This section presents actionable insights for practitioners from our collaboration of experts.
As COVID-19 spread across India and globally, health systems pivoted to respond to this crisis. While a comprehensive response remains essential, the diversion of resources from routine health services has created gaps in access to essential healthcare services. Experts predict that COVID-19 will have a ripple effect across the health system as the provision of essential services, such as pregnancy care, immunization, and chronic condition management becomes compromised.
There is a historical precedent for this concern. The Ebola outbreak of 2014–2015 had devastating effects on health systems, health-seeking behavior and health outcomes in West Africa. Studies show that COVID-19 is having similar repercussions today, for instance, a study by Johns Hopkins researchers suggests that the diversion of resources from routine health services coupled with decreased access to nutrition may result in 10 – 45% more child deaths and between 8 – 39% more maternal deaths in low and middle-income countries.
These troubling projections raise key questions: How has COVID-19 strained health systems, what additional factors are affecting health outcomes, and how can these challenges be addressed?
In order to examine the impact of COVID-19 on health services, this article highlights the experience of two programs that support the provision of essential services in India. NISHTHA, supported by USAID and implemented by Jhpiego, works towards universal primary healthcare by strengthening health and wellness centers in twelve Indian states in collaboration with governments. Vriddhi is a USAID flagship program led by IPE Global that supports governments to improve access and quality of reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) services, particularly in Aspirational Districts.
Ensuring an Effective Early Response
When the COVID-19 epidemic reached India, these programs moved quickly to adapt their activities to the evolving health priorities. The immediate need was to support an effective first response to COVID-19.
The NISHTHA team provided pandemic response training to Auxiliary Nurse Midwives and Community Health Officers and developed information materials on stigma and best practices for these key front line workers. As the outbreak progressed, NISHTHA supported the efforts for zone-wise maintenance of essential services in accordance with government guidance and worked with states on innovative pathways to provide essential services, such as telecare, decentralization of care, and private sector engagement.
Vriddhi was also well-positioned to respond to the crisis due to the platforms, structures and technology it had in place. The team integrated COVID-19 response modules into their existing platforms, such as the Safe Delivery App and the High-Risk Pregnancy App. These were used to conduct digital training on safely providing essential services, while simultaneously sharing COVID-19 information. Innovations like the program’s recently approved pulse oximeter for pneumonia management would also be useful in this crisis.
Impact of the Response on Essential Services
Despite the early efforts, the pandemic caused gaps in the delivery of primary care and reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) services.
Fewer human resources were available to deliver services, due to shifting priorities and reduced mobility. NISHTHA teams observed that health workers, such as Community Health Officers, were pulled into the COVID-19 response and were unable to conduct their routine primary care and outreach activities. This rendered health and wellness centers as largely non-operational. Vriddhi teams noted that this meant health workers could not conduct home-based maternal and child care as well. In addition to service delivery, capacity strengthening processes for these workers — such as the in-person supportive supervision sessions on proper care practices, technology use and data collection — were halted due to restrictions.
In addition to human resource disruptions, system disruptions have also hindered the continuity of essential services. Supply chain disruptions due to the lockdown led to reduced availability of essential resources, medicines, and supplies. Such disruptions may also result in a reduction of public confidence in the health system since patients are unable to receive critical medicines from health centers. While many government directives were issued to guide COVID-19 response efforts in areas including resource distribution, referral processes, facility roles, and others, facilities often lacked the capability to implement these directives or to effectively adapt operations to prevent disruption.
While Vriddhi teams reported that private tertiary care facilities were less strongly affected by the outbreak, system-wide changes and resource diversions also changed how essential services are utilized across these facilities. Some facilities experienced an influx of cases as patients were diverted from designated COVID-19 facilities. The resumption of services at health and wellness centers in many states following the lockdown is expected to gradually ease the burden at these facilities.
Finally, public reluctance to access healthcare services due to fear of infection limited the uptake of essential services. This partly stems from the risk communication used at the beginning of the outbreak — the public was encouraged to avoid using non-essential healthcare services so as not to overburden the system. While this messaging was logical, due to differing perceptions of what essential services are, demand for health services as a whole was seen to fall. Dr. Swati Mahajan, Chief of Party at NISHTHA, noted for instance that many patients stopped seeking antenatal care services because they did not believe they should visit facilities. However, vaccines and immunization were more readily sought out as people recognized their importance.
Mitigating the impact
Moving forward, Dr. Mahajan suggests it will be important to ensure not only that essential health services are available, but also that the public is encouraged to use them wisely. Dr. Harish Kumar, Project Director of Vriddhi, shared that in spite of the devastation caused, the COVID-19 outbreak provided an opportunity to reflect and pursue innovations in the delivery of essential services, based on strong evidence generated as well as the use of new technologies and solutions.
This is then the question that India’s health sector is faced with: Do we continue as we were before, or do we use the pandemic as an opportunity to strengthen our health systems and improve our resilience? It is critical that we strive for the latter in order to ensure a safer, healthier, and more equitable future.
Special thanks to Dr. Harish Kumar, Project Director — Vriddhi, IPE Global, and Dr. Swati Mahajan, Chief of Party — NISHTHA, Jhpiego for sharing their time and valuable insights for this piece.