To safeguard its most vulnerable regions against the second Covid-19 surge, India must engage local solutions and get district-level leaders to communicate Covid-appropriate behaviour. PRACHI SHARMA, a development practitioner with expertise in women’s sexual reproductive health and rights, and ASHISH GIRI, a public health practitioner interested in health systems research, primary healthcare and inclusive development, underline that responses to the pandemic will have to be tailor-made to every region. Most of all, we must not forget what we learned from the first wave.
INDIA has reported 2,73,810 new COVID-19 cases in 24 hours, which means its tally is 19,29,329 active cases. The number of deaths has risen to over 1600. According to the Health Management Information System (HMIS), in March 2020, institutional deliveries in India dropped by 43% compared to March 2019. There was a similar decline in Caesarean-sections, which are often lifesaving. The drop was by over 46% in March, as compared to the same month last year.
According to one estimate, India has added 4,10,413 (best-case scenario) to 3,205,057 (worst-case scenario) additional underweight and severely underweight children from the bottom 20% of the wealth quintile. The reason is bodyweight shocks led by factors that include the lockdown. We have learned from the last surge period that the pandemic does not impact us equally. The poor and vulnerable are pushed to the margins more dramatically than the rest.
The first outbreak caught the global community off-guard, forcing a complete shutdown in most nations, including ours. Providing for both Covid and non-Covid health and nutrition services was a challenge, leading to a significant drop in availability.
For example, the reverse migration of workers was a crisis of national proportions, and here we are again at another alarming juncture just like the one before.
The Novel Coronavirus, which causes the COVID-19 disease, is a particular threat to India for 65-68% of the population lives in rural areas, where the disease burden is globally the highest. While we ramp up vaccination to meet the second wave of the pandemic, we have the experience to guide strategies and interventions. Cities with better health infrastructure can prepare themselves, but it is the most vulnerable they should prioritise.
Decentralising COVID-19 response
Wide interstate and inter-district variations are emerging. There is a wide disparity in terms of new cases in the poorer districts. Darrang and Dhubri in Assam, for example, have seen no increase, while more than 5,000 cases have been reported in Nandurbar. The variations in death rate are similar. While Barpeta in Assam has reported no deaths, Nandurbar in Maharashtra has 306.
This dissimilarity indicates two things, one, possibly, low testing in some states and two, different districts need different strategies to manage the varied intensity of the pandemic.
Even in ordinary times, the Indian healthcare system struggles. The suffering multiplied during the pandemic. It has had a devastating impact on our social and economic lives.
State governments and district administrations need to carefully note the trends. This wave is going to reach different districts at different times and with different intensity. This means there is some room to better allocate resources and attention based on priority.
The rural districts are currently not as badly hit by the second surge as cities such as Mumbai and Delhi. When our rural systems are hit, they are more likely to be overwhelmed as compared to cities. Hence, it is the vulnerable zones that need to be prepared and leverage their experience.
A remote district of Sahibganj in Jharkhand managed the first wave by establishing a District Grievance Redressal Cell (DGRC). The DGRC was established as a convergent action between all departments and civil society organisations. It was chaired by the District Magistrate and met daily. The DGRC was envisioned as several hubs that would receive grievances, give out key information and redress all issues related to COVID-19 in all blocks of the district.
This cell addressed bed availability, take-home rations, ambulance services, shelter for migrants within 24 hours of receiving a complaint, and other issues. Data shows that during the lockdown, it received 1,004 grievances and 987 of them were resolved within 24 hours.
Health helpline services
A large proportion of Covid cases do not require hospitalisation or critical care. They can be managed at home with counselling support. A recent systematic review concluded that telemedicine can minimise the risk of COVID-19 transmission. In the Indian context, the 104 health helplines can be leveraged to provide this assistance and prevent the health system from getting overwhelmed.
