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)
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.
- National Health System Resource Center India, (2018) ‘Ayushman Bharat: Comprehensive Primary Health care through Health and Wellness Centres’ Operational Guidelines, NHSRC New Delhi, India
- 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#
- COVID-19: Innovations in Healthcare. (2020). Webinar synopsis. Retrieved 30 June, 2020, from https://www.innovationsinhealthcare.org/covid-19-innovations-in-healthcare-responds/
- “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
- 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
- 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
- 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
- Ravi, Shamika, Ahluwalia, Rahul, Bergkvist, Sofi. (2016). Health and Morbidity in India (2004-2014), Brookings India, Research Paper No. 092016.
- NITI Aayog. (2019). ‘Health Systems for a New India: Building Blocks’
- 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