Health and Wellness Centres: Role in Pandemic Preparedness and Response

Editor: Samir Pius George
June 14, 2021

Abstract

A Community-centered primary healthcare system, through a network of Health Wellness Centres (HWCs)1, may be equipped to manage large–scale epidemic outbreaks in Indian rural districts. HWCs, under the theme of comprehensive primary healthcare provision, have already been tasked with Non-Communicable Diseases (NCDs) screening, treatment initiation and follow-up, and awareness of associated risk factors through community outreach and wellness activities. In the case of an infectious disease outbreak like COVID-19, a well-managed network of HWCs may be crucial for our preparation and response to the virus through effective mitigation and communication strategies. This may also streamline referral networks with secondary and tertiary hospitals, which can reduce the increasing burden on the healthcare system.

This article, through an implementation case in progress, analyses the various aspects of equipping HWCs for mitigating and managing future epidemic risks, and their impact on critical healthcare service provisions. 

Context and Rationale

A community-centered healthcare system aims to address community conditions that affect population-level health. Community conditions such as norms regarding usage of toilets and hand wash, health-seeking behavior, and nutritional needs among pregnant women/lactating mothers are envisioned to be addressed by this type of system. In addition to this, it also targets the delivery of healthcare facilities and outreach for individual health. A community-centered healthcare system provides a framework for the coordinated delivery of healthcare services through a network of Health and Wellness Centres (HWCs), Community Healthcare Workers (CHWs), and other community-level institutions. 

There is a limit to scaling up health infrastructure during a pandemic such as COVID-19. Localized lockdowns and curfews have been only partly effective in limiting active cases. The story of Bergamo, a small town in Italy that became the epicenter of COVID19, is an example to look toward here as it emphasized that “an epidemic requires a change of perspective toward a concept of community-focused care”2.

A Community-centric healthcare system, spearheaded by frontline Community Health Workers (CHWs) who are already tasked with multiple tasks such as immunization drives and institutional delivery, may enhance preparedness and responsiveness to epidemic outbreaks. Several organizations like Noora Health have leveraged digital platforms to upskill and empower frontline CHWs. They have been empowered to engage patients and families on home-isolation case management and targeted communication on hygiene and preventive measures3.

Community–centric healthcare system augments and reduces the burden of hospital-based management for the following reasons: 

  • Infection prevention and control among caregivers at healthcare facilities: One critical factor is that hospitals may pose a significant risk for amplifying outbreaks if the local healthcare system capacity is not strengthened to manage mild cases. Ebola outbreak 2014-15, as Harvard Professor Paul Farmer argued, had resulted in high fatalities because the weak healthcare system in Western Africa (Sierra Leone, Liberia) failed to prevent spread among caregivers. 4 
  • Continuity of essential healthcare services for the vulnerable population: The lockdown measures – intended to contain the spread of novel coronavirus and limit transmission at the community level – have also resulted in disruption of diagnostic and treatment services. This has made it harder to deal with other persistent problems like Tuberculosis (TB), high malnutrition, and heart diseases. For example, a year-on-year comparison by National Health Mission (NHM) shows that routine immunizations are down by 69% and the number of lab tests for TB are down by 34%.5 A community-focused comprehensive primary healthcare may be better equipped to address these disruptions in services and to ensure non-COVID19 deaths do not shoot up while the short-term focus stays on epidemic control. 
  • Rapid and context-specific information dissemination and behavior change: Epidemics require localized and repeated communication to address the information-action gap and nudge the citizenry towards adopting preventive behaviors. Not only does this necessitate a sharp shift in acquiring and sustaining new preventive behaviors like hand washing but also countering and limiting the spread of misinformation in community networks. The lessons from community-led communication by local leaders during the Ebola outbreak in Ethiopia and Liberia underscore the effectiveness of community-focused care in outbreak response6. The success of Kerala in response to the Nipah 2016 and COVID19 outbreak primarily lies in its community institutions to effectively mobilize and garner support7.
  • Streamline referral system for moderate and severe cases at higher facilities: Indian healthcare provision is weakly anchored in the primary healthcare system. This design results in the underutilization of primary health facilities and overcrowding of tertiary healthcare systems. A Community-centric healthcare system shall be able to reduce active caseload at higher facilities through an effective referral system. 
  • Addressing gaps in coverage and community outreach through confidence building in the public healthcare system: Nearly 75% of out-patient care and 55% of in-patient care is exclusively provided by the private sector.8 However, private provision of healthcare continues to be severely impaired by small solo practitioners, small clinics, and stand-alone hospitals9. This results in a fragmented health system, often characterized by ‘doctor-shopping and switching behaviour’ and induces a ‘culture of in-time transactional healthcare provision’10. This has resulted in poor health-seeking behaviour, wherein a significant proportion of the population doesn’t seek and avail medical facilities due to the ineffective outreach and poor quality of care. This behaviour poses a significant roadblock in containing and managing infection spread during a pandemic. A community-centric healthcare system can institutionalize trust and cooperation while consistently delivering and responding to the dynamic healthcare needs of the community.

