Mumbai: Six of the eight most socioeconomically backward Indian states--together called the empowered action group--which have among the highest infant and maternal mortality rates have discontinued health outreach services during the countrywide COVID-19 lockdown, multiple government and media reports show. Immunisation, antenatal checks (ANCs) and nutrition drives have been halted in all these states except Odisha, which continues apace, and Uttarakhand, which has kept its immunisation services open.
Odisha is using three types of frontline health workers--auxiliary nursing midwives (ANMs), accredited social health activists (ASHAs) and poshan sakhis (nutrition guides who are cadre of the state rural livelihoods mission under the ministry of rural development)--to ensure home delivery of health services and rations. Having reported few COVID-19 cases, Odisha is also utilising its frontline health workers to monitor potential outbreaks.
The ongoing lockdown has restricted the movements of public health workers who are also being drafted into the health ministry’s micro-plan to contain the outbreak of COVID-19 through surveillance.
“Outreach services have closed due to fear of transmission during village health and nutrition days and all our current resources are dedicated [towards] fighting [COVID-19] and surveillance,” said Rohit Kumar Singh, additional chief secretary of health for the Rajasthan government. Registered patients who need immunisation, antenatal check-ups and institutional deliveries must visit district hospitals.
These outreach services, launched in 2007 under the National Health Mission, are meant to improve rural access to maternal, newborn and child health and nutrition (MNCHN) services. They ensure that pregnant women are screened for anaemia and high blood pressure, maintain optimum body weight and are provided free calcium and iron folic acid tablets.
Routine immunisation is also provided to infants against tuberculosis (TB), diphtheria-pertussis/whooping cough-tetanus (DPT), polio and measles.
The services, offered at anganwadis (childcare centres in villages) on ‘village nutrition and health days’ (VHNDs), have played a key role in driving down infant and maternal mortality rates, as this year-long study conducted by the Mamta Health Institute for Mother and Child in Rajasthan and Uttar Pradesh in 2018, concluded. They could enable a 9.4-percentage-point improvement in antenatal checks and a 15-percentage-point increase in deliveries at health facilities, it added.
Health consultants who work with the government say they had no choice but to suspend outreach services. “The present crisis is unprecedented and an unfortunate one; we are individually and collectively fighting a war but the benefits of total shutdown far outweigh the risks [for child and maternal health],” said Chandrakant Pandav, member, National Council on India’s Nutritional Challenges, Poshan Abhiyan. He said ASHAs, anganwadi workers (AWWs) and ANMs have been asked to ensure that beneficiaries get take-home rations for at least one month.
Health workers diverted to COVID tasks
Manju Kumavat, an ASHA supervisor in Rajsamand district in Rajasthan, has been asked to conduct door-to-door checks to trace all those who travelled into the area in recent weeks. “ASHAs also have to tell the people the importance of staying home and handwashing,” she said. “We also monitor those in home quarantine.”
With this diversion of frontline staff, the cessation of outreach programmes, even if temporary, stands to impact millions. “Outreach programmes are important tools in our country for bringing health education and screening services directly to community members and serve to reduce health disparities,” said Sujeet Ranjan, executive director at the Coalition for Food and Nutrition Security, a Delhi-based network of food-and-nutrition advocacies. “Outreach healthcare is a vital strategy which remains the backbone of health/nutrition service delivery since Independence.”
Bihar, Uttar Pradesh, Madhya Pradesh and Rajasthan report higher infant mortality rates than the national average of 33 per 1,000 births, as per the Sample Registration Survey bulletin 2019. For example, Bihar’s infant mortality rate equals that of Republic of Congo and Madhya Pradesh’s that of sub-Saharan country Niger, according to this IndiaSpend story from June 2019.
The discontinuation of these essential health services is despite the Union health ministry’s March 25, 2020 guidelines to ensure routine immunisation activities and antenatal check-ups for at-risk mothers. The ministry recommended more immunisation sessions with smaller groups mobilised over the phones by ASHAs.
“The ASHAs and ANMs have been asked to make a list of the at-risk mothers and children,” Ajay Khera, commissioner at the Ministry of Health and Family Welfare, told IndiaSpend. “These mothers and children have been asked to directly report to the health centres along with TB patients. We have also suggested the use of telemedicine to reach these patients. Furthermore, we have asked states to compensate the telephone bills of ASHAs who are checking on patients.”
