Behind the curve: How COVID-19 exposed India’s apathetic rural health infrastructure

The SARS-CoV-2 virus, which is behind the novel coronavirus disease (COVID-19) pandemic, does not differentiate between rural and urban areas. It just looks for susceptible people, who still do not have the immunity against it.

Since rural India remained largely unscathed during the first wave of the pandemic, the virus has found many susceptible victims there during its second wave.

An analysis by Down To Earth shows that in April, rural districts accounted for 45.4 per cent of the total COVID-19 cases in the country and 50.8 per cent of the deaths. The numbers kept growing through May, when rural districts surpassed urban districts in terms of COVID-19 cases and deaths. That month, rural districts accounted for 53 per cent of the total new cases in the country and 52 per cent of COVID-19 deaths.

Owing to the nature of the virus, its spread was inevitable. The current problem emanates from the fact that the rural areas are ill equipped to deal with diseases even in best of times. More than 65 per cent of the country’s population lives in rural districts, according to World Bank data.

Yet, hospitals in rural areas have just 37 per cent of the beds available in all government hospitals across the country, admits the National Health Profile of India for 2019, a report prepared by the Central Bureau of Health Intelligence.

The problem also stems from the fact that the country has failed to strengthen its rural health infrastructure, despite repeated warnings and advisories.

A parliamentary committee report on ‘Management of COVID-19 Pandemic and Related Issues’ presented to the chairperson of the Rajya Sabha on December 21, 2020 indicated the possibility of the disease reaching rural areas. It had advised the government to ensure testing infrastructure and upgraded health infrastructure in remote and rural areas.

Earlier, on November 21, another parliamentary committee report, ‘Outbreak of Pandemic COVID-19 and it’s Management’, submitted to Rajya Sabha highlighted the poor state of primary healthcare in rural areas and recommended that the government increase its spending under the National Rural Health Mission to strengthen the delivery of healthcare services in rural areas during the pandemic.

It was only in May that some action was visible at the central level. On May 16, the Union Ministry of Health and Family Welfare released a standard operating procedure (SOP) on ‘COVID-19 Containment and Management in Peri-urban, Rural and Tribal areas’.

The SOP outlined the preparations needed in rural areas and detailed the efforts states needed to take for surveillance, screening, isolation and referral of patients. It proposed a three-tier structure — COVID care centres to manage mild and asymptomatic cases; dedicated COVID health centres to manage moderate cases; and dedicated COVID hospitals to manage severe cases.

Implementing the SOP should not have been difficult as India already has a three-tier healthcare system in place — primary, secondary and tertiary. Then where did it falter?

Ritu Priya, professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, said a healthcare system that does not work in normal times is not likely to work during a pandemic and under pressure. Besides, the SOP document does not reflect any sense of urgency by the Union health ministry for rural India. It begins with the line “COVID-19 outbreak in the country is still predominantly an urban phenomenon”, she said.

The SOP document also notes that 80-85 per cent of the people affected by COVID-19 do not need specialised care and can be quarantined at home or at a COVID care centre. However, ensuring treatment to the remaining 15-20 per cent of COVID-19 infected persons requires major upgradation in healthcare infrastructure — community health centres, sub-district and district hospitals and transport facilities — in rural areas. This was unthinkable for a health system that has been strapped for funds for decades now.

India’s public health expenditure (a sum of Central and state spending) has remained between 1.2 per cent and 1.8 per cent of GDP between 2008-09 and 2019-21. This is quite low when compared with other countries such as China (3.2 per cent), US (8.5 per cent) and Germany (9.4 per cent).

The National Health Mission, which envisages achievement of universal access to equitable, affordable and quality healthcare services, receives about 50 per cent of the budgetary allocation for health. Worse, the allocations for the rural component (National Rural Health Mission) has decreased by 3 per cent since last year.