Design: A case in example

A sample intervention in managing the pandemic and ensuring continuity of crucial health services is proposed here. The intervention aims to embed HWCs within the community through partnerships on priority-setting and planning activities. They will monitor and support high-risk groups such as malnourished children, pregnant and lactating mothers, and critical TB patients. This intervention is currently being implemented in Sewapuri block, Varanasi district, the first model block under NITI Aayog’s flagship Sewapuri Vikas Abhiyan. 

A group of HWCs is organized in clusters (4-5 HWCs, 20-25 Gram Panchayats) so as to ensure continued delivery of preventive and promotive healthcare services, supported by a cadre of CHWs, local CBOs, local pharmacies, and local Panchayat representatives. A technical helpdesk involving Community Health Officer (CHOs), Development Partners representative, Panchayat official, and women active in Self Help Groups is constituted at the cluster level to provide strategic and operational guidance to CHWs and community volunteers. The steps involved are: 

  • Identify target groups according to demography, region, and disease profile followed by prioritisation based on vulnerability profiling and scoring in each cluster.
  • Segment high-risk population such as MDR-TBs, High-Risk Pregnancies (HRPs) etc., among identified target groups for periodic community visits by CHWs.
  • Track healthcare needs of identified target groups through community visits by CHWs and consultations (OPDs) at HWCs.
  • Manage referrals and coordinate care with higher facilities such as Community Healthcare Centre (CHC), District Hospital through cluster-level technical helpdesks.
  • Ensure home-based care of asymptomatic/mild cases of COVID19 through periodic follow-up at this cluster-based technical helpdesk.
  • Facilitate high-capacity peer-to-peer monitoring and mentoring system for CHWs within a cluster.
  • Train CHWs on COVID19 IEC and assist them to facilitate in-person and group-level interactions in partnership with local CBOs, SHGs, and Panchayat leaders 

Figure 1: Theory of Change (Causal Pathways) 

Conclusion

The Indian healthcare system is built on the foundation of a network of health subcentres (HSCs), with a selective focus on reproductive, maternal nutritional, and child health (RMNCH) parameters, and some communicable diseases. This system design, under the National Health Mission, has been able to drive overall improvements in maternal and nutritional indicators. HWCs have heralded the transition towards comprehensive primary healthcare. As the global pandemic response has highlighted underlying constraints- resources, quality, and accessibility- in the healthcare system, it’s imperative to place adequate strategic emphasis on leveraging HWCs in deepening community-focused healthcare by institutionalizing and catalyzing local partnerships and leadership. 

The views expressed in the post are those of the author and in no way reflect those of the ISPP Policy Review or the Indian School of Public Policy. Images via open source.

