Manipur, a small state in Northeast India with a population of 2.7 million
and bordered by Mizoram, Assam, Nagaland and Myanmar is the fifth state heading into elections this year. The state is predominantly hilly and is divided into a total of nine districts (five hilly and four valley districts). It is well known for its gender equality and women's empowerment and performs better than the country's average in terms of health.
The previous decade witnessed a decline in Manipur's sex ratio from 1,014 to 962, however, it remains higher than India's average of 919
and one of the highest among the Indian states. Female literacy (age 15 to 49) and employment stand at 85% and 40.9%
compared to the national average of 68.4%
. Despite being a patriarchal society
of women in the state participate in household decisions and 69.9%
women own a house/and or land, almost twice the national average. While these numbers project a very progressive picture of Manipur, they fail to capture some of the key issues around health outcomes, coverage and infrastructure in the state.
The decline in Manipur's sex ratio, from 1,014 to 962 still remains higher than India's average of 919.
Analyses from Observer Research Foundation shows that public expenditure per capita on health (by both Centre and State) in Manipur is ₹1,364 — almost three times that of Uttar Pradesh (UP) and double of Punjab and India. Yet, the percentage of households with any usual member covered by health scheme or health insurance is 3.6
, at least three times lesser than the other election states (apart from Uttar Pradesh) as well as the national average of 28.7
. The percentage is even lower in the districts of Senapati (0.6%), Ukhrul (1%) and Chandel (1.1%)
. This indicates that majority of Manipuris pay medical expenses from their own pockets. (see figure 1
Figure 1: District wise percentage of households with any usual member covered by a health scheme or health insurance (%)
Source: NFHS 4
However, average medical expenditure on account of hospitalisation (private and public) is low at ₹7,226 as compared to the national average (public and private) of ₹18,268, indicating less out-of-pocket expenditure in Manipur. This low average medical expenditure on hospitalisation coupled with high public spending as well as low health insurance coverage implies that since Manipur has good public service provisioning, the concentration of hospitalisation cases is greater in public hospitals (approximately 89% for rural, and 79% for urban) than in private. This could be due to the fact that either public health services in the state are of good quality, or because people may be unable to afford private services, as total medical expenditure on account of hospitalisation is almost thrice as much in the private sector. (see figure 2
Figure 2: Public health expenditure and average medical expenditure on hospitalisation for India and Manipur
Source: MoHFW, NSSO 71st round
This can be viewed as a positive outcome since the burden of medical expenditure is not solely borne by the individual in contrast to states such as Himachal Pradesh (another state with a hilly terrain), where the expenditure stands at 14,431 or Chandigarh, where the same expenditure is ₹34,604. In spite of the average expenditure on account of hospitalisation being lower than the India average, the mean out-of-pocket expenditure per delivery in a public health facility in Manipur is a startling ₹10,076
, the highest in the country. The factors contributing to such a high figure remain unknown and therefore, further research needs to be undertaken in order to explain the unusually high number that rivals even the national capital.
In spite of the average expenditure on account of hospitalisation being lower than the India average, the mean out-of-pocket expenditure per delivery in a public health facility in Manipur is a startling ₹10,076, the highest in the country.
In terms of health manpower, Manipur fares better than most Northeastern states, with one of the highest number of nurses per capita
after Kerala. The state comprises
of two tertiary healthcare centres, seven district hospitals, 59 primary health centres (PHC) and 148 sub health centres (SHC). 76.4% of villages have a PHC within a distance of 10 kms and 75.2% of villages have a SHC within 3 kms. The total shortage of sanctioned specialists at CHCs across Manipur is 96%
as compared to the national average of 81%. While the shortage of specialists at the CHC levels is appalling, it is important to acknowledge the presence of the Regional Institute of Medical Sciences in the state capital, which serves as the hub for specialist care in the Northeast However, this is not to overlook the fact that CHCs are meant to be staffed with specialists. On the other hand, PHCs
seem to be well staffed with only two percent of PHCs in the state without a doctor, 39% without a lab technician and 22% without a pharmacist. Problems of health infrastructure are more prevalent in the hilly districts of Manipur. The number of assisted births by a doctor/nurse/LVH/ANM in two valley districts — Imphal East and Imphal West are 72.8% and 78%
respectively compared to the hilly districts of Tamenglong and Ukhrul, which stand at 32% and 34%
. This is highly problematic since the number of assisted births should ideally be 100%. (see figure 3
Problems of health infrastructure are more prevalent in the hilly districts of Manipur.
Figure 3: District wise percentage of assisted births by a doctor/nurse/LVH/ANM
Source: NFHS 4
In terms of key health indicators, Manipur does better than the national average. Its infant mortality rate (IMR) stands at 22
, compared to India's average of 41
and under-five mortality rates (U5MR) is 26
, half the country’s average. Furthermore, NFHS four data shows that while Manipur's child immunisation are higher than the national average, only 32.1%
of children received a Vitamin A dose, almost half of the all India average. Even though there has been a monumental increase from the third round of NFHS survey of almost 20% from 11.2%, there needs to be much wider coverage, especially in the rural districts. In fact, the disparities are more pronounced between hilly and valley districts (see figure 4
The percentage of men and women in Manipur who are overweight, obese and have high blood sugar levels is higher than that of the country’s average.
Figure 4: District wise percentage of children fully immunised (BCG, measles, and three doses each of polio and DPT) (%)
Source: NFHS 4
Over half of the deliveries in private health facilities are performed by a caesarean section in urban Manipur. The same number for public health facilities is lower, at 30%. However, these numbers are still much higher than the WHO recommended estimates
for caesarean deliveries, i.e. between 10 to 15%. (see table 1
Table 1: Percentages of births delivered by caesarean section in public and private facilities in Manipur.
|Total births in a public health facility delivered by a caesarean section (%)
|Births in private health facility delivered by a caesarean section (%)
|Births delivered by a caesarean section (%)
Source: NFHS 4 Manipur
Both men and women in the state also consume higher levels of alcohol and use some form of tobacco compared to the Indian average. The state also grapples with a major drug issue — heroin being the most common. According to a report by the United Nations Office on Drugs and Crime (UNODC), Manipur has the highest number of female injecting drug users (28.2%)
in the Northeast. Manipur's location
— next to southeast Asia's Golden Triangle, infamous for drug smugglers — exacerbates the prevalence of drug use as it is cheap and easily available. High levels of drug use, especially heroin also furthers the spread of HIV in the state. The current level of HIV among the adult population of Manipur is 1.15%
— highest in the country and four times the all India average. However, knowledge of HIV/AIDS among adults (age 15 to 49 years) in Manipur is considerably higher than that of the general Indian public and prevalence of HIV has dipped since the previous year.
Manipur's location — next to southeast Asia's Golden Triangle, infamous for drug smugglers — exacerbates the prevalence of drug use as it is cheap and easily available.
The overall state of healthcare in Manipur seems to be encouraging. The MDG national targets
for IMR and U5MR have successfully been achieved by a substantial margin. Other child health and maternal health indicators also appear to be doing better than most states in India. While these indicators may present a success story, it is critical for the incoming government to address issues relating to the serious drug problem, which is also contributing to the high prevalence of HIV plaguing the state. Health infrastructure challenges such as the lack of specialists at the CHC level and inaccessibility of trained staff for deliveries in rural, hilly regions also need to be addressed. Furthermore, the onset of lifestyle diseases like high blood sugar and overweight and obesity in adults needs urgent attention.
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