By Eesha Desai, BS, MSc; Hannah Ratcliffe, MSc; Asaf Bitton, MD, MPH; Dan Schwarz, MD, MPH
The precipitous spike in India’s COVID-19 infections is an unfolding humanitarian crisis and a wake-up call about the country’s urgent need for a stronger primary health care (PHC) system.
The situation in India is dire. According to the BBC, India has seen more COVID-19 cases in the last seven days than any other country and it is feared that the official death toll of 200,000 is actually much higher. This fast-paced second wave is hastened by loose restrictions on mass gatherings, mixed messaging across the health system, and inadequate testing. The ongoing crisis has pushed India’s health care system to the edge of collapse, with hospitals and clinics scrambling for basic supplies including oxygen, ventilators, and protective equipment.
The past several weeks have shone a tragic light on India’s public health and health care system weaknesses. Although media attention is rightfully gravitating towards overwhelmed hospital capacity and rapidly depleting ventilator supply, we know that PHC is an essential component of effective COVID-19 response and recovery, especially in mitigating the disastrous wave of severe infections that now threaten to break down acute care hospital systems. Despite weaknesses within India’s PHC system, it can still be tangibly leveraged in this moment to play a critical role in mitigating the ongoing crises.
We know that PHC is an essential component of effective COVID-19 response and recovery, especially in mitigating the disastrous wave of severe infections that now threaten to break down acute care hospital systems.
Here, we outline critical considerations for how PHC can be utilized now to meet the urgent challenges posed by the second wave of COVID-19, as well as ways in which PHC can support vaccine rollout. Additionally, in this moment in which there is an unprecedented focus on — and money for — the health sector, we suggest ways that India can strategically pivot to strengthen its underlying PHC system for a resilient future.
What role can PHC play to mitigate the immediate crisis at hand?
India’s COVID-19 crisis is two fold. As COVID-19 cases, hospitalizations, and deaths mount, a less visible but no less impactful crisis is also unfolding — the burden of delayed or missed routine and essential health services. As a result of the pandemic, the world has certainly delayed or reversed progress toward Sustainable Development Goals and global health targets. A recent UNICEF report on the estimated impact of COVID-19 in South Asia suggests that as a direct result of the pandemic, there will be a 16% spike in maternal mortality, over 200,000 additional deaths among children under five years due to preventable communicable diseases, and over 6,000 additional deaths from HIV, TB, and malaria. These trends are a result of delayed or missed care, and India has not been spared from this fate.
While India focuses on alleviating the current surge of COVID-19 cases, an eye must also be kept on maintaining access to essential health services to prevent an influx of delayed care and disease burden in the future.
The burden of deferred care is not unique to infectious diseases — it is perhaps more profound and pernicious for chronic non-communicable diseases. WHO Pulse Survey Results from the early pandemic showed significant disruptions in chronic disease care with 59% of countries reporting that access to outpatient care was restricted in some way, delaying or limiting important care for conditions like hypertension, diabetes, and mental health. This second parallel crisis is one that India cannot afford, as it already faces a disproportionate burden of maternal and child deaths, diabetes, cardiovascular disease, and respiratory disease. While India focuses on alleviating the current surge of COVID-19 cases, an eye must also be kept on maintaining access to essential health services to prevent an influx of delayed care and disease burden in the future.
PHC has a critical role to play in mitigating both crises. In India, PHC is delivered through a complex mixture of government facilities and private sector pharmacies and clinics. While this system has often been criticized for leading to fragmentation and poorly coordinated care, in this moment the breadth of primary care facilities offers opportunities in both the immediate response to the pandemic and, perhaps more importantly, in building a stronger health system for the future. As the Indian government and aligned stakeholders consider next steps in the coming weeks and months, a coordinated response involving both the public and private sectors can leverage existing assets into a more effective COVID-19 plan. These could include:
> Improve access to testing
Utilizing pharmacies, primary health centers, and health and wellness centers (HWCs) as rapid testing locations. This can help to make testing more accessible, reduce wait times, and alleviate patient volume at larger health centers.
> Make care safer
Improving facility operations requires innovations, including triaging incoming patients prior to arrival at a clinic and ensuring appropriate personal protective equipment (PPE) for staff. Relevant resources include guidelines from India’s Ministry of Health and Family Welfare, both for appropriate PPE use and creating an enabling environment for infection protection and control. Supply chain shortages for PPE at the PHC level can be partially addressed through promoting at home care and telehealth when appropriate (described below).
> Expand telehealth
The Indian government already has issued Telemedicine Practice Guidelines, but uptake has been limited or reserved to larger facilities. Primary care facilities can use telehealth for remote triaging, maintaining essential health services, and even potentially as a surveillance tool to identify potential COVID-19 hotspots.
> Utilize community health workers (CHWs)
When appropriately resourced and paid, CHWs can provide community-based care and address COVID-19 in hard-to-reach and remote locations. CHWs in other countries have been able to continue uninterrupted care during the most difficult moments of the pandemic. The current crisis is an opportune time to increase the service delivery capacity of Accredited Social Health Activists (ASHAs) through training and equipping them with appropriate PPE and payment to provide preventative and appropriate curative services during the pandemic and beyond.
> Help people care for themselves at home
By empowering patients and their families with better information to manage appropriately at home, we can avoid unnecessary visits to health facilities. Enabling self-management at home will be helpful both from an infection control perspective, and also from an operations perspective , especially given how overburdened health facilities already are at this time. As an example, this online tool can be utilized to provide a patient with information of COVID-19 risk and can be viewed in English, Hindi, and Marathi. These broadly circulated infographics may help patients distinguish between when hospital care is needed and when at home care is sufficient.