References

  1. National Health System Resource Center India, (2018)  ‘Ayushman Bharat: Comprehensive Primary Health care through Health and Wellness Centres’ Operational Guidelines, NHSRC New Delhi, India 
  2.  Mor, Nachiket. (2020) COVID-19 crisis: Shift focus from hospitals to primary care. The Hindu Business Line. Retrieved  7 Apr 2020, from https://www.thehindubusinessline.com/opinion/covid-19-crisis-shift-focus-from-hospitals-to-primary-care/article31278485.ece#
  3. COVID-19: Innovations in Healthcare. (2020). Webinar synopsis. Retrieved 30  June, 2020, from https://www.innovationsinhealthcare.org/covid-19-innovations-in-healthcare-responds/
  4. “Silver, M. (2020) ‘The Dread of Responsibility’-Paul Farmer on the Pandemic and Poor Countries  NPR, Retrieved 24 March, 2020, from  https://www.npr.org/sections/goatsandsoda/2020/03/24/820968801/the-dread-of-responsibility-paul-farmer-on-the-pandemic-and-poor-countries
  5. Pai, Madhukar and Das, Jishnu. (2020) How can India address big surge for healthcare after coronavirus lockdown? Devex. Retrieved June 2020, from https://www.devex.com/news/opinion-how-can-india-address-big-surge-for-health-care-after-coronavirus-lockdown-97382
  6. National Academies of Sciences, Engineering, and Medicine. (2016). ‘Global health risk framework: Resilient and sustainable health systems to respond to global infectious disease outbreaks: Workshop summary’. Washington, DC: The National Academies Press. from https://www.nap.edu/read/21856/chapter/1#ii
  7. Tharoor, Shashi. (2020) The Kerala Model, Project Syndicate. Retrieved May 2020, from https://www.project-syndicate.org/commentary/kerala-model-for-beating-covid-19-by-shashi-tharoor-2020-05?barrier=accesspaylog
  8. Ravi, Shamika, Ahluwalia, Rahul, Bergkvist, Sofi. (2016). Health and Morbidity in India (2004-2014), Brookings India, Research Paper No. 092016.
  9. NITI Aayog. (2019). ‘Health Systems for a New India: Building Blocks’
  10. Mor, Nachiket. (2020). An approach towards health systems design in India. Mar 2020, from. https://www.researchgate.net/publication/339971634_An_Approach_Towards_Health_Systems_Design_in_India

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The Swachh Bharat Mission (SBM) was initiated in 2014 to achieve universal sanitation coverage. The cleanliness drive aimed to make citizens health-conscious by providing financial incentives for solid/liquid waste management (SLWM), toilet construction, technical assistance, and capacity building (Aijaz, 2017).

The Swachh Bharat Mission has successfully executed its target of toilet construction with about 99% of Indian cities declared Open Defecation Free (ODF) (Jadhav, 2021). However, toilet usage is still reported to be low. There are drawbacks to the policy that can only be mitigated when citizens and the government work in collaboration and co-design the policy. Behavioural interventions can come in handy to bring about this transformational shift. According to Sharma, by 2021 a very small percentage (about 3%) of the SBM Budget is allocated to behavioural change. 

The potential solution area to improve the policy’s adoption is to reframe the policy for better outcomes using the principles of behavioural science.

Administrative Problems

Apart from the behavioural challenges mentioned above, there are certain administrative issues in the implementation of the program. It is observed that toilets are not properly constructed, either they are left halfway or constructed at far-off places and not in close vicinity creating challenges, specifically for women. Problems concerned with lack of adequate water supply, small and dingy toilets, also hinders the use of the toilet. Many areas even struggle to maintain the Open Defecation Free (ODF) status owing to seasonal and technological challenges (Sharma, 2021). 

To address these challenges, consistent physical availability of functional toilets must be a critical first step to induce latrine-use habits. This can be done by ensuring that toilets are constructed in social contexts beyond the homes such as in schools, hospitals, market places, thereby maximizing the physical availability of enabling infrastructure. It is equally important to map the existing OD locations and reduce the physical availability by repurposing common OD sites for alternate use. 

By making the existing toilet infrastructure easily accessible and user-friendly and by reducing the availability of the products/infrastructure supporting OD, we can correct the barriers hindering toilet usage.

Challenges in the Swachh Bharat Mission (SBM)  

India, with its vast and diverse population, experiences a number of challenges in getting people to use toilets and stop defecating in open spaces. Some of these challenges are listed below: 

  • Status Quo Bias – 100% toilet coverage yet low toilet usage 

According to the IHHL (Individual Household Latrine), there has been an overall 100% household toilet coverage in India, as of 2nd October 2019 (Swachh Bharat Mission (Gramin), n.d.). However, the policymakers underestimated the amount of time it would take to bring in desired behavioural change among the people who largely defecate in the open. 

People have a status quo bias wherein due to the preference for the current state of affairs, individuals do not wish to exercise an active choice but simply stick to the age-old practices and therefore, individuals in India continue to defecate in the open. In the rural areas of 5 northern Indian states, Coffey et al. (2014) found that 21% of individuals continue to defecate in the open, despite owning a latrine. In rural Tamil Nadu, a study by Yogananth & Bhatnagar (2018) reported that 54% of respondents defecated in the open despite having a household latrine.

Individuals are also driven by present bias wherein the inclination towards a smaller present reward (gains from open defecation) dominates larger later reward (gains from toilet usage). This occurs due to a lack of knowledge about the future benefits of using toilets. 

