COVID-19 pandemic’s biggest lesson: Strengthen primary health care services

A case of pneumonia of unknown origin was reported in Wuhan city (China) in December 2019. The causative agent of this disease was identified as of the coronavirus family and initially named novel Coronavirus (nCoV) 2019. This unknown disease spread rapidly across the globe leading to high morbidity and mortality & hence was declared, a Public Health Emergency of International Concern in January 2020 by WHO. By February 2020, the international virus classification commission named this novel entity, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and WHO named it Coronavirus disease 2019 (COVID-19). Based on the data, confirming the unstoppable spread and burden of COVID-19 in the whole world, WHO declared it a pandemic on March 11, 2020.1

COVID-19 pandemic has exposed limitations of the health system of all developed nations of Europe & America. In India, the main responsibility to deal with the pandemic situation was pushed on an already overburdened public health system which was completely unprepared to deal with the COVID-19 pandemic.

The patient’s load was increasing daily by lacs and India’s limited diagnostic services, limited bed capacity, and limited human resources all together were trying to cope with the COVID-19 pandemic situation with daily mortality escalating to thousands. However, with all the damage done globally in terms of lives lost, economic crises, migration, unemployment, and many more, this pandemic taught us many lessons which will guide us in preparing an action plan for any future pandemics.

COVID-19 exposed that the health infrastructure of any country irrespective of its development is incapable to cater to the need of the masses. In India’s context, initially, all patients suffering from COVID-19 were admitted to the hospital, but later depending upon their condition were shifted to the different levels of COVID-19 treatment center’s/isolation centers which slightly reduced the burden of tertiary care hospitals. With the increasing patients load tertiary care hospitals were saturated, Hence the focus was shifted to principles of primary health care delivery i.e. Community Participation, Appropriate Technology, Intersectoral coordination & Equitable Distribution.

Community Participation

Primary Health care played a very crucial role in limiting and containment the spread of COVID-19 in villages and urban areas. Village COVID-19 Control Committee was constituted involving community leaders who worked under the guidance of ANM/ASHA and a home isolation strategy was adopted with the distribution of a home isolation kit (containing drugs with prescription, waste disposal bag & contact number of nodal person) and to all those who were showing mild symptoms of COVID-19. The committee monitored and also ensured no COVID-19 patient is left unattended.

Appropriate Technology

IT-based innovations were utilized during the Covid-19 pandemic in form of the “Aarogya Setu” App. Everyone was instructed to install the App on their mobile. It was also installed in COVID-19 patients so that their GPS location can be tracked and telephonic consultation was done by the State/District/Block control room with all patients in isolation to assess their health status. A pulse oximeter & thermometer was provided to each ASHA so that she can monitor the oxygen saturation level and temperature of patients on home isolation and refer them if required. Online E-sanjeevani telemedicine consultation was initiated by Medical college specialists so that everyone can have access to health care services as routine OPD services were nonfunctional during the lockdown. Various online training of primary health care service providers was done by State/District trainers to ensure that all information necessary to control and manage COVID-19 patients is percolated to the population.

Intersectoral Coordination

COVID-19 pandemic management showed that “Public Health” involves multiple sectors and is not only limited to the health department. Various departments like education, panchayat raj institute, food delivery services, transport sectors, administrative services, police force, NDRF/SDRF/DDRF worked together along with the health department to provide primary health care services to the people residing in villages and hard-to-reach areas. With the active efforts of administrations & police force, the lockdown was imposed and containment zones were created to contain the spread of infection. Schools were converted into isolation and quarantine centers. Community leaders have barricaded villages to ensure everyone coming from outside is quarantined. Patients with mild symptoms were instructed to home isolate themselves. Home isolation kits containing all drugs, prescriptions, and waste disposal bags were provided for mild cases of COVID-19 during home isolation. District level and Block level control rooms were created to ensure proper documentation and maintenance of the supply of drugs. Line listing of patients in isolation and quarantine centers was done on daily basis and sent to block and then to the district.

Equitable Distributions

Health services to all were provided irrespective of their socioeconomic status and as per their needs. Based on the population of each village, Home isolation kits for mild symptomatic patients on home isolation were distributed to the village COVID-19 control committee. COVID-19 vaccines were made available free of cost and vaccination was done on an online registration basis. COVID-19 vaccines were first provided to health care providers and the geriatric population at the fixed vaccination site and later on, made available to other age groups on a priority basis. For those who can afford it in the private sector, price capping was done by the government for COVID-19 vaccines. After fixed site vaccination was over and maximum beneficiaries were mobilized and vaccinated, the government also operated a door-to-door vaccination campaign to ensure everyone receive the COVID-19 Vaccine.

COVID-19 treatment was based on shreds of evidence obtained from various studies and as per guidelines issued by the government. However, major interventions which played a vital role in bringing the disease burden down were:

COVID-19 pandemic has warned us that future pandemics cannot be predicted and controlled with the existing health infrastructure. Tertiary care hospitals are best to provide treatment to the seriously ill and the specialist doctors of tertiary care hospitals can contribute to the preparation of policies for the prevention, treatment & control of any pandemic based on scientific shreds of evidence. However, as seen in the COVID-19 pandemic when it comes to providing services to the masses, eventually it is the Primary Health care services that have to play a crucial role.

Although India has 3 tier health care delivery system starting from the sub-center, primary health centers(PHC) at the Primary level, community health centers (CHC) and District Hospital at the Secondary level, and Medical colleges and hospitals at the tertiary level. But patient referral system is still not streamlined, it is the tertiary care institutions that cater to the health needs of the masses. The majority of health needs of patients visiting tertiary care hospitals could be easily treated at the primary health care level if sub-centers/primary health centers & community health centers work as per recommended IPHS infrastructure. The government is ensuring the availability of specialist doctors by creating medical colleges (tertiary care institutions) in each district but PHC & CHC still needs to be strengthened and streamlined as they are the first point of contact for the population.

Government must increase its allocation to the health sector to at least 5% of GDP and focus on strengthening primary care. So, in conclusion, strengthening primary health care with active community involvement, a robust disease surveillance system, and improved/updated research & diagnostic laboratory services are a must to provide health care services, especially in the context of endemic/epidemic/pandemic diseases of present and future.