Since 2014, the government’s focus has in fact shifted to providing healthcare by roping in the private sector. The National Health Policy (2017) also envisages providing healthcare in collaboration with the private sector. The Pradhan Mantri Jan Arogya Yojana (PMJAY), a component of the Union government’s flagship scheme Ayushman Bharat, is an insurance-based scheme which has seen the highest increase in allocation for 2020-21 at 100 per cent ( Rs 6,400 crore over the revised estimates of Rs 3,200 crore in 2019-20).

The futility of this dependence on private healthcare providers via government-funded insurance schemes has become apparent during the pandemic. The private sector is not active in rural areas, and even the hospitals present refused to provide care to COVID patients during the pandemic.

Even state-level insurance schemes did not perform well. Chhattisgarh, for instance, has a universal healthcare scheme, the Khoobchand Baghel Swasthya Sahayata Yojana. During the pandemic, this scheme should have come to the rescue of each COVID-19 infected person, whether in rural or in urban areas.

But private hospitals refused to implement it. Instead, several of them found newer ways to overcharge patients by providing plasma therapy and other unscientific and unproven therapies that do no good to patients, reveals Sulakshana Nandi, National Joint Convener of Jan Swasthya Abhiyan (JSA) and co-chair of People’s Health Movement, a global network..

The government did not demand services from the private sector though it could have legally done so under the Epidemic Diseases Act, 1897 (just the way Kerala has done). Experiences of the poor say provision of an insurance card is not the same as effective access to free and quality care. Instead of learning from this failure of the private sector to provide any help during the pandemic, NITI Aayog, India’s premier think tank, brought out a report Investment Opportunities in India’s Healthcare Sector, on March 31, 2021, with a focus on private healthcare.

“Going forward, the Centre and NITI Aayog should abandon all plans for healthcare privatisations, such as PMJAY and handing over district hospitals to private medical colleges, and instead invest all money and efforts into strengthening the public health system at all levels,” Nandi said.

Left in shambles

The major reason public healthcare has failed to perform during the pandemic is the deficiency in infrastructure — both in terms of physical structures and human resources.

As of 2018, India faced a shortage of 2,188 community health centres (CHCs), 6,430 primarily health centres (PHCs) and 32,900 sub-centres. The existing ones, too, do not have adequate infrastructure and are poorly equipped.

According to an analysis by World Bank, in 2017 India had only 0.5 beds per 1,000 people, far below the global average of 2.9 beds. Small wonder, the rural healthcare infrastructure is now stretched to the limit during the pandemic.

“In some tribal areas of Maharashtra, not a single oxygen bed is available in the entire block. People here had to travel long distances to access medical facilities, without any assurance of a bed. More often than not, their health condition deteriorates on the way to the health facility,” said Abhay Shukla, co-convenor, JSA.

The isolation centres which had worked well in the first wave were not revived in the second wave. “In rural areas, it is important to have institutional isolation centres to ensure adherence to COVID-appropriate behaviour,” he added.

It is easy to bolster health infrastructure during such times of crisis. Potentially, each rural school can be converted to an isolation centre, which can then be monitored by ASHAs and ANMs. This is a public health measure that has to be implemented and supervised with direction from the top authorities.

Similarly, each taluka in the state has a 30-bed hospital, some of which can easily converted to oxygen beds. “In Chhattisgarh, a number of government facilities got upgraded during the pandemic, and have been doing a very well,” Nandi said.

There is also a shortfall in the number of doctors, specialists and surgeons. For example, as of 2018, there was a deficit of 46 per cent of doctors and 82 per cent of specialists, including surgeons, obste-tricians, gynaecologists, physicians and paediatricians needed in PHCs across India.

WHO recommends 44 health workers per 10,000 population, but India has only 22 health workers per 10,000 population. Rural areas have lower health worker density than the national average.

The Rural Health Statistics 2019-20, brought out by the Union health ministry, points out that at the national level, 11 per cent of ANM (trained female health workers) posts at sub-centres were vacant, as were 35 per cent of the sanctioned positions for male health workers. Similarly, 37 per cent of the positions for health assistants and 20 per cent for those of doctors at PHCs were not filled.

