The agenda for taking on the rural spread of Covid-19 has now been set at the highest level with the prime minister confirming that the pandemic is “spreading fast in the villages”.
There is also the acknowledged need for action at a decentralised district level. With at least 13 states reporting that the total number of new cases in rural areas exceeded those in urban areas, the states with the largest rural populations (Uttar Pradesh, Bihar, West Bengal, Maharashtra, Andhra Pradesh and Maharashtra) face some of the toughest challenges.
A two-judge bench of the Allahabad High Court has observed that the health services in the smaller towns and villages of Uttar Pradesh are “Ram Bharose” (at the mercy of God), indicating the need for a rapid response on a war footing.
But, as the Supreme Court observed, what the High Court expects the executive to do in this regard are “directions that cannot be implemented”. This makes it important to understand how the government plans to upscale the Covid-19 activities in this second wave and control its dance of death in rural areas.
The Ministry of Health and Family Welfare (MoHFW) issued a Standard Operating Procedure (SOP) on Covid-19 containment and management for peri-urban, rural and tribal areas on May 16, 2021.
A fortnight earlier, the ministry had also issued a set of guidelines to the states to augment the availability of trained human resources, bringing in medical interns and final year students for Covid care.
However, the SOP of May 16 betrays no sense of urgency, and says that the “Covid outbreak in the country is still predominantly an urban phenomenon.” It sets out guidance that seems to be ‘business as usual’ and not for a crisis.
Are the key elements of union health ministry’s SOP implementable on the ground?
In our earlier article, we articulated three key systemic approaches to tackle the epidemic in the context of rural India.
These are: adopting a community-based, epidemiological and health systems approach and not merely a hospital-drugs-ICU centred approach; popularising rational protocols and evidence-based guidelines; and, a syndromic diagnosis and treatment of cases as distinct from a laboratory test-based approach. We also highlighted decentralisation and transparency of data as essentials, as was the need to evolve contextually suited solutions. Let us examine the extent to which the ministry’s guidelines are aligned with these core principles.
The SOP is appreciably conceptualised as a decentralised approach and is based on the epidemiology and health systems framework. It is structured around the three-tier rural health services and relating them to the mild, moderate and severe symptomatology that Covid-19 cases suffer from.
However, presently in the country 14.1 per cent of the sanctioned posts of ANMs (auxiliary nurse midwives) and 37 per cent of health workers (male) at Sub-Centres and Primary Health Centres (PHCs) are vacant. At the PHC level, 37.6 per cent of the supervisory cadre, health assistants, and 24.1 per cent of the sanctioned posts of doctors are vacant too.
Community Health Centres (CHCs), the first level of specialist care, face a shortfall of 76.1 per cent specialists. In 2020, relative to the previous year, laboratory technicians at PHCs and CHCs increased by 6.3 per cent but the nursing staff declined by 11.3 per cent. The SOP recommends, “Strengthen primary level healthcare infrastructure at all levels to intensify Covid-19 response in peri-urban, rural and tribal areas” but with no reference to any existing shortages.
However, it does suggest enlarging the base of service providers beyond the government services by drawing in other health providers such as “qualified AYUSH doctors/ final year AYUSH students/ final year BSc nurses may be considered by VHNSC” (Village Health Sanitation and Nutrition Committee) to run the Covid Care Centres.
Anyone aware of the rural scenario in most states can wonder whether these persons can be harnessed by the Village Health Committees or be available to them in adequate numbers. Ignored in this are the most ubiquitous of healthcare providers, the non-degree-holding practitioners who are relied upon for over 80 per cent of regular healthcare in rural areas.
While non-formal healthcare providers are in a complex relationship with communities and formal care systems, a recent experimental study with urban slum population in industrial towns of Odisha demonstrated the effectiveness of these providers in improving case detection and notification of the TB program. West Bengal is also training informal healthcare providers (as grameen swasthya parisevaks) to contain the spread of Covid-19 in rural areas.
Another option that is widely being used all over the world for mild cases is telephonic consultation and support. It brings to under-served areas from far and near advice and monitoring, which is all that is required for mild cases, and also in a way that keeps all safer. The digital divide is what would pose serious problems and therefore the health team on the ground has to be the facilitator for such consultations with networks of doctors and other trained persons. Neither of these arrangements for upscaling the Covid response finds any mention in the document.
Secondly, the SOP still focuses on testing as the primary activity of the primary level health workers, based on which they will isolate the positive cases. There is no mention of syndromic management based on identification by symptoms, despite the WHO guidance of February 2020. It said, “In a large-scale community transmission scenario, individual case identification, contact tracing, and quarantining are no longer necessary. Instead, surveillance will focus on monitoring trends for geographical spread, transmission intensity, affected populations, virological features, and impacts on healthcare services. This multi-source information informs ongoing risk assessments for decision making on appropriate public health measures.”
Further, mortality surveillance can give a realistic picture of the epidemic. Tamil Nadu has already adopted the syndromic approach because of the rising number of cases and laboratory overloads. This entails active case searches through house-to-house visits for persons with suspected symptoms and screening/triaging at Interim Covid-19 Care Centres (ICCC), with all syndromic cases considered as Covid-19 unless proven otherwise.
One reason for the official publication of an unrealistic SOP seems to be the Centre’s resistance to acknowledging ‘community transmission’ in the country. While this had become a debated issue last year, it seems to have been forgotten in the tsunami of the second wave.
However, as already illustrated, steps are being adopted by the states in response to the escalated numbers. Certainly, no one can now deny community transmission, while one may quibble about the extent and numbers it has resulted in. Declaring ‘community transmission’ is not just an academic debating point. It reflects a change in dynamics of the epidemic and requires a shift in strategy that can be adopted only when we transparently acknowledge the reality, grim as it may be.
(Rajib Dasgupta is a medical doctor, Professor and current Chairperson at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University (JNU), and Ritu Priya is a medical doctor, Professor and former Chairperson, Centre of Social Medicine and Community Health, JNU, as well as former Advisor- Public Health Planning at the National Health Systems Resource Centre, GoI)
Disclaimer: The views expressed above are the author’s own. They do not necessarily reflect the views of DH.