Primary health care uses all hands on deck to fight COVID-19: Experiences from India

When asked about her experience with COVID-19, Vineeta Ray, a Community Health Officer (CHO) supporting pandemic response efforts at a Health and Wellness Center (HWC) in the Indian state of Madhya Pradesh, said, “This disease is so dangerous; many people are getting infected and nobody knows how to control it. When people ask me, I have no idea what to answer…”

HWCs, part of the Government of India’s Ayushman Bharat universal health coverage plan, provide comprehensive primary health care services - each HWC caters to a population of 5,000 people. Ray had heard that cases were reported in her state, but had been given no clear guidance on what she could do. Posted in a remote region, she was particularly worried about accessing accurate information quickly.

With the increasing number of cases across the country, many CHOs, like Ray, are working around the clock to inform and protect their communities. However, with increasing panic prompted by false and conflicting information circulating through social media and limited information available, Ray was not sure how she could help her community.

To equip CHOs with accurate information on COVID-19, NISHTHA: Transforming Comprehensive Primary Health Care in India – a USAID-funded, Jhpiego-implemented project - developed a Learning Resource Package (LRP) to train them. NISHTHA works closely with the Ministry of Health and Family Welfare at the national level and 12 state governments to transform, redesign and re-engineer primary health care in India for the provision of equitable, comprehensive and client-centered primary health care that contributes to improved health outcomes for India’s marginalized and vulnerable populations.  One of NISHTHA’s core areas of work is based on building capacity of CHOs, advocating for their deployment/posting at HWCs and providing handholding and mentoring support at HWCs through supportive supervision. In addition, our team is working closely with the Ministry at the national level for policy advocacy for strengthening this cadre of CHOs by creating career progression pathways.

When the country went into a nationwide lockdown in March 2020  - our team at NISHTHA acted swiftly to support first responders like Ray to ensure they had the knowledge, expertise and wherewithal to protect their communities. Detailed LRPs for training primary health care teams including CHOs, auxiliary nurse midwives (ANMs), and tele-counselors handling COVID-19 response centers in states were developed. With severe restrictions on movement, we leveraged technology and conducted all these trainings using online platforms. To date, more than 32,000 primary health care providers have been trained on various aspects of COVID-19 response including risk communication, prevention, identification and management of COVID-19.

 With India’s diverse cultures, ethnicities, religions and languages, our country faces a unique set of challenges in delivering primary health care. Working across 12 states meant 12 different contexts, geographies, populations and different health seeking behaviors. Keeping in mind the different contexts, we contextualized our interventions based on each state’s needs and the people whom we were serving in those regions.

Our team adopted a responsive and multi-pronged approach to amplify our efforts towards the COVID-19 response. This included working with frontline workers to prevent and slow the spread, supporting national and state governments in their requests for COVID-19 response; supporting local communities, especially vulnerable populations, with the tools needed to fight COVID-19 and ensuring continuation of reproductive, maternal, newborn, child and adolescent health, as well as other essential services for all sub-sections of the population including marginalized communities.

