Fixing a Broken Healthcare System: Lessons from the Pandemic
Garima Goel – Student, Kautilya
The COVID-19 outbreak placed unprecedented demands on the Indian health system. The shift in resources towards containment of COVID-19 and the complexity of subsequent lockdowns caused serious disruption in access to and provisioning of other health services. The public healthcare system, in particular, faced extensive pressure on its capacity to provide access to health services. The inadequate data available showcased a horror story unfolding itself. Think tank FRHS predicted 2.38 million unintended pregnancies due to a lack of access to Family Planning (FP) products. Health-seeking behavior of individuals also dived as they feared entering a health facility. A y-o-y comparison indicates that Tuberculosis (TB) notifications in Sept’20 were 33% lower than those in Sept’19. The decision to close down services that are not classified as ‘essential’ further distanced vulnerable communities from difficult-to-access health services.
I was involved in a pan-India COVID study in collaboration with Bill and Melinda Gates Foundation’s policy team in 2020. BMGF undertook an exploratory exercise aimed to understand key challenges in the delivery of essential health services during COVID-19 and innovations/approaches deployed for the resumption and strengthening of the public healthcare system. The objective of this activity was to build on healthcare resumption models successful on the ground and scale them through necessary government support so that essential health service delivery can be re-built.
Our in-depth interviews with 47+ Civil Society Organisations (CSOs) working on-ground revealed that across all services, there were disruptions on both the demand and supply sides. On the demand side, there was a shift in health-seeking behavior and de-prioritization of curative and promotive care due to fear of COVID contraction and lack of awareness of resumed services.
On the supply side, there were challenges at multiple levels. The facility posed limitations with respect to the infrastructure for implementation of scheduling, triaging, infection control protocols & referrals. There were limited clarity and space constraints at regular outreach sites to conduct Village Health and Nutrition Days (VHNDs) in pre-COVID level capacity while adhering to physical distancing and infection prevention protocols. Additional COVID responsibilities were assigned to health workers, leading to difficulty for frontline workers (FLWs) to fulfill their service roles effectively. Apart from these, there was an exacerbation of pre-existing challenges in the supply chain, last-mile drug delivery, and transport of essential commodities.
Working in the social sector felt like a daily war of mental resilience. But amidst the chaos, came an unexpected ray of hope. Multiple consortiums like ACT Grant and Covid Action Platform were created. These consortiums comprised intersectional stakeholders with different sectoral and functional expertise to discuss innovative solutions and bridge the current gaps to resume essential health services, the lack of which has the potential to steamroll an entire generation into drudgery.
One of the approaches discussed was developing a health technology solution to connect patients with service providers for remote counseling and treatment. India’s policy environment is conducive to technology with the advent of the Information Technology Act providing a foundation for e-commerce and electronic data exchange, Telemedicine guidelines ensuring online consultations, National Digital Health Mission with key features such as health ID, personal health records, Digi Doctor and health facility registry and a draft of Health data management policy released for public feedback.
The proposal is to develop a comprehensive platform enabling remote and in-person essential health service delivery through the usage of existing public and private platforms like state-level helplines for information dissemination, Common Services Center (CSC) scheme for delivery of essential drugs and commodities, CSO on-ground services like Gram Vani, 1mg, eGov to assimilate feedback from end users. The advent of technology is envisioned to create stronger and decentralized data points in the healthcare system. This data can then be utilized to build consensus and align the public machinery on specific budget allocation and implementation for healthcare-related infrastructure and personnel.
Another approach for faster resumption of services is to leverage community-based organisations. This approach aims to put the ‘people of concern’ at the heart of operational decision-making so that the schemes developed are sustainable in the long run. Under the guidelines released by the government for the involvement of Self Help Groups (SHGs) in COVID response; State Rural Livelihoods Mission (SRLMs) have been directed to leverage Self Health Groups, Village Organisations, and Cluster Level Federations for the provision of ration or cooked food to poor and vulnerable families using the Vulnerability Reduction Fund or with support from State and district administration. ASHA workers, which form the main pillar for last-mile service delivery, were overworked with additional tasks and longer commutes during the pandemic while having low and irregular remuneration. To combat such issues, a more targeted approach is required for the involvement of Community-Based Organisations (CBOs) to support functions for essential health service delivery. 8,47,81,118 women in the country are currently organised in Self-Help-Groups, that can be tapped into for supporting essential health service delivery.
These Community Based Organisations can be central in demand generation by providing behavior change communication (in local languages) and supporting the efficiency of service delivery by undertaking activities for the diversification of nutrition baskets which can be localized for the mid-day meal scheme. The CBOs can also help provide support to FLWs in the identification of high-risk pregnancies and linking them to the correct health centers as well as sharing feedback on service functioning through forums such as Gram Sabha/Mahila Sabha.
World Health Partners has championed a rural health network model (in Bihar and Andhra Pradesh). The network recruits and trains underqualified rural practitioners to provide general screening services and connect patients with specialists in need through technology. Rural practitioners are also provided test kits to facilitate sample collection for presumptive patients. The model allows for staggering critical care by utilizing a network of rural health practitioners.
The pandemic showcased deep cracks in our systems. However, it has also highlighted the will and resilience of individuals and society much more strongly. Increased intersectional participation, a broad technological base, focus on decentralized leadership are just a few of the telltale signs that make me optimistic that the current time might be the best time to make some everlasting changes in the country’s healthcare system.