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How covid-19 response disrupted health services in rural India

Rural provision of health services declined in February and crashed in March, affecting everything from BCG immunisation to treatment for acute cardiac emergencies, official data shows

India could find itself in an acute health crisis over the next few months and the direct cause of it will not be the SARS-CoV-2 virus. Hundreds of thousands of children might already have missed vital immunizations, shows a Mint analysis of the latest health ministry data. Thousands of adults may have missed potentially life-saving medical treatment as the novel coronavirus epidemic spread and a lockdown came into force.

A range of hundreds of indicators shows a worrying disruption in India’s basic health services in March as local administrations focused on containing the spread of covid-19. These include curtailed immunization schedules, restricted inpatient, outpatient and emergency treatment for infectious and non-communicable diseases, reduced laboratory investigations, and lowered access to mental health treatment.

This analysis is based on data recently released by the National Health Mission (NHM), which usually covers all sub-centres, primary health centres, community health centres, district hospitals and sub-district hospitals, as well as some private facilities. For March, data was reported from 150,000 facilities across 627 districts, which means that data for roughly 40,000 facilities in 75 districts was not reported, presumably on account of lockdown-related disruptions in the administrative machinery.

Data for previous months has been normalized for the same number of facilities as in March, to ensure comparability in the analysis. For each indicator, the numbers for past years were recalculated to be proportionate to the number of healthcare facilities reporting data for March. The number of facilities reporting data in March 2019 had some errors, so the number of facilities in April 2019, which was higher, was used instead. These adjustments could have the effect of underestimating data for earlier periods, and hence the real gap between March 2020 and previous months could be greater than this analysis indicates.

The data shows that many services for pregnant women, including giving iron and calcium supplements as well as tetanus injections, kept pace in March, indicating that accredited social health activists, and auxiliary nurse and midwives were largely able to continue their work. However, there was a sharp fall in medical interventions performed on pregnant women. Given that the number of deliveries is unlikely to have fallen, the number of unattended home births is likely to have gone up.

At least 100,000 children did not receive their BCG vaccination, which can provide some protection against tuberculosis (TB), and another 200,000 missed each dose of the pentavalent vaccine, which provides some protection against meningitis, pneumonia, whooping cough, tetanus, hepatitis B and diphtheria, and the rotavirus vaccine, which prevents diarrhoea-causing rotavirus infections, in March, suggests the analysis.

The past few weeks have seen an intense debate on the incidence and extent of hidden covid-19 morbidity and mortality. The NITI Aayog has claimed that reduced hospital admissions for severe acute respiratory illness and influenza-like illnesses under the Ayushman Bharat insurance scheme “prove" that there aren’t undetected covid-19 cases in the community. However, NHM data indicates that reduced hospitalization numbers could mask a lack of access to healthcare, rather than a lack of illness.

NHM data shows that medical treatment, whether as inpatients, outpatients, or emergencies fell for all diseases, both infectious and non-communicable. At least 350,000 fewer people received outpatient treatment for diabetes, 150,000 fewer people received outpatient treatment for mental illness and nearly 100,000 fewer people received outpatient cancer treatment in March 2020 as compared to March 2019.

“It would be highly inappropriate to use hospitalization data to argue that there has been a fall in disease. The fact that even treatment for non-communicable diseases and emergencies has fallen is of great concern," said Keshav Desiraju, former health secretary.

Yogesh Jain, founder-member of the Jan Swasthya Sahyog, a non-profit public health initiative in Chhattisgarh, said: “The government keeps repeating that our healthcare facilities are all working. However, one thing that we have to keep in mind is that without any means of transport, simply keeping hospitals open is not enough. These numbers clearly show that people have simply not been able to access healthcare since the lockdown."

As predicted by experts, the share of those receiving and completing standard TB treatment registered a decline. Worryingly, screening for HIV/AIDS as well as several other laboratory investigations, also registered a decline.

Taken together, the numbers paint a worrying picture of the potential long-term impact that the severe curtailment of health services in March and April across the country might have. “The argument is not that governments should not act expeditiously in containing an epidemic, but that they must keep part of their routine health services running, so that people do not suffer long-term health consequences," said Madhukar Pai, director of global health at McGill University in Montreal, and director of the McGill International TB Centre. “Unfortunately these numbers show that this has already taken place."

Overall, NHM numbers do not show a spike in deaths or diseases. However, the fall in access to institutional health, including institutional deliveries, also indicates that official data on morbidity and mortality from hospitals will not give the full picture. More people could be falling ill and even dying at home in this period.

“A person who misses her tuberculosis or cancer medication today might not die this month but some months down the line. We should really be pushing for all-cause mortality data for the whole year ahead to understand the impact of this virus and lockdown on broader public health. You don’t want a situation where you save 300,000 deaths from covid and then 1.2 million people die of other causes," said Jain of Jan Swasthya Sahyog.

The analysis of the latest NHM numbers suggests that a serious public health crisis is already brewing, with the potential to erase gains made against a number of diseases over decades.

Rukmini S. is a Chennai-based journalist.

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