‘Near-death situation for the severely malnourished’
India’s maternal mortality ratio (MMR)--maternal deaths per 100,000 live births--fell 27% from 167 in 2011-13 to 122 in 2015-17, according to the Sample Registration System bulletin of 2015-17. Its infant mortality rate--deaths per 1,000 live births--also fell from 42 in 2012 to 33 in 2016.
The health ministry had credited community outreach programmes, along with other factors, for a decline in maternal mortality in 2016. But this rate was still higher than the global average (29), and India’s neighbours’--Nepal (28), Bangladesh (27), Bhutan (26), Sri Lanka (8) and China (8), as IndiaSpend reported in December 2019.
Malnutrition is another area of concern driven by the interruption in health services during the lockdown, said experts. States such as UP and Bihar have some of the highest rates of acute malnutrition (stunting) among children--46% and 48%, respectively, compared to the national average of 38%, as per the National Family Health Survey 2015-16.
“There is fear that without the supplementary nutrition provided by anganwadis, severely malnourished children will face near-death situation and those who suffer medium malnutrition might move into the severe and acute malnutrition category,” said an official on the UP health department who did not wish to be named.
The diversion of resources to the campaign to contain contagion has also impacted Indradhanush, an intensified vaccination programme covering 109 districts of Uttar Pradesh and Bihar--states that have recorded less than 70% vaccination coverage. These vaccines are administered by ANMs.
Even Kerala, a state known for its progressive public health system, has suspended some of its outreach services due to COVID-19. “The Rashtriya Bal Suraksha Karyakram [early childhood health interventions] has two components--screening and treatment of childhood disabilities--and the screening part has been impacted, along with immunisation,” said Abey Sushan, district programme manager for Pathanamthitta district in southern Kerala. “We are currently in stage two of the outbreak and if we progress to the community level, then this ban on outreach will have to go on for longer. We are also worried about TB patients.”
Odisha continues apace
Odisha, however, has decided not to drop its outreach services and is delivering rations at the doorstep. “These are basic services that people require in order to live, so how can the government stop these services?” said Atulya Champatyray, project director, panchayati raj department, Odisha.
In Odisha, stunting (low height for age and a sign of malnutrition) among children below five years of age fell from 46.5% in 2005-06 to 35.3% in 2015-16; and the proportion of underweight children for the same age group declined from 42.3% to 35.8%, as IndiaSpend reported in August 2019.
The state government has asked three sets of frontline health workers to handle both outreach services as well as COVID-19-related tasks, as we mentioned earlier. “Though gatherings have been banned, doorstep delivery of services has not,” said Babita Mohapatra, the additional chief executive officer of Odisha Livelihoods Mission. Poshan sakhis (part of the national rural livelihoods mission) work in tandem with ASHAs and ANMs to provide health services and rations at home.
“ASHAs are going door to door with poshan sakhis and identifying beneficiaries such as pregnant and lactating mothers and children who may need immunisation,” said Mamta Patra, an ASHA from Angul district in central Odisha. “We are even [observing] village health and nutrition days by getting people from their homes to the anganwadis--wearing masks and asking them to queue up to maintain a safe distance.”
One reason why Odisha has managed to continue with its outreach work is the low number of COVID-19 cases it has detected, as we said earlier--61 in all, ranking it 17th in the country (as on April 19), according to the Coronavirus Monitor of HealthCheck.
“We have COVID-positive patients only in 4-5 districts and most of the samples that we have collected have tested negative,” said Saroj Nanda, medical officer, Kishorenagar, in central Odisha, 150 km from the capital, Bhubaneshwar. “As soon as poshan sakhis or ASHAs spot a person who has travelled in from outside, the medical officer or ANM is informed.”
Harapriya Behera, a poshan sakhi from Koraput in south Odisha, is among those who are responsible for the isolation of suspected patients. “If a person has travelled here from infected areas, they are asked to be quarantined and if they do not have the space for this, they are directed to the nearest quarantine facility,” she said.
The lists of beneficiaries of these programmes are coming in handy during the ongoing crisis, the workers said. “We use the list to call beneficiaries and enquire about their immunisation records and ANC check ups, if someone is due for a check up, I inform the ASHA didi who then takes the woman to the hospital,” said Behera
(Salve is an IndiaSpend contributor.)
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Correction: An earlier version of the story erroneously said Jharkhand had a higher infant mortality rate than the national average. We regret the error.