Covid-19 tests rural health services

The second wave of Covid-19 has now started a rural deluge leaving the large cities limping to recovery. Two-thirds of India’s population resides in villages, which have widely varying levels of development and urban connectivity. Paradoxically, only a third of India’s health workforce is serving the rural population. There are several challenges that the diversely developed health systems of different states face as they grapple with the virus and its variants.

The central government has provided elaborate guidelines for managing the epidemic in rural areas. While they have great merit in terms of an extensive itemisation of areas to be addressed and a high level of specificity on the actions to be taken, the ground realities of health system resources and readiness may pose problems in implementation.

Availability of adequate human resources in the health work force is not assured in all levels of care in all states. While Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and Anganwadi workers are a well-established team at the rural frontline, their numbers are not optimal relative to their workload. Their duties have now been severely stretched across an array of routine duties that they were performing before Covid and must continue to deliver even now and a new list of tasks that are related to Covid diagnosis and management. The Covid vaccination programme too will require their participation in the rollout. They would need the support of citizen volunteers from the local community, especially the younger and more energetic members such as high school students and the women’s self-help groups.

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Symptom based syndromic surveillance through household visits has been mandated. This is intended to identify persons with Influenza-Like Illness (ILI) and Severe Acute Respiratory Infection (SARI). This requires the use of a checklist, a provisional clinical assessment, testing as indicated, reporting of diagnosis, advice on home care under isolation or transfer to an intermediate care centre or advanced care institution and follow up visits to monitor home care and evolving clinical status. This requires fresh training in areas which their previous training has not covered, under the great time pressure of a public health emergency. As the vaccination programme gains speed, the frontline workers will also be asked to help with that. This oversized demand on the time and skills of the frontline workers cannot be met unless the local community offers support from panchayats and citizen volunteers. The poor pay scales and limited task-based financial incentives offered to these frontline workers must also be revisited and revised by the health administrations of Central and state governments.

Suspected cases

Rapid Antigen Tests (RAT) have been advised for suspected cases and high-risk contacts. Apart from understanding the probability that a fraction of such tests will yield false negative results, the ability to reconcile the test result with the findings of the ILI-SARI questionnaire and pulse oximetry reading requires new understanding and skills. How well are these training needs being addressed by different states, especially the district health authorities? Technological innovation is seen as a solution, but it can only provide support to, and not substitute for, a skilled health workforce.

Intermediate-level Covid Care Centres are proposed close to the village. How quickly can they be set up and how will they be staffed? Will there be adequate and assured oxygen supply? How will the availability of drugs be ensured? Will there be enough doctors available to manage these and the advanced care facilities? Will emergency transport be available for early and efficient transport to an advanced care facility? Will states with feeble public healthcare systems be able enlist sufficient support from the private healthcare providers, including the ubiquitous informal care providers? Each state will configure systems as best as it can from its available resources. To what extent will the centre supplement resources to states with weak health systems and narrow fiscal space, to manage and manoeuvre? We will see the answers emerging in the next couple of weeks.

States which have invested for several years in building efficient health services, with particular attention to rural health services, will do well in responding to the challenges despite the pressures. The southern states, especially Kerala and Tamil Nadu, will cope better than the northern and central Indian states. They will also use their engaged panchayat institutions and community-based organisations to advantage. Odisha, which has substantially increased public financing for health since 2010, and has efficiently engaged the panchayats even in the first wave, will function with quiet efficiency. The central and north Indian states, which have neglected their health systems and mostly scorned civil society organisations, will be put to a hard test. States in the North East have an admirable culture of social solidarity and community engagement which will probably enable them to respond with the best use of their limited resources. Again, we have to wait and see how these expectations will be realised by the time the second wave ebbs.

To end on a positive note, a report by Puja Changoiwala who recently reported, in the National Geographic, on Janefal village in the Aurangabad district of Maharashtra. Despite great reluctance on part of the villagers initially, health workers and local community influencers persuaded the entire eligible population of the village to get vaccinated. We also read of Covid-free villages in different parts of India which successfully managed to keep the virus away by scrupulously observing public health advisories and drawing upon the strength of social solidarity. These should give us the confidence that communities can rally and respond with resilience and resistance rather than resignation to a malign fate.

However, policymakers too must renew their commitments to build efficient and equitable rural health systems, so that the questions posed to them in this piece will not be repeated when a new public health emergency threatens our villages.

(The writer, a cardiologist and epidemiologist, is President, Public Health Foundation of India)