The first case of SARS-COV-2 was reported in India in 30^th January 2020.  A few months down the line, the Government of India announced a sudden lockdown on  24^th March. Following the lockdown, all local transport, private and public, came to a halt, private healthcare providers closed their clinics, and government health facilities significantly reduced the scope of services they provide. Throughout country, it has resulted in huge reduction in utilization of essential healthcare services.  

We run a network of six not-for-profit primary healthcare clinics in remote, rural and high migration communities in Udaipur district in South Rajasthan, India. Called AMRIT Clinics, they provide preventive, promotive and preventive care to these communities . More than 90% of the population is tribal, and from about 60% of households, at-least one male family member has migrated to a city for livelihoods. In these communities, about half the children are malnourished and 1 In 3 mothers of a live child reports a child death, still birth or an abortion. Populations live in in dispersed settlements in a hilly terrain.

Tuberculosis, diarrhoea, pneumonia, reproductive tract infections among communicable diseases; and COPD, hypertension and diabetes among non-communicable diseases are among the common reasons for clinic visit. Women additionally seek care for other reproductive health needs: contraception, childbirth and medical abortion; and children for severe acute malnutrition.

We describe the impact of COVID and the lockdown on provision and utilization of healthcare in the rural underserved communities that AMRIT Clinics serve. We highlight the importance of community based primary healthcare services in minimising the disruptive impact of the pandemic and lockdowns, in such communities.

Realizing the huge healthcare needs, we decided to continue providing full scope of services. For ensuring safety of our staff and patients, we revised and instituted personal protection and infection prevention practices. For example, we shifted the consultation room in an open space, while maintaining privacy; and created a separate corner for patients presenting with acute respiratory infections. Entry to the clinics was restricted. We developed criteria when patient requires closer examination and when can it be deferred.

Free availability of hand sanitizer (made from denatured spirit and glycerine), and double layered cloth masks as well as surgical masks was ensured. For those requiring a procedure (such as incision and drainage, insertion or removal of urinary catheter etc), gowns, gloves and goggles were used. Any staff with a respiratory symptom was asked to self-isolate at home. Community health education sessions as well as sessions for providing antenatal care in the community was stopped.

To prevent stress among nurses and other staff, we communicated transparently about risk of COVID infection; and effectiveness of protective measures. We encouraged them to take intermittent leave and facilitated transport to spend some time with family. Senior management stayed in close contact with the Clinic teams through visits and zoom calls.

Clinics teams listed chronic patients such as those with TB, HIV and diabetes, who were not able to access clinics, and visited their homes to deliver the drugs. Many of the patients reported how they were not able to come to the clinics because of lack of transport and fear of police.  HIV patients in our catchment area visit the city ART centres monthly for check-up and picking up their drugs, and after lockdown, they were unable to collect their drugs. Our support   team in city coordinated with ART centres, collected the ART and for last two months has supplied the drugs at their doorsteps.

During this period, many labour-migrants started coming back from the cities to the catchment villages, walking hundreds of kilometres. Many of them would come down to the clinics for clarifying their doubts, and share their fears of the infection and epidemic, spread by social media. For example, many people thought that anyone who has corona virus infection would die. Responding to the situation, we started tele-counselling with our volunteers and other community members, to address their fears and doubts.

Utilization of clinics in the months of March and April was not only maintained but increased (Table-1). Footfall increased by 24%, patients detected with TB increased, and numbers of women who availed medical abortion increased, vis-à-vis the same periods in the previous year. Similarly, more women availed safe childbirth services at the clinics. Numbers of women provided antenatal care however decreased slightly, because of the stopping of outreach sessions. While more children with severe acute malnutrition were detected and managed, fewer recovered, possibly because of huge decrease in food availability during these times, and closure of government-run food supplementation services for children (Anganwadis).We had to home isolate two staff members during this period because they developed symptoms of acute respiratory infection.

Editorial Note : BMJ Global Health Blogs is not peer-reviewed. 

Table-1: Key indicators of utilization of healthcare at AMRIT Clinics in

March-April 2019 as compared to similar period in 2020

Primary healthcare services rooted in the community are critical to meet healthcare needs of vulnerable populations  . In high morbidity situations, ensuring full scope of continued healthcare is a human rights imperative – even during pandemics. Our experience suggests that this is possible.

About the author

Pavitra Mohan is a paediatrician and a public health physician and is co-founder of Basic Health Care Services, a not-for-profit organization working in remote, underserved communities in rural South Rajasthan, India.

Competing Interests:

The author manages AMRIT Clinics, whose experience is shared in this blog. We are passionate about primary healthcare. No other conflict of interests to declare