Sikkim, at times, can be a state of contrasts. When seen from the prism of one of the ‘northeast states’, it is, undoubtedly, the most developed, the most peaceful, and the most affluent. The state, given its serene landscapes and close-knit communities, is hardly ever in the news for the wrong reasons; barring natural disasters. With the highest per capita income among all Indian states, to say that Sikkim has done well after it joined India in the 1970s would neither be a hyperbole nor an exaggeration.
But there is another side of Sikkim that often gets overlooked; something that continues to impact locals. The state, for all its affluence, has only one major hospital, the Sir Thutob Namgyal Memorial Hospital, and even as we step into 2025, the state does not have a government medical college.
And this has begun impacting locals’ lives and health. Perhaps the most damning data to support this argument is that Sikkim needs eight specialist doctors for its CHCs, but, currently, no positions are filled, highlighting a complete absence of specialists, as revealed by the Health Dynamics of India report 2022-23, released by the Ministry of Health and Family Welfare.
There is no doubt that Sikkim, also known as the Himalayan State, faces unique challenges in delivering robust public healthcare, particularly in its remote rural areas. What might be a one-hour ride in other parts of the country may become a day-long ride in Sikkim; and during the monsoon season, such a ride may not even be possible thanks to landslides, especially in the higher altitude regions.
Extensive conversations with community health providers like ASHA facilitators and mid-level health officers reveal the strengths and shortcomings of the system. Their stories highlight the dedication of healthcare workers and the systemic reforms necessary to improve the well-being of the state’s indigenous populations.
A well-structured system missing crucial pieces
Healthcare in Sikkim is structured across multiple levels, from state referral and district hospitals that provide specialized care to community health centres (CHCs) and primary health centres (PHCs), which serve as lifelines for remote regions. These institutions, supported by sub-centres, form the backbone of public healthcare, relying on professionals like Kala Pradhan, an ASHA facilitator at Lingdok Health and Wellness Centre, and Laso Moong Lepcha* (name changed), a Community Health Officer (CHO) in Tingvong, North Sikkim.
Kala Pradhan, with nearly two decades of experience, plays a critical role in her community. She ensures timely vaccinations, maternal care, and management of emergencies despite numerous logistical challenges.
Recalling one harrowing night during the monsoon, Kala described how a pregnant woman in critical condition was transported using a truck and a private vehicle, exemplifying the ingenuity and determination required to deliver care in rural areas.
Each ASHA facilitator is assigned a specific area of responsibility. “We receive regular training through various formats, including phone calls, online sessions, and in-person workshops. The nurses engage in telecall-ing with doctors, although we do not have a doctor on-site. The nature of our work has become increasingly challenging, particularly with the transition to online tasks such as data entry, which we struggle to manage effectively due to technological limitations.
While we are equipped to handle medical emergencies involving women and children, we have not yet facilitated home deliveries; such cases are referred to the main hospital for further assistance,” Pradhan tells this reporter.
Similarly, Laso Moong Lepcha sees her four-year tenure as transformative. Far from dulling her skills, working in rural areas has sharpened them, requiring her to address diverse cases. However, she underscores the pressing need for infrastructure improvements, increased manpower, and the deployment of specialists to PHCs, which rely on referrals to distant centres for advanced care.
What public health, when even roads are missing?
The challenges of healthcare delivery in Sikkim are multifaceted. Remote areas like Lingdok and Tingvong suffer from severe road connectivity issues, which are exacerbated during the monsoon season. Kala notes that having an ambulance in these regions would be a “game-changer.” In addition to transportation hurdles, key facilities often lack essential equipment and medications. For example, the Rabongla PHC is unequipped with diagnostic tools such as CT scans and X-rays, forcing patients to travel to Namchi or Gangtok for basic services.
Manpower shortages further strain the system, with existing staff stretched thin due to the absence of specialists. Behavioural and cultural barriers also complicate healthcare delivery. Laso Moong Lepcha explains that many patients initially consult traditional healers or rely on herbal remedies, delaying critical care and worsening health outcomes. Addressing these cultural hesitations requires sustained health awareness campaigns.
Tashi Dem Bhutia* (name changed on request), a resident of Kewzing village, Ravangla, South Sikkim, who has closely observed the healthcare scenario in her area, confirms that the Primary Health Centre (PHC) provides basic services and has essential medical equipment. “…the recurring problem is the unavailability of doctors at times, which forces us to travel further to Namchi District Hospital for treatment,” she pointed out.
