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Covid-19 has Disrupted India’s Routine Health Services

Rukmini S.

The scale of disruption in routine health services in the wake of the Covid-19 pandemic in India is even larger than was earlier estimated, new official data show.

April saw a higher fall in immunisations, maternal health interventions and treatments of conditions including kidney failure and cancer than in March, while some indicators showed signs of revival in May and June. These delays could lead to long-term health effects, experts say.

The National Health Mission’s Health Management Information System tracks indicators on the utilisation of health services from over 2,00,000 health facilities, from primary health centres to district hospitals in every district of the country and is updated nearly every day.

These health facilities are predominantly in rural areas and in the public sector. Earlier this year, March data, after just a week of the lockdown, showed that health services were severely curtailed in the country as compared to previous months in and to March 2019. Subsequently, the NHM stopped publishing these data. This week, the NHM published updated data for April, May and June.

Fewer women accessed maternal healthcare in March and April when the lockdown was at its strictest, data show.

Routine checks on pregnant women and tests that are vital for the health of the mother and child were missed, and the number of institutional deliveries fell. There were over 5,80,000 fewer institutional deliveries in April than in January, which could indicate that many more women had potentially unsafe deliveries at home.

Chart: Routine checks on pregnant women fell during lockdown

The number of women who received benefits that they are entitled to under the Janani Swasthya Suraksha Yojana (Mother’s health protection programme) has also declined to under half of its January level, the data show.

The numbers also point to a disruption in immunisation services, which if not restored, could have potentially lifelong impacts on children, experts said. The number of children who got the Bacille Calmette-Guérin vaccine, which prevents severe tuberculosis, in April was half that of the number for January – that is, 1 million fewer children got the vaccine that month.

Chart: Children Immunised Before and During Lockdown

Even at the risk of infection, “we cannot delay polio, DPT [Diphtheria, Pertussis, Tetanus], hepatitis and pneumococcal vaccines”, Ravindra Chittal, a consultant paediatrician and neonatologist at Hinduja Hospital and Lilavati Hospital, Mumbai, had told IndiaSpend in May.

Outpatient attendance in April fell to half its January levels, NHM-HMIS data show, with 69 million fewer outpatient visits. This included outpatient treatment for serious conditions including cancer and acute heart disease. Doctors who have been observing this decline in their outpatient departments are aware of what this implies–a coming storm.

Chart: Outpatient Treatment for Acute Heart Diseases Fell During Lockdown

“What we are already seeing is that when patients start to return to OPDs, they will have a much more dangerous and unmanaged form of the disease they were suffering from,” SP Kalantri, medical superintendent at the Mahatma Gandhi Institute of Medical Sciences in Wardha, Maharashtra, warned.

In April, inpatient treatment of serious communicable diseases declined by 60% over January levels, and the decline was greater among women than men, the data show.

Chart: Inpatient Treatment for Dengue Fell During Lockdown

Other worrying indicators from the data include a 45% decline in the number of patients registered for TB treatment and a 60% decline in the number of men being screened for HIV in June, even as the lockdown was opening up, as compared to January. The number of surgeries–both major and minor–also fell by over half in June as compared to January.

The NHM numbers do not show any sharp increase in deaths from any other disease or cause, but these immediate numbers do not show the long-term impact of, for example, a person missing dialysis treatments.

Madhukar Pai, director of the McGill International TB Centre at Canada’s McGill University termed this disruption as “worrisome”.

“Every immunisation dose missed during this crisis might be a TB or a measles case in the future,” he said in an email. “Every patient not diagnosed with TB now might end up with advanced disease with higher fatality in the future. If institutional deliveries have gone down, that increases the risk of maternal and newborn mortality.”

India will be lucky if it ends tuberculosis by 2035–a decade later than targeted–Pai had told IndiaSpend in May, pointing to an 80% drop in monthly notifications of TB because of Covid-19-related disruptions.

For public health and development experts, the potential harm to Indian health that these numbers indicate suggest reconsidering India’s Covid-19 response.

