Containing the Second Wave of Covid-19 in Rural Odisha

The Second Wave of the COVID-19 pandemic has been very devastating for the rural areas of Odisha. A webinar with the purpose of looking into the challenges faced by our people to cope up with the inevitable pandemic, was organised by Odisha Dialogues in which various medical experts, public health professionals, grassroot workers as well as COVID patients and survivors took part and had extensive discussions.

The Context

It has been seen as well as reported that the second wave of the pandemic is affecting Odisha’s rural areas more than its urban centers. Taking note of the challenges that our people and institutions face in coping with this unprecedented pandemic and to ascertain the ground situation, the Forum for Odisha Dialogues held several rounds of extensive discussions and consultations with medical experts, public health professionals, Covid patients and survivors, civil society organisations and grassroot workers with hands-on experience of managing Covid-19. We also took into account the measures announced by the Government of Odisha to mitigate the impact of the pandemic, including the decision to empower locally elected representatives at Gram Panchayat level, home-based screening by offering additional incentives to ASHA workers and resumption of community-level Temporary Medical Centers (TMCs).

What follows here is a set of policy prescriptions that could help make the government’s intervention effective in rural areas. Our key concern is rural preparedness for the 2^nd wave and any resurgence of the pandemic in future.

1. Community level awareness and effective communication, in partnership with multiple state and non-state local actors, on prevention and care aspects of COVID-19 to inspire trust.

Key issues emerging from field surveys in rural areas are as follows (Also see Annex-I):

1. Fear of hospitalization: It is understood from multiple field reports that there’s a palpable hesitancy among people to proactively come forward and report on experiencing symptoms corroborating with COVID-19. Anecdotal evidences suggest a fear of community quarantine or hospitalization could be driving this hesitancy.
2. Lack of clarity on symptoms in 2^nd wave: A lack of clear guidance on symptoms of COVID-19 in the 2^nd wave and clarity of treatment and triaging protocol could be driving uncertainty in community. This information asymmetry also puts community health workers and local government officials in a difficult position to plan locally or communicate to public effectively.
3. Low levels of testing resulting in difficulty of risk communication: While awareness of a disease may result in improved community knowledge, risk communication and surveillance may need diagnosis to effectively guide community behavior.
4. Lack of clarity on health monitoring, treatment & onward care process: The hesitancy to report symptoms could also be from lack of clarity on how to monitor the disease. As is statistically documented, 80% of COVID-19 cases can be cured with rest and hydration accompanied by monitoring of vitals like oxygen saturation. Moreover, the journey of a COVID patientafter they are shifted from home is not clear and a protocol on proactive communication with patients and their families is missing.

Our recommendations for effective community level awareness on the gravity of the 2^nd wave of the pandemic in rural areas of Odisha are in the lines of addressing these field issues.

1. Communication material with clarity of symptoms, processes for health monitoring and clear treatment map of out-of-home journey of a potentially COVID patient be designed and shared door-to-door.
2. Orientation of local youth leaders, SHG groups, health workers and elected representatives on this communication material is needed, specifically in presence of medical counsel. It is being perceived from stakeholder conversations that medical community will be able to build trust in the rural areas.
3. In conditions of poor testing, providing clarity on treatment protocol and out-of-home journeys of potential COVID patients can support in risk communication as well as reduce hesitancy to access available treatment facilities.
4. Minimum equipment for home screening and monitoring including pulse oximeter and glucometer be provided to community level health workers for effective communication to patients.
5. Community health workers be enabled with PPE Kit and N95 Masks for frontline work.

2. Immediate release of funds to Gram Panchayats basis unit costs of re-instating and operation Temporary Medical Centers including funds for infrastructure, staffing for care, maintenance of hygiene and cooking nutritious food.

Odisha’s recent empowerment of elected representatives at Panchayat point is a welcome move towards decentralizing management of COVID-19. However, an intent-matching outcome of this initiative will be possible only with timely release of funds to support quick response on field. Some challenges as shared by stakeholders on ground are:

1. Certain field reports indicate that in the 1^st wave of the Pandemic, local elected representatives had to experience reimbursement of expenses over a period of time. Reimbursement process is time consuming and has many operational barriers towards prompt provision of services.
2. Suggestive unit costing on TMC – infrastructure set-up, deploying care personnel & sanitation & hygiene personnel — can help local governments in effective planning and faster execution of such centres at ground level.
3. Oxygen preparedness for combating Covid in rural areas will mean availability of oxygen and personnel to enable it for patients at community level.