The PHC, she said, lacked advanced diagnostic tools such as ECG, CT scans, ultrasounds, and X-rays. “Although the medical staff, including female healthcare workers, are approachable and make us feel comfortable, critical services like chronic illness management are absent…the lack of pediatric care and specialist consultations creates significant challenges for families like mine and others in the community,” she added.
Talking about Health workers, including ASHA workers, she added, “They play an important role in our village. They visit occasionally, especially when needed, to provide essential information about vaccinations, maternal health, and basic health checks like blood pressure and sugar levels. I’ve participated in health awareness programs and found them helpful, though I believe there is room to enhance these efforts to inform and educate the community.”
Financial strain adds another layer of complexity. Although government schemes like the Pradhan Mantri Jan Arogya Yojana (PMJAY) exist, their reach remains limited.
For patients like 26-year-old Gaebu Lepcha, who sought treatment for sepsis outside Sikkim, the financial burden was overwhelming. “I was referred from the state hospital to Neotia Hospital in Siliguri, West Bengal, where I underwent treatment. The journey to seek care wasn’t easy, as it involved relocation and managing logistics for my condition. Financially, the experience has been tough on my family. The high cost of treatment outside the state has directly impacted our financial stability, and unfortunately, we received no financial aid. Additionally, I wasn’t aware of any government health insurance schemes, which could have possibly provided some relief,” he laments, advocating for expanded access to specialists within the state to reduce such expenses, a sentiment echoed by Maltongmu Lepcha, whose father’s retinal condition forced their family to travel to Siliguri for specialized care. “Despite Sikkim’s facilities, we had to endure emotional and financial stress for effective treatment,” she adds.
Passingdang PHC, though accessible for locals like Denmit Lepcha, lacks critical diagnostic tools such as X-rays and ultrasounds. “The PHC is a lifeline for us,” Lepcha shares, “but villagers from more remote areas like Sakyong and Pentong face delayed treatment, especially during emergencies or floods.”
“Affordability is a common concern for families in Kewzing. While some healthcare expenses are manageable, others can become a financial strain, often requiring us to borrow money. I’ve noticed that many families, including mine, prefer private clinics due to their prompt services, though these come at a higher cost. Government schemes like PMJAY are known in the community, and some residents benefit from them, but broader implementation could help reduce the financial burden further,” Tashi Dem added.
Small successes show not all is lost
Despite these challenges, Sikkim’s healthcare system has seen notable successes. Community engagement has been a cornerstone, with regular vaccination drives and maternal health programs ensuring vital outreach. Workers like Sandhya Hingma, based in Rhenock CHC, have fostered trust and participation by coordinating with local Panchayats and conducting targeted screenings for conditions such as hypertension and diabetes. The gradual adoption of digital records and virtual training has also enhanced operational efficiency. National programs like the National Tuberculosis Elimination Program (NTEP) and SAANS (for respiratory ailments) have contributed significantly to improved health outcomes.
There is consensus among stakeholders about the reforms needed to strengthen Sikkim’s healthcare system. Improved road connectivity and reliable ambulance services are essential for bridging the gap in emergency care. Infrastructure upgrades, including advanced diagnostic tools, adequate drug supplies, and dedicated rooms for ASHA workers at hospitals, could transform healthcare delivery. Recruiting paediatricians, gynaecologists, and chronic illness experts to CHCs and PHCs would address critical service gaps. Financial support, including higher travel allowances for health workers and expanded insurance coverage for patients, would alleviate the burden on families and healthcare providers.
Expanding health awareness campaigns is another priority, as these efforts can encourage early care-seeking behaviour and overcome cultural hesitations. By addressing these systemic gaps, Sikkim can build a stronger, more inclusive healthcare system.
For healthcare workers like Sandhya Hingma, the mission goes beyond medical care. “We’re fostering trust, educating families, and saving lives,” she says. Their dedication underscores the need for a healthcare system that matches their commitment.
Sikkim’s journey toward healthcare excellence is ongoing, but, with targeted reforms and community-driven solutions, the state can ensure that every resident, from bustling towns to high-altitude tribal villages, has access to timely, affordable, and quality healthcare.
This story has been published as part of the AIPP-EastMojo Fellowship 2024.
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