  • Limited awareness:

Even in places where toilets are functioning, citizens lack awareness in terms of the importance of sanitation and hygiene. Construction of toilets is not enough, the government should stress on effective communication to induce behavioural changes as well as focus on the differential usage and access to these facilities (Sharma, 2021).

Recommendations

It can be noticed from the above discussion that individuals often stick to what is the default setting due to limited cognitive abilities and biased perceptions. In his book, Thinking Fast and Slow, Daniel Kahneman points out several biases and heuristics that limit our ability to make the best decisions for ourselves and others. Such decisions not only impact us but also those around us, leading to negative externalities. It is the need of the hour to change the behaviour of individuals through appropriate interventions to eliminate the negative outcomes. These interventions, by enabling reflective thinking, can nudge people to start using toilets and bring in desired changes.

Using the learning from behavioural science, some policy recommendations can be enacted for the effective implementation of SBM:

  1. Behavioural changes and nudges would be able to facilitate a shift that would build upon existing social norm bias and induce citizens to make rational choices. To encourage citizens to stop defecating in the open, individuals can be informed of how their neighbours are making the best use of toilets. Using messages such as ‘9 out of 10 households in your vicinity use toilets ’, ‘no toilet, no bride’ can induce people to positively change their behaviour.
  2. Linking the existing cues with desired changes can yield effective results. Open defecation (OD) is a part of the morning routine and ‘piggybacks’ on daily rituals of a time to walk and socialize. Measures can be taken to enable latrine use to piggyback on these established, daily behaviours. For example, shaded areas near community toilets can be constructed to provide space to socialize.
  3. Effective monitoring, surveillance, regular reminders, and ground-level checks can help in examining the use of toilets. Incentivization can be another measure to encourage people to make the best use of toilets. Households making use of toilets can be awarded as the “Best Household” and can be given badges as a token of appreciation for supporting the cause. This could be publicly visible and generate a badge effect, motivating others to participate in the drive. Moreover, techniques like campaigning, social messaging, priming, can be used to bring desired behavioural change.

Conclusion 

Experiments around the world have shown how behavioural principles can be used to design policies that address development and policy challenges. Good data and good analysis are thus very essential for being informed about issues and making good policy recommendations. Open Defecation (OD) is a deep-rooted socio-cultural concern. Thus, without intervention in behaviour, the use of toilets will not increase even where latrines are available. To transform India into a truly ODF society, it will call for significant interventions to design latrines amenable to sustained daily use and to induce significant behavioural change.

‘Open defecation is a battle with the mind and hence must be won mindfully’

References

 About Us | Swachh Bharat Mission—Gramin, Ministry of Drinking Water and Sanitation. (n.d.). Retrieved October 25, 2021, from https://swachhbharatmission.gov.in/SBMCMS/about-us.htm

Aijaz, R. (2017, July 19). Swachh Bharat Mission: Achievements and challenges. ORF. https://www.orfonline.org/research/swachh-bharat-mission-achievements-challenges/

Coffey, D., Gupta, A., Hathi, P., Khurana, N., Spears, D., Srivastav, N., & Vyas, S. (2014). Revealed Preference for Open Defecation. 38, 13.

Jadhav, R. (2021, January 28). Flush with success, Swachh Bharat scheme on path to sustainability. https://www.thehindubusinessline.com/data-stories/data-focus/flush-with-success-swachh-bharat-scheme-on-path-to-sustainability/article33686833.ece

Kahneman, D. (2003). Maps of Bounded Rationality: Psychology for Behavioral Economics. The American Economic Review, 93(5), 1449–1475.

Sharma, A. (2021, October 28). Here’s Why India Is Struggling to Be Truly Open Defecation Free. The Wire. https://thewire.in/government/heres-why-india-is-struggling-to-be-truly-open-defecation-free

The  Behavioural  Insights  Team  (2015),  ‘ FAST:  Four  simple  ways  to  apply  behavioural  insights ’,  http://38r8om2xjhhl25mw24492dir.wpengine.netdna-cdn.com/wp-content/uploads/2015/07/BIT- Publication-EAST_FA_WEB.pdf

Yogananth, N., & Bhatnagar, T. (2018). Prevalence of open defecation among households with toilets and associated factors in rural south India: An analytical cross-sectional study. Transactions of The Royal Society of Tropical Medicine and Hygiene, 112(7), 349–360. https://doi.org/10.1093/trstmh/try064