From SHGs to PRIs to NGOs, there is a lot of capacity at the grassroots that is going unutilised. Need to harness this to contain spread in rural areas
By Ranjana Das
Requests for beds, oxygen cylinders, remdesivir, and emergency beds on our social media timeline were replaced by visuals of bodies floating in the Ganga, buried on the banks of the river or lying around half-eaten, of patients hooked to saline drips on the roadside, pleading with doctors to see them, and of people dying gasping for breath.
Last year, rural India very nearly escaped Covid-19. This year, the spread wasn’t anticipated and, like everywhere else, our healthcare systems—both public and private— were far from prepared.
The reported numbers might not be representative of actual Covid cases in villages because rural India lives with low health awareness, crumbling basic health care and infrastructure, and low testing. With digital registration for vaccines, the accessibility for rural population will be even more problematic. At the moment, rural India is stuck between abysmal healthcare services in the villages and sheer lack of affordability and accessibility in nearby cities and towns.
No lessons were learnt from 2020. At least now, the states can strengthen their community-based institutions to support an ill-equipped, under-staffed rural healthcare systems.
According to the Rural Health Statistics (RHS 2019-20), there are 155,404 rural Sub Centres (SC), 24,918 Primary Health Centres (PHCs) and 5,183 Community Health Centres (CHCs). As per RHS 2018, there is a shortfall of 18% SCs, 22% PHCs and 30% CHCs. What makes it worse is the inaccessibility of PHCs and CHCs; in some cases, these centres are quite far from the villages because of which people often turn to unregistered private healthcare practitioners—jhola chhaap—to save time and energy. Moreover, these healthcare centres are in run-down, dilapidated government buildings, are rarely open and are ill-equipped to address even basic illnesses.
India has a doctor-population ratio of 1:1445; the World Health Organisation (WHO) recommends a ratio of 1:1000. The doctor population ratio in Bihar is 1:28,391. Other reports have shown a deficit of 600,000 doctors. According to RHS 2018, there is a 14.1% deficit in ANMs (Auxiliary Nurse Midwife) at SC and PHC level; ANMs are crucial is ensuring the last mile delivery of basic medical services. With such infrastructure and human resource crunch, rural healthcare system is not in any shape to handle the spread of the pandemic.
The MoHFW guidelines on Covid management states three types of Covid management facilities— (i) Covid Care Center (CCC), which shall offer care only for cases that have been clinically assigned as mild or very mild cases or Covid-19 suspect cases, (ii) dedicated Covid Health Centre (DCHC) which are hospitals that shall offer care for all cases that have been clinically assigned as moderate and (iii) cedicated COVID Hospital (DCH) are hospitals that shall offer comprehensive care primarily for those who have been clinically assigned as severe.
The guidelines are clear on what the above facilities should comprise to take care of mild, moderate and severe cases. For instance, the DCH should be a full-fledged hospital or part of a block hospital and must have oxygen and ventilator facilities along with doctors and nurses.
SCs and PHCs aren’t qualified to handle even suspected and mild cases. Last year, these centres acted as isolation centres for migrants in states like Bihar and UP, but did not work well. Non-availability of food, proper sanitation and hygiene facilities were major areas of concern.
Apart from guidelines, there are few basics that need to be ensured to provide a healthy environment for patients including proper food, water, and gender-specific sanitation and hygiene requirements, and herein lies the need to work closely with panchayats and local institutions.
Much has been talked about looping in panchayats in managing Covid spread, and this should have been done from the very beginning. It isn’t too late, and panchayats can, even now, play a greater role in ensuring quality services in Covid management centres, mainly the ones that deal with suspected and mild cases. Local self-help groups can be roped in to provide basic and home-cooked meals. Last year, what greatly helped a few of my colleagues recover from COVID at a care facility in Parsa (outside Patna) was home-cooked meals by women group members who prepared the meals at the homes and provided to the facility. This aspect often receives little attention and can make isolation miserable for the patients if not provided.
One of the key elements of the National Health Mission is the Village Health, Sanitation and Nutrition Committee (VHSNC). The committees were formed to take collective actions on issues related to health and its social determinants at the village level. These along with the local youth can be trained as care givers with basic training on Covid care from clinically reputed institution and on creating awareness on social distancing, mask protection, hand wash, vaccine awareness, isolation and preventive Covid care. In fact, members of these groups can work closely with SHGs to ensure quality food for patients in Covid care centres located nearby.
We know that identification of Covid-positive people is turning out to be a challenge in rural areas. Often, people are treating it as flu and depend on home-based remedies. By the time they realise it is possibly Covid, it is often quite late. Providing digital thermometers and oximeters to village level health workers to simply do a door-to-door monitoring on a regular basis will help identify positive cases early on.
Then there are the Rogi Kalyan Samitis which can play a critical role in setting up, functioning, monitoring and resourcing of the Covid management facilities. These Samitis or Patient Welfare Committees consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from Government sector who are responsible for proper functioning and management of the hospital, First Referral Unit (FRU) and CHC. These Samitis have the power to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services. This makes them critical players in managing Covid facilities. In fact, NGOs can work in coordination with the Samitis to set up Covid facilities in rural areas.
The crumbling rural healthcare infrastructure calls for quick action and the best way to do so without reinventing the wheel is harnessing the power of local communities. The ASHA, Anganwadi workers and ANMs are anyway the key players for tracking and isolation of Covid suspected cases and counselling of rural communities and if VHSNCs and Rogi Kalyan Samitis function along with them it can make for the most effective way of managing rural spread.
(The writers leads Private Sector Engagement, Oxfam India. The views expressed are personal and not necessarily that of Financial Express Online)