World Bank in India
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 World Banksupported 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.
“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.
“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.”
Vizonuo Thaprii, Chief Health Officer at
the Peren District Hospital.
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-yearold 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.
In Nagaland, the health indicators for pregnant women are among the lowest in the country.
Project Impact
Institutional deliveries increased from 33% to 46% (NFHS 4 to 5);
Antenatal care increased from 15% to 50%
Patients using OPD services increased by over 38%: From 8,81,480 in 2015 to 12,21,882 in 2023 (HMIS*)
Birth registration increased from 0% to 78%
In 2013-14, only 3.6% of pregnant women received full antenatal care, compared to the national average of 20%.
Only 18.6% of pregnant women delivered their babies in a health facility, compared to the national average of 79%.
Immunization increased from 40% to 76%
Registration of pregnant women to health facilities increased from 49% to 77%;
People who have received essential HNP services in targeted areas increased from 34,737 in 2018 to 3,64,025 in 2023
Development Dialogue
Logistics is key for India as a business destination
Auguste Tano Kouamé
An efficient logistics sector is pivotal for India to become a globally preferred business destination. It reduces manufacturing costs, makes businesses more competitive, and links them with global value chains, boosting the Make in India initiative. The sector is also one of India’s largest employers, employing over 22 million people.
In 2023, India ranked 38 out of the 139 nations in the World Bank’s Logistics Performance Index (LPI), up six places from the previous rankings in 2018. India has now set the ambitious goal of ranking among the world’s top 25 nations by 2030, bringing logistics costs down to the equivalent of less than 10% of GDP.
Decisive actions have been taken to develop a logistics backbone for the country. The national highways have expanded at an unprecedented rate, connecting ports to hubs of economic activity. The railways too have taken a quantum leap by building electrified freight-only corridors that link manufacturing centers to ports on the eastern and western coasts. Longdefunct inland waterways are being rejuvenated. Many routes — including National Waterway 1 — have been strengthened, and efforts are on to move cargo through new river-to-sea connections.
Over 22 million people are employed in the logistics sector in India.
The Pradhan Mantri Gati Shakti National Master Plan and the National Logistics Policy are key initiatives. The PM Gati Shakti initiative is breaking down the siloed approach to the planning and execution of multimodal infrastructure projects by integrating data from 16 ministries and departments onto a single Geographic Information System-based platform.
Port and customs services have also seen significant improvements. Cargo is now cleared much faster and containerized cargo can be tracked digitally. Today, it takes about a day for a ship to turn around at the Nhava Sheva (JN) Port in Navi Mumbai. This is almost at par with Singapore, a world leader in logistics, which takes just 0.75 days. Gujarat has been ranked the top performer among coastal states in India, and West Bengal is taking advantage of its strategic location by placing a new thrust on logistics infrastructure and services.
Average Turnaround Time at Port Mumbai
Even so, new technologies such as big data and artificial intelligence can be put to greater use to fulfil the vision of a nationally integrated, cost-effective, reliable, and digitally enabled logistics ecosystem.
First, the PM Gati Shakti platform can be overlaid with information on trade flows across the country. This will enable planners to mine the plethora of data available from the Goods and Services Tax Network and E-Way bills to see where infrastructure needs to be improved.
Second, the multimodal logistics parks planned with connectivity to railway corridors can serve as warehouses and data centers, attracting private sector service providers and investors, while giving manufacturers last-mile connectivity.
(24 hrs) | Singapore (18 hrs)
Third, the country’s youth will need to be equipped with the skills needed by this dynamic industry. Women too can benefit from new jobs, especially in softer skills such as packaging, sorting, and warehouse management. The Logistics Sector Skill Council is training workers in newer technologies to help them become full-fledged logistics professionals.
The World Bank has been supporting India through a variety of rail, road, and inland waterway projects. It is also helping the country increase digitization and improve trade services, among other measures, and supporting the development of skills for this rapidly evolving industry.
India’s push to improve its logistics performance will not only improve its trade competitiveness, but will also increase jobs, and enable the country to emerge as a logistics hub for the region and beyond.
Auguste Tano Kouamé is the World Bank's Country Director for India.
This Opinion piece first appeared in The Financial Express on July 17, 2024.
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