Even nurses and AYUSH (Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy) practitioners were short by 13 per cent and 9 per cent respectively.

The most basic health workers are missing even in a rich state like Maharashtra, where the number of sanctioned positions for ANMs at the sub-centre level was 11,975, of which only 10,492 posts were filled.

Poor states like Uttar Pradesh and Bihar, as classified by the number of people living below the poverty line under the NITI Aayog’s SDG India Index for 2019, were worse off. While in Uttar Pradesh, out of the sanctioned 23,656 posts, only 20,389 were filled, in Bihar, only 13,425 posts out of the sanctioned 20,544 were occupied.

ASHAs and other frontline workers worked well during the first wave of the pandemic, but as they were not adequately protected, many got COVID-19. ASHAs in Pune, Maharashtra, have not been paid or remunerated for the extra work they are doing, Shukla said.

Mitanins (female health volunteers) in Chhattisgarh have been working non-stop in the community since the pandemic began, but they have neither been remunerated nor provided adequate protective equipment, Nandi said. So they are demoralised, discouraged, sick and scared during the second wave.

Strength in community

However, these community-level workers are needed to improve India’s response to COVID-19 and improve health basics. Some states have made an effort to improve the working of rural workers. On May 17, 2021, the Odisha government issued a directive to provide a one-time support of Rs 10,000 to ASHA workers to purchase protective equipment to help them work safely.

“Health cannot be produced, it can only be co-produced— the public health system and people have to work together. Co-production of health is imperative in time of a pandemic. Everyone has to be mobilised,” Shukla said.

The non-degree holder rural doctors too need to be included in this fight, Ritu Priya said. These practitioners provide healthcare to over 80 per cent people in rural areas. Some states like West Bengal have woken up to this potential.

The state government is now enlisting these healthcare providers who are being officially recognised as grameen swasthya parisevaks and being trained to contain the spread of COVID-19 in rural areas, particularly to counsel the increasing number of patients in home isolation.

SATHI, or Support for Advocacy and Training to Health Initiatives, a Pune-based non-profit, has set up 30 help desks during the second wave to guide patients on where to go for tests and vaccinations, and what treatment to avail. This is of huge help as the existing staff is preoccupied with clinical care, and it can be easily set up across the country.

States like Kerala, that have had some experience with pandemics, have fared better in COVID-19 control due to participation of civil society in outbreak control and health service delivery. Team building among frontline functionaries and community leaders was spontaneous without any political or religious barriers as people had experience through the previous outbreaks of H1N1 in 2009, Nipah in 2018 and leptospirosis in 2019.

“Mobilising volunteers who are ready to go the extra mile was a deliberate strategy adopted by Kerala since 2008 through the People’s Campaign for Decentralised Planning,” said Antony KR, a Kochi based public health expert and an independent monitor of the National Health Mission.

Because of this, 45,000 registered volunteers are now helping the Kerala government in COVID-19 control activities. They are in addition to 26,310 ASHA workers, 33,115 anganwadi workers, and 4.54 million women entrepreneurs under the banner of Kudumbashree, a scheme for neighbourhood women groups. Another 21,682 elected ward members from village panchayats, municipal corporations or councils, too, have joined this army of unpaid workers to tackle the pandemic.

Over the past year, these volunteers have played a crucial role in tracing and isolating the infected persons at airports, railway stations, inter-state borders and bus terminals; running community kitchens to feed quarantined people, especially the elderly, patients in isolation hospitals, the poor and the homeless; and to distribute dry ration kits, Antony explained.

Ritu Priya pointed out that India can fight the pandemic successfully only with a decentralised approach. The entire government and the whole society must come together and take action, keeping local-level conditions in perspective. In Dharavi, the government machinery worked, but the community also participated actively. The private sector does not have a role in pandemic control as it is not likely to do contact tracing or go to rural areas.

As of now, vaccines appear to be the only way out of the pandemic. These would be especially useful in rural areas where healthcare is patchy.

