Note: This is a version of a document presenting the strategy of Aajeevika Bureau, Basic Healthcare Services (BHS) and Shram Sarathi, working in Southern Rajasthan. I wrote this along with my mentor Dr. Sanjana Mohan Brahmawar, co-founder and director at BHS. 

Background

The second wave of Covid-19 has hit even the remotest and deepest rural areas of southern Rajasthan where BHS, Aajeevika Bureau and Shram Sarathi operate. The first wave affected mainly the urban parts of the country and the few cases in rural areas were mostly among the migrant workers and their families returning home from cities like Ahmedabad, Surat and Mumbai. Last year, as a result of the national lockdown, the major crisis was related to shrinking resources, specially food in these extremely fragile families. The situation then, had created a need for relief work and food support to these families. This year, the situation is different.

Everyday, we are getting to know of villages where large number of families are affected with fever, cold, cough, and other symptoms. AMRIT clinics, run by BHS situated in far-off villages of Salumber, Gogunda and Kherwada blocks are also seeing an increasing number of patients with fever, cold and cough. There is a huge fear in seeking care from government facilities, as people feel “they will be taken away to the city and may never come back”.

Community members are flocking to the quacks in their villages whose treatment is irrational and often dangerous, besides being crazy expensive. Their charges have gone up even more since the pandemic set foot here. We are also hearing of several deaths being reported from the villages.

At the same time, there is a significant section of local people who are in complete denial of Covid-19 and are participating in large gatherings including weddings and other events. There are large groups of people often sitting together in small spaces without masks or any personal protective measures. “Last year, when the bimari (illness) was not much, people were more careful, wore masks and did not organize large scale weddings. This year, when the bimari has spread so much, people have also stopped taking these precautions”, laments Bheru, one of our health workers.

There are many misconceptions about the disease and the vaccine floating around in the villages – “Corona does not happen to those who work under the sun in fields, it happens only to those living in cities, those who sit in AC rooms”. “Vaccine is for population control, people who take this will die within six months”. These fears mean that much lesser people have gone ahead and got vaccinated.

To say the least, public health facilities in the region have been fragile even before the pandemic hit us. With the increasing spread, they are now much more stretched and unable to keep pace with the growing burden. Facilities for admission of someone with severe Covid symptoms exist only at district headquarters which means people have to travel long distances. Also, the hospitals in the cities are fully packed with scarcity of available beds, supplies of life-saving oxygen, as well as vital drugs.

The need for these times are clearly different from last year. The strategy of Aajeevika Bureau, BHS and Shram Sarathi has three components – Community Response, Block level Covid Care Centres and Telephone Helpline.

Community Response

Together, with our network of village volunteers, we are working on the ground for promoting awareness about Covid, and care and support for those affected by the disease in the community. Awareness will focus on ensuring personal protection (wearing a mask, hand hygiene), avoiding large gatherings, importance of getting vaccinated, and practices to follow if anyone has symptoms suggestive of Covid. This is being carried out across large areas, using messages, Whatsapp videos and posters. Here’s some of the material openly available. To know about what you can do if you have the symptoms of Covid-19, watch this video:

The communication material being used is in simple hindi or the local dialect. Our team connects with the important stakeholders in the region, including local leaders, panchayat representatives, village volunteers, teachers, and shop owners. Then these stakeholders help us disseminate important information across their villages.

In selected panchayats, in addition to building awareness, our teams are also supporting communities in home care for people with symptoms of Covid. With large number of people falling sick and testing facilities in block levels being overburdened, people with Covid symptoms are not being pushed to get the RTPCR tests done. Those with any symptoms like cold, cough, fever, diarrhoea, weakness, loss of taste or smell are considered as suffering from Covid.

In line with recent guidelines from the state government, our volunteers are providing medicine kits to the affected persons. Additionally, they are counselling them for home care, including self-isolation and self-care, suggestions to consume plenty of fluids, and staying active as much as possible. These volunteers also motivate and encourage the patients. In times of excessive information coming through social media building excessive stress, everyday well-being of the Covid patients is an important task in home care.

Volunteers are also following-up with the patients and providing them any extra support required, such as food, or fuel, or water. Families are being counselled for early recognition of any danger signs. If any patient reports a danger sign, volunteers contact the telephone helpline where a primary healthcare nurse or physician will guide the treatment. For those who are advised a referral, volunteers help organize transport to the nearest Community Health Centre. If referral is refused, the patients will be provided home care in consultation with the helpline and block team will deliver the required medicines.

The teams working on awareness building and home care includes village volunteers partnering with village functionaries such as ASHAs and AWWs as well as educated youth. A block level support team supervises and supports the village teams. The block team also trains the volunteers for personal protection and providing home care. They work closely with the block government team for effective roll-out, and ensure the provision of any required material such as food ration to any identified families in the villages.

Our efforts for awareness building are spread across five blocks in Udaipur, Dungarpur, Banswara and Sirohi districts. Our support to communities for home care is across nearly 25 panchayats in Salumbar and Gogunda blocks in Udaipur. I have been closely involved in this effort for the last few weeks and plan to continue sharing my experiences and stories from the field.

Covid Care Centres

Our team is working with block health teams for setting up Covid care centres at the block level. Three such centres are being set up – in Sabla (Dungarpur district – already functional), and in Salumber and Gogunda blocks (Udaipur district). The centres aim to provide care and oxygen support to people affected with moderate to severe Covid symptoms and falling oxygen levels, at places closer to their homes. This will improve access to care for tribal communities living in far-flung areas and will also help to reduce pressure on the already over-burdened district hospitals.

Each centre will have 20-30 beds and will be equipped with 15-20 oxygen concentrators as well as 5-10 oxygen cylinders. Block health team will provide the premises, human resource (doctor and nursing staff), drugs and other supplies. BHS will support with the provision of oxygen concentrators, training of the staff, and quality assurance. We are also placing a nurse manager at the Covid care centres to ensure high standards of care. In addition, we have developed standard operating procedures and a toolkit for running such centres. The toolkit is available here.

In Sabla, a ward in the Community Health Centre is converted to the Covid centre. In Gogunda, where I live, an Ayurvedic college building has been converted into one, and we had three referrals within a day of the centre being set up. Preparations for setting the centre up are underway in Salumbar block.

Telephone Helpline

The telephone helpline aims to provide expert guidance to families receiving home care. This will be managed by a team of primary healthcare nurses, supported by physicians. The team will be intensively trained and equipped with protocols, for identifying and also managing (as much as possible) common health problems as well as emergencies related to Covid. This will be extremely valuable in the present times, when there is so much fear to step out from the villages, the increased difficulty in travel, and health facilities in blocks and cities being fully stretched. 

The helpline number will be shared with village and block teams and also made available to the local residents. Covid patients can call the helpline directly, or the volunteers can first obtain the required details from the patients and then call the helpline. Depending on the condition of the patient and specially the oxygen levels, the helpline will advise for referral, or treatment of the patient. Further, in situations where the family refuses referral, helpline will advise for home treatment.

Block teams will ensure that the required drugs reach the volunteers so that they can make it available to the patient. The helpline will also guide the patient regarding the method of administrating drugs. The team will maintain records of the patients seeking care as well as the common reasons for consulting.

These initiatives aim at helping reduce transmission and new infections, promote rational care of those affected with Covid, improve access to care for those with severe symptoms and co-morbidities, and also help reduce the burden on the overstretched district hospitals.