Understanding the role of Primary Care in Covid 19 response In India

Primary Care is the essential foundation in covid 19 response globally because it can meet more than 80% of people’s health needs. It plays a significant role in gatekeeping and clinical responses in identifying and triaging potential COVID-19 cases, ensuring early diagnosis, helping vulnerable people cope with their anxiety, and reducing the hospital service demand. During the initial pandemic Phase, the World Health Organization emphasized the role of Primary Care and provided interim guidance on the role of Primary Care in the covid 19 response. This guiding document identified Six principles that guided the roles of primary care in this pandemic. These six principles are maintaining delivery of essential health services; Identifying and managing potential cases; Avert the risk of transmission of infection to contacts and healthcare workers; Enhance existing surveillance such as for influenza-like illness (ILI) and Severe acute respiratory infection (SARI); Strengthen risk communication and community engagement; and Provision of Covid 19 vaccination services.  

In India, Primary Health Care is the backbone of the health system through a vast network of community health workers, Health Sub Centers, Health and Wellness Centers, and Primary Health Centers. In India, Primary Care was in the center for Covid 19 response since the initial phase. All six principles of Primary Care for Covid response have been integrated into the strategies, which most state governments followed. This is to highlight here that health is the state subject.  Multiple guidelines have been issued keeping in mind these specific principles.

Maintaining essential health services: The COVID 19 Pandemic has put massive pressure on the health system. This resulted in essential health services halted due to the elevated demand for services. It is essential to maintain essential health services even during the pandemic to maintain the people’s trust in the health system and the population’s health status. We have learned from Ebola Outbreak, 2014-15, the number of deaths caused by measles, malaria, HIV/AIDS, and tuberculosis was much higher than Ebola. The Government of India took lessons from such learnings. It emphasized the need to maintain essential health services through the detailed guidelines to states on Enabling Delivery of Essential Health Services during the COVID 19 Outbreak, Provision of Reproductive, Maternal, Newborn, Child, Adolescent Health Plus Nutrition (RMNCAH+N) services during & post COVID-19 Pandemic, Immunization Services during and post COVID-19 Outbreak.  In all these guidelines, community health workers’ roles (ASHA-Accredited Social Health Activist, ANM-Auxiliary Nursing midwife, AWW-Anganwadi Worker) and rural and urban health centers are described in detail. One of the key strategies for maintaining the health service was the clear distinction between Covid 19 & Non-covid service delivery institutions (Essential health services).

Identify and manage potential Cases: Identify & Triage, Isolate, Assess and advise are the critical elements of under-identification and potential case management. At the primary care level, Micro Plan for Containing Local Transmission of Coronavirus Disease (COVID-19) guideline has clearly defined community health workers’ role in screening through household visits, if confirmed, then contact tracing, quarantine, and isolation. This guideline also details the role of the Primary health apparatus in overall identification and potential case management. About 1007045 ASHAs,  2543113  Anganwadis,   832445 Ayush Medical officers are contributing to the Primary Care apparatus. Additionally,   927000 MBBS medical officers also contribute to COVID 19 response, in which the majority of medical officers belong to the Primary Care apparatus.

Avert the risk of transmission of infection to contacts and healthcare workers: Averting the infection transmission risk to contacts and health workers is at the center of any pandemic response. To minimize this, India’s Government came up with specific guidelines on human resources safety at the community and facility. More than 2000 Human resources for health (HRH) were infected in  New Delhi alone till June 2020.

Enhance existing surveillance such as for influenza-like illness (ILI) and severe acute respiratory infection (SARI): Influenza-like illness and Severe acute respiratory infection surveillance is an integral part of the Integrated Disease Surveillance Program (IDSP). Under India’s government strategy, the degree of ILI and SARI surveillance increased multi-fold in public and private hospitals, where the footfall is very high. Apart from the facility, community health workers have been capacitated on ILI and SARI reporting under IDSP program.

Strengthen risk communication and community engagement: Risk communication is the critical element in the fight against any pandemic. It was in the core strategies in Covid’s response in India. The Indian Government has developed Communication strategies guidelines for Vaccination and Containment Plan, mostly executed by the front line workers in primary care. In India, the first awareness video aired on 3rd March 2020 . Later, on Doordarshan (Government-owned Television Channel), around 28 different risk communication videos aired between 3^rd March to 20^th April 2020.

Provision of Covid 19 vaccination services: Primary Care apparatus has played one of the most significant roles in provisioning COVID 19 vaccination services in India.  The  Government of India Operational Guideline for COVID 19 Vaccines, has clearly defined the role of primary health care in Covid 19 vaccination. Considering Vaccination is a sensitive concern in multiple communities, India’s Government has developed Communication Strategy for Covid 19 vaccination. Potentially, these guidelines and directives enabled the health system to vaccinate     12,26,22,590   (Total Doses including 1^st and 2^nd) till 18^th April 2021.

Conclusion: Primary Health Care providers and facilities played a critical role in the fight against Covid19. The Government of India and the state governments has been cognizant of this and issued relevant guidelines to manage both Corona and non-corona services. These guidelines followed WHO advised six principles. These guidelines provided a clear direction to the entire primary care apparatus. Due to this, many state health systems have shown resilience in the fight against Covid 19.  However, few of the states were struggling primarily because of shortage of skilled Human resources,  infrastructure (hospital beds, equipment), testing facilities.

The author acknowledges Rajeev Kumar Singh for his valuable feedback and comments.

Authors:

Sanjeev Kumar is currently working as a Research Specialist in the Health Systems Transformation Platform (HSTP). He has worked with multiple State Health Systems in India.  

Anand Kumar is currently working as Urban Health Specialist in Care India based in Bihar. He has extensively worked in strengthening MCH Services in Bihar, India.