr. Tumchobeni, the Medical Superintendent at the district hospital in Wokha. This shift has not only cut fuel costs but has also led to a 1,240-tonne reduction in carbon dioxide emissions.

Diagnostic services

In addition, patients no longer need to travel long distances for simple medical tests. The lab at the Chunlikha PHC, for instance, has received equipment that makes medical tests possible at the facility. The lab, which serves 10 villages and over 15,000 people now gives results on the day of the test, saving patients time, effort, and expense in travelling 58 kilometres to Kohima.

"I go to the PHC for a kidney function test and liver function test every six months; these are done free of cost," said Senlo Kath, an 80-year-old patient of hypertension and diabetes.

Sanitation and waste management

To tackle the non-availability of water, the project introduced rainwater harvesting. Around 70-80 lakh litres of water are now collected every year which, along with other water storage systems, meet the needs of 176 health facilities across the state, helping improve handwashing and sanitation.

The introduction of scientific biomedical waste management at district hospitals in the state has also made a difference.

"These facilities have transformed the way we handle medical waste and have played a huge role in reducing infection among the handlers and the larger population," said Dr Senilo, Medical Officer at Tuensang District Hospital. In fact, the hospital at Tuensang was awarded for being the cleanest and most eco-friendly hospital in the state.

Digital Interventions

The project has also supported inventory management of drugs and medicines at all warehouses and health care facilities up to the PHC level. This inventory can be viewed at the state level and by the public, helping plan drug supply and preventing stock-outs. A similar management system has been created for medical equipment up to the PHC level, which includes physical verification, monitoring, and maintenance.

Through these comprehensive efforts, the World Bank supported Nagaland Health Project has significantly transformed healthcare in Nagaland, ensuring better health outcomes and an improved quality of life for the people.

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