> Provide clear health messages
Establishing a consistent and reliable risk communication stream to eliminate mixed messages at local and national levels. Anchoring consistent messaging across private and public primary care clinics can help to reach an expansive audience through frequented touch points with the health system. In more remote areas, ASHAs can lean on connections with local communities to provide consistent information.
The promise of PHC, now and in the future
Beyond the immediate crisis, vaccination will be essential to ending the COVID-19 pandemic, but here, too, India faces major obstacles. About 130 million vaccine doses have been distributed in India, including first and second vaccinations. According to the Lancet Citizens’ Commission Dashboard, as of April 26, 141.9 million people have received at least one dose, approximately 10% of India’s population. At this current pace, India isn’t expected to vaccinate 70% of its population until the end of 2022, according to research by the Economist. Given its status as one of the largest vaccine manufacturers in the world, India has the industrial capacity for expansive vaccine production. However, supply chain disruptions and difficulties in acquiring raw materials can result in shortages at vaccination sites and delays in production.
Here, too, PHC has a pivotal role to play in promoting and delivering COVID-19 vaccinations, as seen with historical smallpox campaigns and ongoing polio eradication campaigns. Primary health care staff — whether in clinics, mass vaccination, or mobile sites — can be trained to responsibly and safely administer vaccines. The primary care workforce can reduce hesitancy and build interest and trust not just in the vaccine, but also in the health system. They can support the design of an equitable COVID-19 vaccination strategy, for instance, by leveraging existing systems like the national AB-PMJAY or other state-based insurance schemes to identify and ensure vaccination for the most marginalized populations. PHC staff can monitor for adverse events and ensure second doses are given through tracking data in coordinated information systems. While large health centers will likely be used for vaccinations, shots should also be distributed through pharmacies, HWCs, and primary health centers.
Using the present crisis as an opportunity for lasting change
The substantial increase in donor and government funding to support vaccine rollout provides an unprecedented opportunity to not just prioritize quick wins, but also simultaneously improve the delivery and underlying capacity of PHC in India. For example, The Global Fund’s “Resilient & Sustainable Systems for Health” investments demonstrate that disease-specific funding (AIDS, tuberculosis, and malaria in the Global Fund’s case) can be strategically invested to support health systems strengthening for the future.
This is not a “nice-to-have.” Stronger PHC systems will be essential for mitigating the burden of morbidity and mortality from delayed essential care; continuing COVID-19 vaccination and booster efforts into the future; improving baseline population health status — including from chronic conditions that have made individuals so susceptible to severe COVID-19 infection — to build resilient populations; and strengthening health systems to be better able to respond to unforeseen future stressors and shocks. Opportunities to strengthen PHC through the COVID-19 response include:
> Promote trust by getting proximate
Through vaccination programs, primary care facilities and providers will have the opportunity to expand community engagement activities, build local trust through associating with community leaders and becoming respected messengers and sources of truth, and even interact with people who may never otherwise touch the health system. Given the diversity of India’s population, this engagement will need to be tailored in ways that resonate with a community of interest. Avenues for engagement include adapting materials and tools to local dialects and linking messaging with cultural traditions and customs.
> Building better information systems for the future
This moment can be used to collect minimal but essential data to start building information systems and disease registries that enable better care relationships over time. The government of India launched the Arogya Setu mobile app in 2020 for contact tracing and symptom mapping. More recently, the CoWin portal was added and is now the required scheduling system for vaccine appointments in the 18 to 45 year-old population. This platform has the potential to be further expanded for scheduling routine care visits to build towards more timely care. For patients without a usual source of care, this vaccination touchpoint can be used to assign patients with a unique ID, register them with a provider or facility, and even schedule well visits for the future. This can help to further anchor primary health care as the point of first-contact.
> Support an ailing health workforce
As India’s workforce shortages are addressed during COVID-19 through short-term contracts and incentive schemes, the moment can be used to build health workforce information systems and registries that help to better monitor workforce activities and distribution. The past year has also seen an expansion to the roles and responsibilities of ASHAs, as seen in Kerala’s effort to mitigate COVID-19 at the community level, and should be maintained, leveraged, and better remunerated beyond the course of the ongoing emergency.
Lastly, it is not lost on us, as we write from the United States, that the massive issue of vaccine equity is at play. We strongly support calls on the Biden administration to lift restrictions on materials exports, temporarily halt vaccine patents, and to release millions of stored doses of AstraZeneca vaccine for shipment to India and other hard hit countries. Countries such as the US, while simultaneously needing to support their own communities, must also fulfill their global obligations to foster vaccine and health equity.
The pandemic will not be over locally until it is over globally; no one is safe until we are all safe.
The pandemic will not be over locally until it is over globally; no one is safe until we are all safe. This past year has highlighted the interconnectedness of the world and the need to invest in the health and safety of the global community. Therefore, as India tackles its second wave of COVID-19, simultaneously strengthening its primary health care system must be a priority for not just India, but also the entire global community.
Eesha Desai, BS, MSc, is a Research Assistant in Primary Health Care at Ariadne Labs.
Hannah Ratcliffe, MSc, is the Assistant Director of Research in Primary Health Care at Ariadne Labs.
Asaf Bitton, MD, MPH, is the Executive Director of Ariadne Labs.
Dan Schwarz, MD, MPH, is the Director of Primary Health Care at Ariadne Labs.
Illustration by werbeantrieb / iStock