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Commentary

Repercussions of lockdown on primary health care in India during COVID 19

Vyas, Shaili1; Sharma, Neha1,; Archisman, 2; Roy, Pritam3; Kumar, Raman4

Author Information
Journal of Family Medicine and Primary Care: July 2021 - Volume 10 - Issue 7 - p 2436-2440
doi: 10.4103/jfmpc.jfmpc_1991_20
  • Open

Abstract

Background

Primary healthcare is defined as “a whole-of-society approach to health and well-being centered on the needs and preferences of individuals, families, and communities.” It targets physical, mental, spiritual, and social wellbeing and assures comprehensive care to all people. It is the basic need, but the crises of COVID-19 pandemic have deeply affected the primary healthcare sector of almost all countries.[1] It is said that the “a strong health system is the best defense against any outbreak.” The pandemic of novel coronavirus showed the fragility of the existing healthcare delivery systems of many countries, thereby compelling them to take certain steps. COVID-19 has literally strained the healthcare delivery system globally. The countries that spend even up to 8–10% of their Gross Domestic Product (GDP) on healthcare services have also succumbed under COVID-19 crises, whereas India spends just 1.4% of its GDP on the healthcare sector and ranks 145 out of 195 countries in providing accessibility to healthcare services to its country people.[2] Every country is coming up with their own models to tackle COVID-19. There are a few countries that have not put in strict lockdown measures, while India introduced lockdown phases with gradually lifting the strictness. Indian rural health system comprises of a three-tier approach, i.e., community health centers (CHC), primary health centers (PHC) and subcenters. According to recent data, although there has been a rise in healthcare facilities in India, in human power, India still falls behind the recommended levels by WHO. There are 3.2 government hospital beds per 10,000 people in rural India compared to 11.9 in urban area. The most populous state of India, Uttar Pradesh, has about 2.5 beds per 10,000 population followed by Rajasthan, Jharkhand, and Maharashtra. Further, there is dearth of specialists at the CHCs.[3] The primary healthcare delivery system in India is still in its primeval stages with lack of human resources and quality of care. In defiance of Government's accountability to ensure affordable and adequate healthcare to every citizen, the situation seems to be delusional. The state is more focused on curative care rather than concentrating on poor infrastructure and coordination leading to lack of preparedness for catastrophies like COVID-19 pandemic. Our primary healthcare system is not capable of facing the brunt of novel corona virus attack in rural areas.[4] The exact figures of novel corona virus hitting the rural areas is inadequate. With an inadequate surveillance system, low testing, and impoverished health care, the number of cases is already in lakhs. The greatest impacts are on the people of rural areas where thousands of people have become unemployed at one go.

Problem Statement

Case scenarios

A 35-year-old migrant laborer who walked for nearly 1200 kms to go back to his home to take care of his family members is now under dismay to see his lifeless mother who died of diabetic complications and deceased wife who gave up fighting with tuberculosis. This man visited the primary healthcare centers several time only to witness the nonavailability of doctors as they are on COVID-19 duty. With the last hope, he also visited “non-formally trained local practitioner” doctors, but everything went in vain. Next is a case of migrant worker who was on antitubercular therapy and was fetching medicines in Allahabad from a private clinic. Due to lockdown, he could not visit the private clinic and thus was unable to continue with the TB treatment. He also visited PHCs for the same, but medication provided to him by the doctors did not work. The malnourishment and lack of treatment succumbed him to death. Similarly, a 55-year-old patient met with the same fate due to malnourishment and nonavailability of medicines.[5]

There have been many more similar cases as mentioned above. There has been a prodigious collateral damage to primary health care services due to COVID-19 in India. Providing access to quality healthcare services, especially maternal and child healthcare has always been challenging in the past also. With novel coronavirus, this has increased a lot. The vice-president and healthcare policy practice lead of Chase India also stated that diverging the 1.4 million Anganwadi workers and 1.3 million ASHAs in managing COVID-19 can strongly disrupt the maternal and child healthcare schemes. The senior researcher fellow at Rajiv Gandhi Institute for Contemporary Studies also backed up the same thing by adaging that there will be increase in maternal mortality, infant mortality, IUGR rates, and anemia due to the lack of antenatal checkups. The Executive Director of Population Foundation of India (PFI) showed concern that if there will be restricted maternal and child healthcare it will lead to rise in unmet need for contraception and unsafe abortions.[6]

