How to stall COVID’s march in rural India

As cases of COVID-19 emerge in India’s rural areas, the time is ripe in strengthening implementation of National Rural Health Mission and decentralised governance

As COVID-19 marches onto rural India, it is time to strengthen the National Rural Health Mission and decentralised governance. Photo: Flickr

The country-wide lockdown imposed by Prime Minister Narendra Modi from March 25, 2020, impaired the lives of many urban migrants who lost their jobs overnight.

With all modes of public transport being suspended, urban migrants had no choice but to walk on foot to their native places. P Sainath, veteran development journalist, called it a “gigantic movement in Indian history.”

After many cities lurched under its calamitous impact, the novel coronavirus has unearthed a new hunting ground in rural areas. With several migrants returning to their native places, there has been a trend reversal. 

The rural areas of many districts are now reporting an upsurge in the number of confirmed cases of novel coronavirus disease (COVID-19). The World Health Organization’s chief scientist, Soumya Swaminathan, has also expressed her concern, stating that rural India is the next coronavirus hotbed.

Uttar Pradesh, West Bengal, Madhya Pradesh, Bihar, Assam, Odisha and Jharkhand, that are now witnessing a heavy spike in the number of cases, are the states that have received the highest influx of migrants.

The rural areas of Rajasthan and Karnataka have also started to record an escalation in the number of cases.

Nearly 6.7 million migrants returned to 116 districts in six states from urban centres, according to preliminary data compiled by the Union Ministry of Skill Development and Entrepreneurship.

Of them, about 4.4 million or two-thirds returned to 53 districts. Bihar topped the six states, with 2.36 million migrants returning to 32 districts, followed by Uttar Pradesh, with 1.748 million returning to 31 districts.

Urban to rural transition of COVID-19 in India

The above time series data depicts the transition of COVID-19 from urban megacities to districts with a higher share of rural population. The pre-lockdown phase saw cases emerging in urban epicentres such as Mumbai, Delhi, Ahmedabad, Chennai, etc.

These are the cities where much of the migrant population is concentrated. During the lockdown, barring the North Eastern states, cases started emerging in other states.

However, post-lockdown, when urban migrants started moving and restrictions began to be eased, cases started emerging in many rural areas, including North Eastern states. A total of 684 out of 736 districts have reported confirmed coronavirus positive cases in double digits, according to recent data.

Only 13 districts have not reported any positive cases as of July 14, 2020.

Dismal rural healthcare infrastructure

The public healthcare infrastructure is dismal in rural India, characterised by a chronic shortage of medical professionals including doctors, nursing staff, paramedics as well as hospital beds and equipment.

The COVID-19 pandemic presents a special challenge due to inadequate testing and isolation facilities in rural India. Moreover, there are high levels of non-communicable diseases (for instance diabetes, hypertension, etc), infectious diseases (tuberculosis, diarrhoea, etc) and malnutrition in rural areas.

Healthcare services are quite distant for many villages in several districts, especially remote ones. This is coupled with a lack of transportation in rugged terrains that may exclude many from seeking timely COVID-19 testing and treatment.

According to the Census of India, rural populations are comparatively older, placing them at a higher risk of contracting the COVID-19 infection. They also live much farther from hospitals than their urban or suburban counterparts and a majority of them list access to good medical care as a major community problem.

As the current pandemic has stretched an already overburdened medical infrastructure, other healthcare services such as reproductive and child health, healthcare for the elderly and other curative services have taken a backseat.

Rural households with no access to water and soap (in %)


The challenge becomes even more serious when some of the basic sanitation indicators in rural areas are scrutinised. More than 60 per cent households in rural areas of Bihar, Madhya Pradesh, Jharkhand, Chhattisgarh and Odisha do not have access to water and soap. These are also the states which are major destinations of returnee migrants.

Data from the National Family Health Survey-4 in terms of accessibility of rural primary health centres (PHC) / rural hospitals and community health centres or CHC (key delivery points that can be utilised for testing and treatment for COVID-19) is only 25 per cent.

Since these are the only existing public delivery points in rural India, there is a dire and urgent need to strengthen the healthcare delivery system of rural India.

State of rural healthcare access in India

Strengthening the National Rural Health Mission

The pandemic presents an opportunity to realise the true potential of the existing National Rural Health Mission (NRHM) and its associated budget allocation. Expedient efforts for effective management of COVID-19 in rural India should be done under the broad umbrella of NRHM. These efforts should be done in a strategic manner so as to strengthen health infrastructure and service delivery mechanism in the process.

Launched in 2005, the NRHM, now the part of National Health Mission, seeks to provide effective health care to the rural population by strengthening public health systems for efficient service delivery. It seeks to provide effective health care to vulnerable population groups in rural areas by improving access, enabling community ownership and demand for services.

Since more than 12 percent of India’s rural population accessed PHCs or outreach health service delivery points, there is a need to rapidly develop a robust referral system from PHCs to CHCs / rural hospitals and the nearest COVID-19 testing and treatment facilities.

The strategy may include clustering and increased coordination among four-five CHCs / rural hospitals accessible by road to strengthen testing outreach, with one of them being the COVID-19 RT-PCR testing node.

Arrangements of RT-PCR testing kits, reagents and associated equipment for such CHCs identified for the purpose will be in interest of better management of COVID-19 in rural areas. Training of health personnel in CHCs needs to be provided at the nearest COVID testing centres.

The rural population will greatly benefit if a vehicle from the nodal COVID-19 CHCs could visit the two nearby CHCs on one route for pre-defined timings on fixed days of the week to collect samples for RT-PCR tests.

On alternate days, the vehicle could cover the other one or two CHCs. There needs to be coordination and a referral and COVID-19 reporting mechanism in place between PHCs and CHCs about the testing day and time so that contacts of confirmed cases and suspected COVID-19 cases can be referred efficiently.

Decentralised governance

A holistic approach needs to be adopted by the administration if the spread of coronavirus to rural areas has to be curtailed. Pre-planning and a decentralised administration, with effective decision-making and implementation powers placed in the hands of the Panchayats is necessary.

The Gram Panchayats should be equipped with measures for handling breakouts. Quarantine centres need to established and managed efficiently, private and local doctors should be trained for COVID-19 handling and management.

Adequate measures should also be in place to ensure that there is no stigma and discrimination against COVID-19 patients or their families. Awareness campaigns should be organised to increase awareness regarding self-care and sanitation facilities.

A recent study by the Massachusetts Institute of Technology warns that India might be the worst-affected nation by coronavirus by the end of winter of 2021, with nearly 0.287 million cases surfacing every day in the country.

If the cases keep increasing at the current rate and the spread of the infection to the rural areas is not kept in check, the above mentioned forecasting might prove itself true and this could prove disastrous for India and its already-stretched healthcare system.

If this is to be prevented, strategic attempts to isolate the rural areas as much as possible should be made and concerted efforts need to be put in place to ensure that rules are adhered to and healthcare facilities are provided.

Nand Lal Mishra, Sayeef Alam and Akancha Singh are research fellows at International Institute for Population Sciences, Mumbai. Kanupriya Kothiwal is an associate researcher with Urban Health Resource Centre, New Delhi

Views expressed are the authors’ own and don't necessarily reflect those of Down To Earth

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