The second wave of COVID-19 pandemic in hill states of the Northeast is a wake-up call for the governments in these states and at the Centre for revamping the health systems on a war footing. Surging positive cases and fatalities in these states have also exposed the critical gaps in the health sector which needs to be bridged on a priority basis. Ministry of Health and Family Welfare data shows that the recovery rate as of May 24 for Meghalaya is as low as 72.58 %. Nagaland with a recovery rate of 75.27 % and Mizoram with 75.86 % also present a worrisome situation in the two states. Against the country's current recovery rate at 88.69 %, the Health Ministry data show that Manipur's recovery rate is 83.62 while that of Arunachal Pradesh is 87.56 %. High active caseloads have led to a fast decline in several beds available for critical COVID patients. These states were caught ill-prepared to handle the current wave of the pandemic and the situation calls for urgent measures to upscale health infrastructure to stay better prepared for the third wave. While it is difficult for the health experts to predict how the virus mutants behave in the third wave, lessons must be learnt from the first wave and the current wave to identify the gaps in terms of availability of beds with oxygen support, beds in intensive care units, oxygen generation and storage capacities, human resources and initiate corrective measures. Setting up more COVID care centres for the isolation of asymptomatic patients and those with mild symptoms will help free the hospital's beds for moderate and critical patients. Lack of public health awareness makes home isolation a challenging task. Constant monitoring of the health status of the infected patients is important to take a timely decision on hospitalization if the symptoms aggravate to a moderate or critical stage. Besides, the high transmissibility of the mutants in the second wave has led to a faster spread of the infection compared to the first wave. Immediate isolation of the positive cases can reduce transmissibility among the family members or in the neighbourhood and thereby prevent the health systems from being overwhelmed. It is heartening to know that Assam has been supplying oxygen to these states in the region. Surplus production in Assam has lessened the worries of the neighbouring states. The arrival of the first oxygen express in Assam is going to ensure the availability of 80 MT of the additional quantity of medical oxygen every week for the states in the region. The hill states have initiated work on setting up oxygen plants with the support of the Central government which need to be expedited. Vaccination in these states has been progressing at a much slower pace which is an area of concern. Vaccination for the 18 plus group started late compared to the rest of India and could not be started in the first two weeks. It is unfortunate that despite having a smaller population, the hill states are struggling to get adequate vaccine supplies. Being located in a disaster-prone zone, the states in the northeast region vaccinating the entire population at the earliest is critical to building its resilience against multiple-disaster. Delhi has already fully vaccinated 11.25 lakh people with two doses whereas Mizoram with a 10.97 lakh population has so far administered second doses to only 50,982 people and first doses to 2.52 lakh people. In Maharashtra, 43.90 lakh people have already received the second dose. To draw a parallel, the combined population of Meghalaya and Nagaland is 45.49 lakh. In Meghalaya with a 25.70 lakh population, 74,149 people have been administered second doses and in Nagaland with a 19.79 lakh population, 51,845 people have received second doses. The hilly difficult terrains make vaccination drive in these states a challenging task. The shortage of adequate medical infrastructure and human resources compared to advanced states make it imperative for the states and the centre to reduce vulnerability in the population by vaccinating the population on a mass scale. Fully vaccinating the population in the region is also important to ease the restrictions for outside visitors to tourist destinations as soon as the chain of transmission is broken and the pandemic curve is flattened. Tourism is a major source of revenue for these hill states and the prevalence of COVID-19 pandemic for a longer duration due to shortage in health infrastructure and delays in vaccination will cause a huge loss of revenue for these states. The spread of infection to rural areas where health infrastructure is grossly inadequate has sounded the alarm bell to set up more hospitals with adequate beds and equipment in all districts and within the shortest distance from villages to better manage health emergencies. The Ministry of Development of the North Eastern Region and the North Eastern Council in collaboration with the states can draw up a comprehensive vision plan for improving health systems in this strategic region.