“Recent sero-survey evidence of Covid’s low fatality rate in India calls for a reconsideration of some of the harsher measures that have been imposed, including those that contribute to the disruption of health services,” Jean Drèze, a development economist, told IndiaSpend.

“India cannot just focus on Covid-19,” Pai said. “Every effort must be made to resume routine health services, and build surge capacity to deal with all the morbidity that has been missed during the past few months.”

“Can the children who have missed immunisations be given booster shots? Are we at risk for disease outbreaks for measles and diphtheria because of missed immunisations? Have the mothers who had to deliver at home come through safely?” asked Keshav Desiraju, India’s former health secretary.

“They need to be immediately checked on,” he said. “They’re going to have to take stock at the block level to see what has happened to all the people who missed their medications and treatments.”

(Rukmini S. is an independent journalist based in Chennai. Article courtesy: IndiaSpend, a data-driven and public-interest journalism non-profit.)

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Hunger and Malnutrition Loom Large Over India as Anganwadis Stay Shut Amid Coronavirus Pandemic

Radhika Bordia

“Ever since Babu died I can feel fear stuck in my throat, rising to choke me,” said Pooja Kumar, who lives with her husband Ramesh in an area called Shahbad Dairy in north-west Delhi. Their son Sevak Ram died at the end of June, just days before his second birthday.

Ramesh was a shop assistant, but after the Covid-19 pandemic unfolded, business dried up and food has been hard to come by. It is a story repeated across hundreds of similar slum neighbourhoods in a city that is among India’s richest by per capita income.

“I have lost my son, I want to hold on to my daughter,” Pooja told me, holding the pallu of her purple printed sari in one hand while clutching Rhea, her four-year-old daughter with the other.

Despite economic growth and a steady improvement in hunger and malnutrition indices over the years, India struggled even before the pandemic. In the 2019 Global Hunger Index, India ranked 102 of 117 qualifying countries, ranking below Pakistan and Nepal in South Asia and suffering from a level of hunger categorised as “serious”.

At the best of times, politicians in India rubbish claims of malnutrition. In 2012, when Narendra Modi was chief minister of Gujarat, he attributed his state’s high malnutrition rates to “beauty conscious” young women.

In a country where governments work harder to deny deaths by starvation than they do to prevent them, it would be impossible to establish Sevak Ram died due to acute malnourishment. He did have an underlying medical condition – diagnosed as epilepsy – but what transpired over the last three months of Sevak’s life speaks for itself.

In April, Pooja started noticing her son was getting weaker. By early June he was hit by bouts of diarrhoea, she said. She took him to a private doctor and then to a hospital where he was prescribed oral-rehydration packets, but it was not enough to save him. Neighbours said when the child died, his body was so frail, it was hard to imagine there had been life in it.

Inside her house, away from the neighbours who have gathered, Pooja broke down, the stress of the last few months evident in her words. Her husband’s shop shut, there was no money coming, and they were finding it hard to ensure enough food for the family. Her biggest guilt, she said, was that her breast milk “dried up” and she could not give her son his top feed.

Pooja used to take her son regularly to the government-run anganwadi – or creche, although it is much more than that – near the house when it was still open. Jyoti Verma, an anganwadi worker, said Sevak was already underweight when they last measured him, but she could not weigh the child after anganwadis across the country shut due to the pandemic.

In Delhi, the order to close schools and anganwadis was issued on March 6. Initially, they were to close till March 31, but their lockdown had not been lifted when this story was published. So far, only Chhattisgarh has decided to reopen its anganwadis.

Long-term impact

“Post the pandemic and the lockdown, the biggest impact has been due to a lack of food reaching families, communities,” said Sumitra Mishra, executive director, Mobile Creches. “In addition, the meals that children and pregnant women were getting at the anganwadis are no longer available.”

“This multiplies hunger,” Mishra said. “We are seeing more cases of diarrhoea and other illnesses due to constant nagging hunger.”