• Bolstering the frontline warriors: As per the Global Burden of Disease study, nearly 200 million people in India have experienced a mental disorder, nearly half of whom suffer from depressive or anxiety disorders. This was the situation that existed even before the COVID-19 pandemic. With the widespread outbreak of COVID-19, people and communities suffer from psychological distress and mental health issues. This is worse among the vulnerable who face everyday barriers such as limited physical accessibility, affordability of health care, limitations on health insurance, and discriminatory attitudes and stigma. Cognizant of this, we provided technical assistance to the Ministry of Social Justice and Empowerment to develop a training package for tele-counselors of the mental health helpline.  This package was also adapted and used to train frontline primary health workers on mental health, stigma and psychosocial disabilities and to date around 6,900 health workers have been trained across four states.
• Tailored solutions: We provided assistance based on requests from each state. Whether the need was to map essential suppliers of personal protective equipment, masks and ventilators at primary, secondary and tertiary health care facilities for enabling rapid procurement, or supporting state governments to assess district preparedness for quarantine and isolation facility/wards at district-level hospitals for containing this highly contagious novel coronavirus.
• All hands-on deck: In addition to working with governments, we also partnered with private and local community-based organizations to conceptualize and roll out interventions to respond to each states’ needs.  In the state of Maharashtra - which currently reports the highest caseload in the country - we partnered with a private technology-based organization, Gramener, to develop a citizen /mobile application which will provide real time data on a person’s current health status based on a self-conducted assessment, details of health facilities, helpline information and other key advisories by the state government.
• Keeping track of the numbers: We created a data analytics dashboard and a predictive modeling dashboard to help policy makers better understand the trend and status of COVID-19 cases at a glance which will help them make evidence-based decisions on preparedness of health care facilities, areas for rigorous testing and other preventive measures against COVID-19.
• Voicing solutions: We supported active surveillance of COVID-19 using Interactive Voice Response (IVR) based technology. This IVR system is primarily for persons under home quarantine, persons in home isolation and patients who have been discharged from hospitals post recovery from COVID-19. The IVR will follow up with people under home quarantine and home isolation for early identification of symptoms of COVID-19 and enable the right care at the right time for better health outcomes. Additionally, the IVR will also track patients discharged from the hospital to ensure their overall wellbeing and provide any support including psycho-social and support for mental health after their recovery.
• Building resilient communities: The most affected and impacted are our primary health care workers, who need to balance provision of essential primary health care services with the extra effort and time needed to deal with the pandemic. To supplement efforts of the government to track returning migrants and screen them for COVID-19, we engaged a local community-based organization, Samarthan, based in the state of Chhattisgarh. Through Samarthan, local field workers were deployed at community level to trace the migrant workers returning back to their hometowns and ensure they follow the quarantine norms at the quarantine institution centers as well as at their homes. Further, these field workers were also involved in contact tracing of those migrant workers who tested positive for COVID-19 and linking them to appropriate health departments.
• Engaging the community: We engaged local community leaders and created community level groups for monitoring the quality of quarantine centers. Through these community groups, local issues were resolved by tapping on community-level sources.  Field workers from the local partner NGO were also trained to disseminate key messages on preventive measures of COVID-19 and anti-stigma and discrimination messages. To date, more than 200,000 people have been sensitized on these key preventive measures.
• Piggy-backing on digital and mobile-based communication: Through our work, we found that one of the key challenges was lack of access to information especially in remote and rural areas where people were confined to their homes and unable to interact with the community who more often than not are also their key sources of information. This was all the more true for vulnerable populations like the elderly and persons with disabilities. In light of this, we developed an alternate medium of communication through IVR where people could listen to key messages on COVID-19, right at their homes.  

At the heart of all of all our interventions is to strengthen the existing primary health care systems to be robust, responsive and resilient to face any future public health threats. In times of a pandemic, we ensured that even routine maternal and child health services, family planning services and tuberculosis services are not interrupted and left behind. Our efforts continue towards strengthening HWCs to reach the last mile and cater to health care needs of all sections of society.  Regardless of caste, religion, ethnicity, marital status, socio-economic status or disability, we, at NISHTHA aim to provide free access to medicines and diagnostics, thereby reducing out-of-pocket expenditure for marginalized and vulnerable communities.

In the words of Anusha Pradhan, a trained primary health care worker who works with us in the far northeastern state of Sikkim providing door-to-door antenatal care check-ups, immunization, and key family planning services to ensure continuity of primary health care services, “I want these vulnerable women to know that the whole state with its entire health taskforce is working to prevent COVID-19 and to keep everyone safe. We’ve got their back.”
 
To learn more about NISHTHA, visit the website linked here or visit NISHTHA’s twitter handle @USAID_NISHTHA 

Jhpiego is a global health non-profit and Johns Hopkins University affiliate supporting the PHCPI partnership and the goal of transforming the global state of primary health care.