Decentralised solutions to COVID-19: Arming frontline warriors to lead the charge

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Poonam Muttreja, ED, Population Foundation of India strongly urges that frontline warriors like district magistrates and panchayat heads should lead the charge in the battle against COVID-19 by tackling on-ground surveillance of COVID-19 management

The rural heartlands of India, especially in its most populous states, have been severely impacted by the second COVID-19 wave. The need for developing localised, context-specific solutions has been amplified by key experts in light of rapidly changing on-ground situations, varying numbers of COVID-19 cases across districts, and disparities in health care capacities. Recently, at an interaction with District Magistrates from severely affected regions, Prime Minister Narendra Modi acknowledged the critical role of district officials, calling them ‘field commanders’ in the fight against COVID-19. The Prime Minister’s Office has stated that decentralised initiatives could help in “developing more effective response plans, targeted strategy implementation and support necessary policy interventions.”

This statement comes more than a year after the Odisha government first took unprecedented steps to give Gram Panchayats across the state full authority over COVID-19 management in the areas under their jurisdiction. As early as April 2020, as per media reports, panchayat heads in the state were given the powers of District Collector – that of the chief executive and administrative officer – and were mandated to ensure that migrants returning from other parts of India or from other countries strictly adhered to quarantine guidelines. Media reported that panchayat heads were also equipped with decentralised community-based monitoring mechanisms to help register cases.

The Odisha model included engaging frontline workers such as Anganwadi workers, Accredited Social Health Activists (ASHA) and teachers in relief interventions undertaken by panchayats. The government engaged Women’s Self-Help Groups (SHGs) to assist in awareness generation, the delivery of public health and hygiene, and provision of food security to vulnerable groups, especially during the lockdown. The state’s proactive response in handling the twin challenges of managing the first wave of COVID-19 infections and the impact of cyclone Amphan earned it national and global attention, including from the World Health Organisation.

Meanwhile, in Kerala, where a history of decentralisation existed well before the pandemic, panchayats in the state took proactive measures to combat the crisis, setting up war rooms and help desks to track the availability of beds and oxygen and tying up with local medical stores to deliver to residents’ doorsteps. In Kasargod district, a special taxi service called COVEHICLE, was set up to enable residents of seven neighbouring panchayats to travel to and from testing sites or hospitals free of cost.

In fact, several states have witnessed positive results from engaging Gram Panchayats in the fight against COVID-19. Andhra Pradesh, Bihar, Assam, Madhya Pradesh, Karnataka, Kerala, Maharashtra, Chhattisgarh, Nagaland and others have all shared best practices from Panchayats, with recommendations ranging from enforcing home isolation and COVID-19 management, and disseminating information, to more novel initiatives, such as converting autorickshaws to ambulances or installing handwashing facilities made of bamboo.

As India reels from the shock of the second, more devastating wave of the COVID-19 pandemic, all eyes are on local institutions to implement quick decisions for the delivery of solutions aimed at mitigating local problems. Despite initial successes, we have witnessed terrible failures in anticipating, preventing and responding to a fresh surge in infections. Given the diversities within the Indian context, governance must be region and context specific. Central and state governments must support decentralisation by collecting accurate data and information and disseminating it in a timely manner to all states and districts. By encouraging scientific, evidence-based decision making, we can mitigate apprehensions around the validity of planning efforts.

Population Foundation of India has been working with a coalition of Civil Society Organisations (CSOs) across states to provide a rapid rural community response to COVID-19. The need for accurate and trustworthy information dissemination mechanisms and the value of harnessing all types of frontline workers, including private sector sales and distribution staff, postmen, and teachers to disseminate information has been highlighted.

Additionally, by decentralising distribution systems, ASHAs and other frontline workers can contribute to the quick delivery of health care at the grassroots level. Frontline workers, with their intimate knowledge of the region, would be best placed to identify those most at risk and also provide critical interventions as well as essential medicines and medical equipment, such as thermometers and oximeters, on time. Encouraging a shift away from hospitalisation to care at home or at smaller, block-level health centres is key to managing mild-to-moderate illnesses, preventing deaths and reducing the burden on hospitals. As many as 20-33 per cent cases have been estimated to be mild and treatable at home.

The current focus on mass media approaches for vaccination have very made little penetration in rural areas. In many states, a large proportion of health providers themselves not vaccinated, which in turn makes them unable to convince and mobilise communities. Communities have faced indefinite waits at vaccination centres, and often returned without a vaccine, due to operational issues and shortages. Registering for vaccination via the Co-WIN portal has been challenging, especially for women and the elderly in rural India, due to multiple barriers to using technology. Organising district- and block-level vaccination drives and equipping frontline workers to register candidates for vaccination are important steps to ensuring this live-saving intervention is rolled out equitably across the country. ASHAs and frontline workers can play an essential role in reducing vaccine hesitancy by responding to communities’ fears. Governments, in turn, can support frontline workers by strengthening their capacity to conduct surveillance and increase their confidence in engaging in this work by ensuring these workers have comprehensive health insurance cover.

In April this year, Amitabh Kant, the CEO of Niti Aayog, interacted with over one lakh CSOs in the country to thank them for their ground-level efforts to combat COVID-19 and urge them to continue taking key measures, such as information dissemination, to control the pandemic in rural India. He outlined the many ways in which grassroots organisations could work in partnership with the government, including by raising awareness, supporting underserved families, connecting beneficiaries in need with existing schemes and subsidies, and aiding the delivery of essential public health services.

Decentralised efforts through district working groups and planning committees are also critical for ensuring that local authorities have the resources to implement localised solutions. By providing technology infrastructure at the district, town, block and panchayat levels, we can enable timely information sharing to manage demands for tests, medical oxygen, ambulance, drugs and supplies, and other emergency requirements. Quick access to this information could, for example, help ASHAs register patients directly from the community level into the triage system.

By empowering local authorities to take targeted action in response to local needs, we can ensure that quick and effective steps are taken to mitigate the COVID-19 crisis. The impact of the second wave on the physical and mental wellbeing of the country has been severe. A concerted effort, with the Centre in a supportive role and local administrations taking the lead in preparing for and fighting the on-ground impact of the virus, will help us work faster to control the spread of COVID-19 even as the vaccination campaign intensifies.

ASHAsCOVID-19District MagistratesGram PanchayatsWomen’s Self-Help Groups
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