“Severe malnourishment is an acute situation with a close relationship with mortality and six months is a long time for an essential service like an anganwadi to be shut,” said Vandana Prasad, PhD, a paediatrician, public health expert and part of the Right to Food campaign. “This is going to have long-term consequences on mortalities, morbidities and malnutrition.”

This anganwadi in north-west Delhi’s Shahbad Dairy has been shut since March 7.

Sounding part apologetic, part defensive, Jyoti explained how difficult it had been to monitor children registered at her anganwadi.

“I did go twice or thrice to check on him but it was not possible to take his weight as during this period I cannot enter homes,” she said. Till date, the government has provided no protective gear to anganwadi workers like her.

The anganwadi was established under the central government’s Integrated Child Development Scheme nearly 45 years ago and is now one of the world’s largest early childhood development programmes, providing supplementary nutrition to children under six and pregnant and lactating women, apart from other services, such as early education, immunisation and monitoring of health parameters.

Those delivering these services – the anganwadi workers – are trained women from the community. More than a million anganwadis across the country are among India’s frontline health workers, serving over 80 million children younger than 6 years and over 19 million pregnant women and lactating mothers.

Right-to-food activists and nutrition specialists have warned of the impact of a prolonged disruption to this key programme. It is now six months and reports from across the country are chronicling adverse health and nutrition impacts of the shutdown, unfolding at a time when nearly 20 million Indians below 40 years lost jobs (between April and July).

Impact on mothers, children

In the course of reporting from five settlements across Delhi, it was clear that the impact of the shutdown is, predictably, being felt by young children, pregnant women and nursing mothers.

Madan Lal has worked with anganwadi workers in the area for the past three years as project leader for Mobile Creches, an NGO that has been active in the field of early child development for over 50 years.

“We may not be able to prove that Sevak’s death was caused by malnutrition,” said Lal. “But our experience shows that a trained anganwadi worker can help lookout for signs of weakness, illness and can step in to help a mother cope in situations like this.”

Another Mobile Creches worker, Geeta, said Sevak was already listed as “atikuposhi” or acutely malnourished – a category that is normally monitored closely and given supplementary feeds in an anganwadi. This became impossible after their closure.

“We had made steady gains in both malnutrition and immunisation coverage,” said executive director Sumitra Mishra. “With the closure of anganwadi services, this is a big danger.”

In mid-March, the Supreme Court directed states to find ways to compensate for the meals children would have got in schools and anganwadis. The Delhi government responded by sanctioning take-home rations for anganwadi beneficiaries. States responded in different ways, but none have adequately made up for the closure of the anganwadis.

In Delhi, each child under six was supposed to be given the following rations every fortnight:

Wheat dalia Plain – 1,300 g

Black channa raw – 260 g

Jaggery – 130 g

Roasted Bengal gram – 130 g

Total grams of food: 1,820 g

Pregnant and lactating women were also sanctioned the same ration, 1,820 g or 1.8 kg of food, with the amount of dalia increased to 1,690 gram. But these measures are not proving to be enough.

‘Does this look enough’

A lane away from Sevak’s home Suman holds up a small packet of channa given as part of the rations.

“Sometimes, we get the packets every two weeks, sometimes in 20 days,” said Suman. “You tell me, does it look enough?” Her husband Vivek used to carry sacks at the vegetable mandi, but even the demand for such labour has dried up.

Their ration card allows them a subsistence diet, but that is not proving to be enough for her one-and-a-half-year-old daughter Lakshmi, who weighs 6.5 kg. She is malnourished, according to World Health Organisation guidelines.

While the anganwadi was still working, Lakshmi’s condition had actually been improving and she had emerged from a more acute category of malnutrition. Now, that is slipping.

Vivek and Suman are among the fortunate ones who have a ration card. Preet Lal and Lakshmi moved into this colony a year ago from Uttar Pradesh. Dependent on manual labour for a living, they have found work increasingly hard to come by.

