COVID 19 and rural India: better now than later

Sir,

COVID 19 is devastating lives worldwide and India is no exception. Government of India on 15^th April classified districts as hotspots or red zones (123 districts with large outbreaks and 47 with clusters) and non-hotspots or orange zones (207 districts). This leaves more than 300 of the country’s 731 districts which are not yet affected by the pandemic, classified as non-infected districts or green zones. Of India’s 1.21 billion people, about 376 million people live in the districts now classified as green zones and while 68.8% of India’s population lives in rural areas (Census 2011), the share of rural population in the green zones is relatively higher at 84%. This stands true across big states, Kerala being the only exception.¹ It is this proportion of population who has to be protected in the battle against COVID 19 to ultimately emerge victorious and limit any further spread.

Currently, dedicated COVID health centers (DCHC) and dedicated COVID hospitals (DCH) are the tertiary care facilities and district hospitals (DH); predominantly urban centered. Rural populations live far from these tertiary hospitals and any strategy of testing for COVID 19 and management that is based on large hospitals is not likely to be effective or sustainable.

India’s primary healthcare system is braced by primary health centers (PHC), health sub centers (HSCs) and the team of health workers headed by PHC medical officers (MOs). The grass root workers including auxiliary nurse midwives (ANMs), health worker male, accredited social health activists (ASHAs), anganwadi workers (AWWs) and village health guides (VHGs) augments the efforts of PHC team in delivering such care.²

The coverage of health services in any public health system depends on provision of health services and utilization of these health services. The provision of health services in turn depends on availability of health workers and availability of supplies and equipment’s whereas, the utilization of health services depends on the demand and access to these health services (Figure 1).³ With the advent of COVID-19 the health system in India may be grossly threatened if rural healthcare delivery is not equipped at the earliest.

COVID 19 is expected to be with us for a long time, ("Make no mistake: we have a long way to go. This virus will be with us for a long time and can easily ignite, "WHO director-general Tedros Adhanom Ghebreyesus) the decision to have basic health services suspended is irrational, especially with rates of communicable diseases like tuberculosis, HIV/AIDS etc., non-communicable diseases, malnutrition, maternal and child mortality. Because of the lockdown, there is also a difficulty in accessing healthcare and drugs for many patients in rural areas. Though use of tele-health in PHCs had been proposed by the Ministry of Health and Family Welfare, Government of India (MoHFW, GoI) its efficacy, utility, provision of optimum care is questionable.⁴

The solution is to have COVID 19 surveillance and response activities in addition to the basic health services being delivered through the PHC system. By the nature of being closer to the communities, PHCs and other primary care providers can significantly ameliorate the situation. Under integrated disease surveillance project (IDSP), the grass root workers are expected to report any abnormal increase or cluster or outbreak of particular diseases based on syndromic surveillance. A weekly report is submitted to the PHC using ‘S’ form and PHC reports it to the community health center/peripheral surveillance unit (CHC/PSU) weekly in ‘S/P/L’ forms.⁵ This network has to be strengthened with COVID 19 surveillance and response, ensuring other basic health services being delivered without compromise.

The advantages of integrating the COVID 19 response with primary healthcare system includes curtailing stigma for the person and the family, improved access to care, treatment and follow-up, improved prevention and early detection. In short, better physical, financial accessibility and better acceptability.

But the challenges are many. It includes shortage, skewed distribution and misalignment between health worker competencies and current or future population health needs in meeting the surge in needs for COVID 19. Re-assignment of staff to treat COVID-19 patients and loss of staff who may be quarantined or infected is likely to pose further challenges. The other challenges would be to ensure staff safety and security measures, ensuring supplies of medicines and diagnostics, appropriate training and capacity building activities.

It is the need of the hour to ramp up the primary healthcare systems. It would go a long way in not only managing the epidemic but also strengthening the health systems in the medium and long run.

REFERENCES

1. 1. Letter to States regarding classification and containment of hotspots. MoHFW. Available at: https://ndma.gov.in/images/covid/MoHFW-Letter-States-reg-containment-of-Hotspots.pdf. Accessed on 14 May 2020.
2. 2. Chokshi M, Patil B, Khanna R, Neogi SB, Sharma J, Paul VK, et al. Health systems in India. J Perinatol. 2016;36(S3):S9-12.
3. 3. Roberton T, Carter ED, Chou VB, Stegmuller A, Jackson BD, Tam Y, et al. Early Estimates of the Indirect Effects of the Coronavirus Pandemic on Maternal and Child Mortality in Low- and Middle-Income Countries. Rochester, NY: Social Science Research Network; 2020: 3576549.
4. 4. Enabling Delivery of Essential Health Services during the COVID 19 Outbreak: Guidance note. MoHFW. Available at: https://www.mohfw.gov.in/pdf/EssentialservicesduringCOVID19updated0411201.pdf. Accessed on 14 May 2020.
5. 5. Home. Integrated disease surveillance programme (IDSP). Available at: https://idsp.nic.in/. Accessed on 14 May 2020.