According to a study that analysed data of the 104-health helpline from Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Karnataka, Maharashtra, and Sikkim, these helplines received more than 6.4 million calls over six months (February to July 2020). Out of these, 2,280,291 were valid calls. Close to 36% of these calls were related to COVID-19. In May, the Covid-related calls went as high as 51% of all calls received.
The volume of calls mirrored key announcements and events taking place in India as a response to the pandemic, such as the nationwide lockdown, extension of lockdown, and so on.
Ensure continuity of essential services
India’s gains in essential care such as safe institutional deliveries and immunisation are at a huge risk of reversal. During the first wave and subsequent lockdown, the institutional delivery rate fell by more than 40% in Jharkhand, West Bengal, Gujarat, and Andhra Pradesh.
Jharkhand, Manipur, West Bengal, and Delhi recorded a more than two-fifths reduction in the number of children receiving BCG vaccinations.
A study estimating the additional cases of underweight and severe underweight also highlights that Bihar, Uttar Pradesh and Madhya Pradesh will account for the highest share in estimated child additional underweight and wasting cases among the poorest households.
Village Health Sanitation and Nutrition Day (VHSND) is a critical health service delivery platform. Conducting VHSNDs is imperative for a range of services including nutrition, immunisation and ante-natal care. A staggered approach in VHSND worked well for us towards the end of last year’s lockdowns. Using the list of expected beneficiaries, time slots were allotted and communicated to the families through PRI members and ASHAs.
Additionally, the district administrations should be leveraging operational Health and Wellness Centres (HWCs). The government aims to operationalise over 1.5 lakh HWCs across the country. The ones that are already operational are currently involved in the vaccination drive and act as a triage, screening COVID-19 cases and providing appropriate referrals. This function, if done efficiently, could reduce the burden at Community Health Centres and First Referral Units that provide essential healthcare services including institutional deliveries.
Institutional deliveries took a major hit last time. Freeing up spaces within the existing health facilities and allocating separate space for delivery-related services is critical.
HWCs can help reduce the load at higher facilities by appropriately triaging COVID-19 cases. Additionally, in districts with high caseloads, the testing function could also be moved to select HWCs.
Alter and strengthen communication strategy
A primary reason for the current surge could be the rampant fatigue in adopting Covid-appropriate behaviour. Irrespective of the reinforcement by the government, media channels and civil society organisations, people are attending parties, indulging in travel for leisure, gathering in large numbers for weddings, etc. On the other hand, hesitation in getting vaccinated has been noted. There is apprehension among citizens in taking the vaccine due to myths and misconceptions that are raging.
It is time to come up with a communication plan that sensitises people towards the vaccine and re-energises citizens in adopting Covid-appropriate behaviour. Districts that are far from state capitals could be difficult to reach with campaigns based on urban concerns. Therefore, community radio services and local influencers need to be engaged to emphasise Covid-appropriate behaviours.
The ongoing pandemic is one of the most severe crises in global public health the world has ever faced. COVID-19 requires a public health strategy that is built on a foundation of scientific epidemiology.
There is a need to scientifically study the causes for this viral pandemic and to identify the appropriate population-based behaviour and education programs. This pandemic will impact India’s health goals and disrupt the progress made in previous decades. If adopted in parallel, the above strategies could prepare us to manage the havoc this pandemic is capable of inflicting.
(Prachi Sharma is a development practitioner with expertise in women’s sexual reproductive health and rights. She has worked in various gender and women’s health projects in India and Africa. For her work with women and young adults, the Swedish Institute recognised her among 60 young gender leaders in South Asia and the MENA region. She is currently with the Piramal Foundation. Ashish Giri is a public health practitioner interested in areas like health systems research, primary healthcare and inclusive development. For his work in the disability space, he has been shortlisted on the list of NextGen leaders by the Ganga Foundation. He has previously published scientific papers in the primary health space and currently works with the Piramal Foundation. He is an adventure sports enthusiast and enjoys outdoor sports. The views expressed are personal.)