Vaccine conundrum

Ideally, the COVID-19 vaccination programme should have been a success in India, which is not only a global leader in vaccine development but also has an existing universal immunisation programme in place. But in its attempt to address the issue of vaccine shortage amid the second wave, the government has instead introduced new strategies that have now resulted in unjust and lopsided distribution of the vaccine.

While rolling out the COVID-19 vaccination programme, the Centre had sanctioned Rs 35,000 crore, which is enough to purchase a vaccine for every citizen above 18 years of age. On December 28, 2020, it also released the COVID-19 Vaccines Operational Guidelines to ensure a smooth rollout of these vaccines.

But deadlines were not set, and all that was mentioned was that everyone who is eligible for the vaccine would get it. The guidelines aim to vaccinate some 300 million people — healthcare workers, frontline workers, those above the age of 50 years and those who have co-morbidities — by July 2021.

The vaccination drive was then opened up for people aged 45 years and above on April 1, 2021. With the second wave, the demand for vaccines increased and shortages were evident on the ground. But the government did not have a plan to meet this demand.

On April 19, 2021, the government unveiled the Liberalised and Accelerated Phase 3 Strategy, according to which states and private hospitals could procure half of the vaccine produced in the country. The manufacturers were allowed to sell these doses at a higher price.

Now, those above 45 will receive the central quota and this can be dispensed for free to the population. The states could provide vaccines to those citizens they consider vulnerable, while the private industry could vaccinate all those who do not necessarily fall in the vulnerable category but have the purchasing power.

This strategy has led to chaos and confusion on the ground. Bharat Biotech has announced that it would sell its vaccine, Covaxin, at Rs 400 per dose to the states while Serum Institute of India (SII) has set price for its vaccine, Covishield, at Rs 300 per dose. While SII has set the price at Rs 600 per dose for the private players, Bharat Biotech has not revealed its price. These higher prices have resulted in an increase in the price of vaccine at private centres, where Covaxin is available at Rs 1,250 and Covishield at Rs 900.

Since neither of these companies have enough vaccines to meet the shortages, states have tried to issue global tenders to expedite the vaccination process.

Uttar Pradesh, with a population of more than 200 million, floated a tender for 40 million doses of the vaccines on May 7. A couple of days later, the Municipal Corporation of Greater Mumbai (MCGM) invited expressions of interests to supply 10 million shots.

Many other states, including Delhi, have also floated similar tenders. But these states have not been successful in procuring vaccines through the tenders. “Things that should have been decentralised have been centralised and vice versa,” Shukla rued. “We have a decentralised system for vaccine procurement but a centralised system for vaccine administration.”

The companies and the government are now trying to increase production too. As Covaxin is indigenous and developed by the Indian Council for Medical Research, it is possible to licence the technology to multiple manufacturers. Some efforts have been made regarding this and facilities at three public sector vaccine manufacturing units are being ramped up so they are able to manufacture soon. Bharat Biotech, too, is increasing capacity.

Taking suo motu cognisance of the development, on May 31 the Supreme Court has also questioned the Centre about its vaccine procurement policy and different price mechanisms for the jab. So far, all the vaccines for India’s universal immunisation program were procured by the Centre alone and administered by the states free of cost, as per the established universal immunisation programme.

The pandemic is an indicator of India’s failure in providing healthcare to all in the country. Now, years of incremental improvements in health indicators in rural areas are lost as routine surgeries, antenatal care and immunisation coverage, dialysis and care of the kidney patients, routine chemotherapy and radiotherapy of cancer patients are adversely affected.

It is a wake-up call and experts hope that some good would come out of this chaos too. For example, this is the first time that all of adult population is reaching health centres for vaccination. These people can be screened for blood pressure and blood sugar and counselled for hypertension and diabetes. These are integral to comprehensive primary care proposed in the National Health Policy, 2017.

This was first published in Down To Earth’s print edition (dated 1-15 June, 2010)

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