It is reported that there has been a massive decline in routine vaccinations like MMR vaccinations which has gone down by 69%[7] Almost 100,000 children could not receive BCG vaccine and around 200,000 children also missed their pentavalent vaccine doses[8] There is a fall in the OPD of acute heart illnesses by 50% and oncology by 70%, and IPDs for hepatitis patients by 59%.[7] As compared to March 2019, there has been decline in the OPD of diabetes, mental illnesses, and cancer cases by 350,000, 150,000 and 100,000, respectively during March 2020. However, these figures can be underestimated as well and it would be unreasonable to say that there is a fall in such diseases.[8]

The neglect of other noncommunicable diseases will increase their burden and there will be a rise in disease sequelae as well in the long run. The elective surgeries getting postponement can lead to detrimental brunt on the quality of life among such patients.[2] Most of the primary and hospital care in India are being taken care of by private sectors and the closure of those clinics and hospitals due to corona fear has put the treatment of many patients on hold. As per one mathematical model, there could be near addition of 40,000 TB deaths in another next five years for every month of lockdown in India.[7] Recently, a study commissioned by the Stop TB Partnership reported that with this lockdown and protracted time to refurbish all the services, the efforts gained during the last 5–8 years to combat TB will get lost.[5]

The COVID-19 numbers are increasing day by day and very soon public sector will lose its capacity and private sector will need time to become fully operational and those few that are opened will also demand heavily from the patients even for simple procedures. For underprivileged people, the scenario is even worse as they will be unable to seek adequate treatment for acute conditions.[7] One important thing that has to be in consideration is merely opening hospitals also will not suffice as transportation plays an equal role.[8] The recent rise in cases of anxiety, depression, and suicide among people during this lockdown because of forced isolation, domestic violence, and unemployment is quite detrimental. As per the recent survey conducted by the Indian Psychiatry Society, mental health illnesses have increased 20% during this lockdown, with at least one in every fifth individual getting affected. Experts have warned that mental health disorders can be India's next crises and it will be difficult to deal with it in the long run.[9] Figure 1 shows the impact of lockdown on primary healthcare in India.

Figure 1
Figure 1:
Impact of Lockdown on Primary Health Care in India

Measures that can be taken to Improve Primary Health Care Services and for Future Preparedness

Apart from planning, performing surveillance activities, making standard operating procedures, notifying about disease spread, and maintaining infection prevention and control by the primary care physicians, this corona pandemic has put up an unrivalled strain on them. Primary care physicians are playing their part significantly for the early confinement of this pandemic. But they must be equipped with resources for better performance. This lockdown has put large number of people on the risk of developing psychiatric disorders, which has put an extra burden on the primary care physicians in dealing with psychological problems along with medical illness of patients.[10] The following measures can not only enhance the performance of the primary care physicians but can also improve our primary health care services.

Financial

The current pandemic has made us realized that if we will not invest in our health sector today, then we will have to spend more during the coming times. The vaccine-preventable diseases and other chronic diseases if not taken care of today can lead to epidemic diseases and also a rise in the cases of drug resistant diseases which will require at least 10–100 times more money in the near future.[7]

Role of family physicians and public–private partnerships

Family physicians are often the first point of contact for the people in treating and managing health problems. It has been observed that patient satisfaction, better clinical outcomes, and hospitalization rates have improved because of access to a family physician.[11] In South Africa, family physicians are those postgraduate doctors who have expertize in working at primary care centers and at district hospitals. Different countries like Ghana, Nigeria, Uganda, and Kenya have established training programmes for such doctors. Brazil has emerged with a primary healthcare model with multidisciplinary teams for both primary care health centers and community teams.[12] In Nova Scotia, family physicians have been providing additional management for complex healthcare needs. Thus, as family physicians play a paramount role in primary healthcare like dealing with a variety of medical problems, educating patients and their family members, and practice patient-centered medicine, they should definitely be incorporated for providing the essential health services. Engagement in the private sector now can also lead to fruitful results. Private hospitals and clinics can be utilized for structured training, vaccinations, and monitoring and management of noncommunicable diseases.[7]

Use of mobile vans

The use of mobile vans in delivering essential medicines and vaccines in remote areas throughout the country can bring about major changes and will decrease the morbidity of other diseases as well. This flexible concept can supplement the healthcare infrastructure substantially.