• • Availability of oxygen in hospitals alone will not be enough.
  • All ambulances in use must be equipped with oxygen and the crew be trained for properly administering it.
  • TMC at Panchayat level, especially in remote areas, will need a certain number of beds with oxygen, for stabilizing patients until ambulance help arrives. This may be done with oxygen concentrators, trained ANM staff and technicians who can ensure maintenance and administration of oxygen.

3. Structured capacity building to enable local elected representatives with toolkits for GP level war rooms, triaging protocol, tele-consulting and early warning systems & enabling their access to medical community for counsel.

1. Best practices from other states indicate that they are battling Covid effectively at ward-level and in a decentralized manner which makes best use of local resources, initiatives and expertise. In the light of the recent empowerment move for Sarpanches, enabling them with such toolkits will help them in GP level micro-planning.
2. Need for early warning systems based on simple triaging planning is underlined to prevent escalation which would put the under-equipped and under-prepared rural health system under great stress. Hence, a well-knit early warning system is required in the rural areas which could be monitored centrally at the divisional level for providing adequate guidance in times of need. A sample process flow is attached (Annexure B).
3. Providing easy access to medical community of grassroots elected representatives would build a very effective partnership for providing low-cost prevention and early intervention mechanisms. This would be the right way to address needs at the rural level by leveraging under-utilized resources and capacities.

We continue to monitor the situation in the rural areas of Odisha through well-established and experienced networks. Accordingly, this policy brief will be updated as and when required.

End Note: The above policy note has been prepared in collaboration and consultation with Public Health Resource Network (PHRN), Jana Swasthya Aviyan, Bharat Gyan Vigyan Samiti, Harsha Trust, National Association Women Organisations (NAWO), Centre for Public Policy Alternatives (Bhubaneswar), Citizens Forum(Bhubaneswar), Sewak (Sundargarh), DAPTA (Kalahandi), Youth for Social Development (Ganjam) and Jagruti (Kandhamal). Dr Bidhu Kalyan Mohanti, member of Board of Advisors at Odisha Dialogues, led the consultations, while Dr Manoj Dash and Ms Lipsa Bharati were responsible for preparing the draft note.

Annexure – I : Notes from Public Health Resources Network (PHRN), dated May 18, 2021

1. The ASHA and AWW have been designated to screen Covid 19 cases in the community based on the symptoms and also visit the patients who are in home isolation. In Rayagada, ASHA and AWW in rural areas and ASHA, AWW, ANM and school teachers in urban areas have been designated to do formal screening on Saturday and Sunday. Our two blocks in Kalahandi report of one formal screening in the last one month). Malkangiri, Nabarangpur and Koraput reports of no formation of such screening team in the second wave. In Malkangiri, ASHAs have been instructed to visit at least 10 household for system screening and report if any symptom is found. Based on visible symptoms, ASHA/AWW workers refer for testing and isolation.

Issues:

• It has been reported that safety equipment like masks, gloves, sanitizers, PPE kits have not been provided to frontline workers making them more vulnerable. FLWs in Rayagada report of using GKS funds for masks and sanitiser.
• The FLWs have not received any training in regard to the modified protocol for identifying symptoms and case management when the Covid 19 positive patients in home isolation.
• They have not been provided with thermal scanners. It is available only at the migrant entry points. Oxymeter is available with AWWs in Rayagada, and some villages of Kalahandi. Malkangiri has oxymeters available at the ANM level.

2. The testing has been very low during this wave. Very few cases have been reported in our intervention districts.
3. In Nabrangpur, it has been reported by the medical officer that there is a shortage of staff for conducting Covid 19 test at the facility. The shortage has also resulted in lack of engagement of health staff at the community level for screening and case management. It was reported that there is lack of availability of protective kits for the staff.
4. In Kalahandi district at the village level, door-to-door screening was done in the month of April but has been discontinued.
5. For positive cases home isolation is encouraged in the rural areas as well but availability of space is a challenge in most of the households. Infrastructure has not been created for isolation and Covid care in rural areas.
6. Temporary Medical Care centres have been created for the migrants but are not adequately used. Most of the people returning back home prefer going to their homes.
7. In Kalahandi and Malkangiri, it has been observed that there is a hesitation of going for testing for Covid 19 and there are cases where people also tend to hide symptoms. This is mainly because of fear of getting hospitalised and deaths. The media has negatively impacted the behaviour.
8. Transportation is one of the major challenges for people in rural areas. For getting the test done, they have to travel in public transports which may result in transmission of infection to other people.
9. Vaccination is being done at the PHC, CHC and some selected sub centres and based on the availability of the vaccine micro-plans are being made. Currently the target is to complete the 2nd dose to the people above the age of 45 years.