The lack of a ration card has meant that the food ration handed out to the children is shared with the family. This is an increasingly common situation: young children who would be fed at the angandwadis now find that with their families earning less, the food ration meant for them is being shared by adults and older children.

Lal and Lakshmi’s six-month-old daughter Tulsi had all the corrosive signs of hunger –bulging eyes, protruding belly, legs that are disproportionately tiny and frail.

“I am scared to put her down for even a moment,” said Lakshmi, who carried her close, fearful of losing her.

As Lakshmi spoke, a group of women gathered around to express just how desperate their lives had become. Like many other women in this neighbourhood, Reena had started recycling waste ever since her husband had been unable to find work. It was a gruelling task, which involved stripping the outer rubber casing of tyres to access the wire inside.

The wire must be ripped out bit by bit. A kg of the wire will fetch Rs 10, but the wire is lightweight and three people working all day may together end up earning Rs 10 to Rs 20.

Reena has four children. The two under six used to go regularly to the anganwadi. Today, she struggles to feed all four.

“When those tiny packets of food come once in 20 days, I have to give all four of my children a little gur from it and it finishes in two days,” she said.

Situation worsens

The closure of the anganwadis has exacerbated a situation that was precarious, to begin with. A 2019 survey by Mobile Creches found 47% of children in Shahbad Colony were underweight, as contrasted with the national average of 27%.

Clearly, the anganwadis were no magic wand, but they provided critical input in a bleak scenario.

At the VP Singh camp in South Delhi, 30-km away, the higher incomes of residents is visible in the size of homes. Many here were employed on regular salaries, in small companies, factories or as government sanitation workers but have lost their jobs in the past few months.

Umda Devi’s husband Arun Paswan was a sweeper at an Okhla company, which has shut down. They have three children but with no income coming in they are finding government rations inadequate.

Her immediate concern was for her youngest. “My son used to be sick all the time but I think the anganwadi worker had helped him,” said Devi. “Over the past year he was getting better, but now I am not sure.”

Having lived here for 25 years, the family is now thinking of heading back to their native village in Darbhanga, but they own nothing there.

There is nothing unique about Umda’s situation. Her neighbour, Sunita Jha, comes out with her grandson, Prince Kumar Jha, who is almost nine-month-old. He was 800 g when he was born. His weight, as measured by the workers of the Mobile Creches, is 5.75 kg, which continues to place him in the WHO category of acute malnourishment.

Another resident, who used to work for a courier delivery service, has also lost his job. His two-year-old son Shaurya is acutely malnourished. He was last weighed in February at the anganwadi, and at 6.5 kg figured among the acutely malnourished.

Both Prince and Shaurya needed close monitoring before the lockdown and were not faring too well, despite support from the anganwadi and their current situation is even more precarious.

A few kilometres away, at Nardan Basti, Matri Sudha, an NGO, has been working on improving child nutrition, health and education. Its health and nutrition advisor, Arvind Singh, has been associated with the work for the past 10 years. He summed up the gravity of the current crisis.

“Concerted groundwork had ensured that the nutrition parameters were improving in a place like Nardan but in the past six months we were watching that slip away,” said Singh. “We have been trying to help those without access to apply and get rations.”

“We have been trying to distribute some food, but it cannot cover and compensate for some essential services – the anganwadi was that especially for the most vulnerable children,” said Singh. “It is hard to see some of the gains made to secure better rights for children to slip away.”

Matri Sudha, along with several other organisations doing similar work, has repeatedly pressed the government to start some of the critical anganwadi functions. On August 25, the Delhi government announced that immunisation programmes run through anganwadis would be restarted, but that will not address the issues of hunger and malnutrition.

Prasad emphasised that it was “possible and necessary” to restart anganwadi work on “growth monitoring and nutritional inputs”. Sumita Mishra of Mobile Creches said it requires governmental will.

That is not yet in evidence – except for gyms, pubs and malls.

(Radhika Bordia is an independent journalist and Director, Global Programme, India at the University of Missouri School of Journalism, USA. Article courtesy: Article-14.)