Telemedicine

The recent research shows that telemedicine has been acceptable and successful for primary care physicians and for community suffering from COVID 19 pandemic as well.[10] Telemedicine, teleconsultancy, e-pharmacy, and phone-based consultations should be encouraged for easy and smooth delivery of healthcare services.[7] While eHealth can help in triaging of the patients, home isolation and reduced contact period between patients and healthcare workers will decrease hospital burden. The Ministry of Health and Family Welfare in collaboration with the NITI Aayog had released “Telemedicine Practice Guidelines” that enables a registered medical practitioner to enhance healthcare services in remote settings through telemedicine.[2] But we require laws that safeguard a doctor from landing into medicolegal implications.

Role of nongovernmental organizations, nonprofitable organizations, and community-based groups

India can also utilize various nongovernmental and nonprofitable organizations and community-based groups in enhancing the healthcare services.[7]

Use of nonmedical equipment companies

During this current pandemic, many nonmedical equipment companies in India started manufacturing ventilators and other medical equipments. These equipments can not only help in tackling COVID-19 but can also be used later on. Thus, promoting such companies can bring about an improvement in our healthcare delivery services. A push through “make-in-India” for medical equipments can further strengthen this trend by supplying generic medicines like hydroxychloroquine.[2]

Strengthening the Government infrastructure

It is now a need of an hour that government infrastructure should be augmented through the establishment of new tertiary centers, with increase in medical seats and expanding primary healthcare through Ayushman Bharat.[2]

Fast-tracking of biological and public health emergencies within the National Disaster Management Plan

In November 2019, Biological and Public Health Emergencies (BPHE) were made a part of the National Disaster Management Plan (NDMP) for enhancing the pliancy of health systems by incorporating the disaster risk reduction plan at all the levels of healthcare. Several short-term, medium-term, and long-term goals like establishing early warning systems, alert sharing at community levels, intensive care units and isolation wards equipped with pressure control and lamellar flow systems, strengthening quarantine facilities, developing emergency response plans, stockpiling of medical supplies that are essential like vaccines and antibiotics etc., providing adequate personal protection equipment to all the health workers in case of biological emergencies, and creating specialized laboratory facilities to face biological emergencies were framed to be achieved by 2022, 2027, and 2030 respectively.[13]

Behavior change communication in community

Behavioral change communication plays a critical role in driving awareness, especially during this COVID-19 era. The prevalence and source of issues like misinformation, stigma, and herd behavior can also be tackled.[14] With the prediction of resurgence of COVID-19 in the coming months, it is important that focus should be on preventive measures like wearing face mask, maintaining hand hygiene and social distancing, and of course frequent disinfection. This can be merged with Swachh Bharat Abhiyan to have more positive impact.[2]

Conclusion

Primary health care requires discharging ample amount of essential services to remote people. The Indian primary healthcare delivery system strongly lacks adequate human resources and efficient quality of care. The COVID 19 pandemic has greatly impaired the primary healthcare services in India leading to disrupted routine vaccinations, neglection of noncommunicable diseases etc., For intensifying the performance of primary care physicians and improving the primary healthcare services, there has to be a strong financial support from the government, adequate human resources for family physicians, availability of telemedicine services, strong behaviour change communication etc., The hurriedly execution of lockdown by the government led to detrimental effects on the vulnerable population. Public health measures were not fully implemented, especially in overcrowded and remote areas. The food and financial securities offered by the government were insufficient.[15] Lockdown can prevent the emergent surge but cannot be an authentic strategy to break the chain of transmission and make the curve flat without having vaccine, treatment, and competent testing and without compromising on economy. Despite the heaps of challenges for the government, a multipronged approach is the need of an hour to engage in handling the epidemic by simultaneously working on the provision of other routine health services to prevent long-term health consequences; otherwise, in no time there will be a surge in vaccine-preventable diseases and chronic illnesses. The scenario should not come that while saving thousands of people from COVID-19, we let millions of people die of other infectious and noncommunicable diseases. Primary care physicians are directly involved right from the planning phase and their role in this pandemic is indispensable. It is time to reconfigure and rebuild our existing fragmented health system. Much attention is required to build a strong public health sector, especially at the primary care level.[15] As per public health experts, there could be serious repercussions, if India just targets on COVID-19 emergencies at the risk of other priorities. Investing in strengthening the primary health care will not only decrease the impact of COVID-19 but will also prepare India to face the next pandemic with accomplishing the target of “health for all.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

COVID-19; lockdown; primary health care

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