Our existing healthcare delivery system is not fully equipped to handle a pandemic like situation where there might be a sudden spike of morbidity among people. This may lead to utter chaos and breakdown of the healthcare delivery system. Key Issues are:
- Lack of staff.
- Staff’s capacity to handle disasters like COVID-19.
- Lack of infrastructure (Bed/ Critical care unit/Oxygen/Medicines etc.) to handle such disasters.
- Lack of expertise in scaling up healthcare activities when a surge in healthcare delivery is required.
Below are the set of activities which need to be taken up on an urgent basis.
7.2.2.1 Collaborate with Government
Priority: Immediate
It is important that every effort involves collaboration with government authorities at different levels - State/District/Panchayat. As COVID-19 has been declared by the Government of India as a national health emergency, developing proper coordination with District / State authorities is essential. Wherever needed, a proper approval also needs to be taken from the concerned authority. This will also minimise the duplication of efforts.
Areas where Civil Society Organizations can help:
- Engage with the Government to identify gaps.
- Work with Civil Society Organizations to address the identified gaps.
- Share the broad plan of action with the district / state authorities and seek approval.
- Work towards addressing gaps in the government’s efforts, without duplication of effort.
- Be sensitive to the evolving situation and make adjustments based on the changing needs.
7.2.2.2 Analysis of Present Healthcare Infrastructure
Priority: Intermediate
There can be a great level of variation between districts in the strength and capacity of their health systems. Some districts have easy access to tertiary healthcare centers with better facilities by virtue of having more urbanized areas within their limits while more rural districts have lesser resources. The backbone of a structured planning in better handling of such mammoth pandemic is proper assessment of present healthcare infrastructure of the district. This will help us to figure out the gap in the healthcare infrastructure based on the projected patients load for the district. Hence better planning. See Appendix A10 for guidelines.
Areas where Civil Society Organizations can help:
- Support govt in the capacity development of the district/block level health functionaries on how to use the assessment tool.
- Support the government in development of online assessment tools enabling better collation and analysis of information.
- Support govt in the follow up with the health functionaries to get the filled up assessment tool.
- Support govt in the compliance and preparation of the district level assessment report.
- Support govt in the preparation of the healthcare infrastructure gap fulfillment plan based on the projected COVID 19 caseload of the district.
7.2.2.3 Build capacity of ANM, ASHA & Angawadi Worker
Priority: Immediate
COVID-19 pandemic is altogether a very different type of disaster and there are immediate requirements of building capacities of frontline workers (ANM, ASHA & AWW) on how to handle the pandemic situation as the frontline health worker has the responsibility, the reach and the influence within the community. ANM, ASHA and AWW workers are currently being projected for field surveillance activities for home visits of quarantined people or clusters of infection and form an important part of the disease surveillance and mitigation mechanism. They are also very important in the continuation of routine activities such as ante-natal care, nutrition among vulnerable populations. Since these activities during the outbreak pose considerable risk and require expertise, there is an urgent requirement to build their capacity and equip them for the job. Capacity development module can be based on the COVID-19 FACILITATOR GUIDE Response and Containment Measures Training toolkit for ANM, ASHA, AWW, published by the Ministry of Health and Family Welfare, mentioned in Appendix A1.
Areas where Civil Society Organizations can help:
- Develop interactive training module including in digital form (Tiktok video/ animated version) based on the SOP.
- Support Govt. in conducting the training both with technical support and logistical support.
- Follow up after the training to understand the change in the understanding level of the participants and provide periodic training in cases of increasing risk or changes in the dynamics of the pandemic.
7.2.2.4 Supply of Personal Protective Equipments (PPE)
Priority: Immediate
COVID-19 infection is known to be transmitted through droplets and fomites (articles on which the viral particles / droplets settle). Therefore, caretakers of patients including medical and para-medical personnel are at a very high risk of contracting the infection and are the most important stakeholders in this battle against the pandemic. Thus their safety is of prime importance and the appropriate usage of Personal Protective Equipment (PPE) plays a very crucial role in keeping them safe. Thus proper importance is to be given to ensure adequate supply of PPEs for the medical and para-medical personnel. The government has already issued guidelines on rational use of PPEs during the COVID-19 pandemic. A list which is current as of March 30, 2020 is mentioned in Appendix A2 along with a link to the full government guideline. These guidelines provide the specifications of PPE to be used under healthcare situations of varying risk thereby advocating adequate protection while avoiding wastage and unnecessary stockpiling of PPE that can cause shortages.
Areas where Civil Society Organizations can help:
- Support govt in the assessment of PPEs requirements in a district.
- Support govt in the procurement, transport and distribution of the PPEs as per projected assessments.
- Orient/build awareness among the medical and Para-medical personnels on the importance & method of using PPEs, their donning and doffing and their role in the entire infection prevention and control spectrum.
7.2.2.5 Creation of Isolation/Quarantine Facilities
Priority: Immediate
A large number of migrant labourers/daily wage earners are returning back to their respective villages due to the long lockdown and loss of jobs. Many of them might already be infected by COVID 19 and quarantining / isolating them for at least 14 days is necessary to slow down the infection spread in the community. Thus there is an immediate requirement of development of temporary quarantine and isolation facilities at the village/Panchayat level. School, Panchayat Bhavan, student hostels etc. can be developed as temporary quarantine/ isolation wards. The National Center for Disease Control (NCDC) has guidelines for setting up quarantine facilities and isolation facilities. See Appendix A3 for NCDC guidelines on setting up quarantine facilities. See Appendix A4 for NCDC guidelines on setting up isolation facilities/wards.
Areas where Civil Society Organizations can help:
- Support govt in selecting the place for developing such facilities at the village/panchayat level.
- Support govt/ panchayats in setting and operation of such facilities.
- Motivate/counsel the returning migrant labourer on the importance of mandatory quarantine/isolation
- Update the data of quarantined persons health situation to concerned authorities at the Block/District/State level
7.2.2.6 Supply of Medicines and Healthcare Consumables
Priority: Immediate
Smooth and uninterrupted supply of medicines and other consumables like oxygen, sanitization materials for the healthcare facilities at different levels (sub-center, PHC, CHC, District hospital) will be very critical in dealing with the pandemic of this size. Thus proper assessment of requirements based on the projected patient flow as well as quick expansion of the supply chain will play a very critical role in minimising the mortality rate.
Areas where Civil Society Organizations can help:
- Support govt in the assessment of the requirements.
- If needed, support the government in the quick procurement of those requirements after proper approval and quality check.
- Procurement will be initially restricted to general non-pharmaceutical items (non-restricted) such as sanitization consumables, oxygen, generic requirements such as syringes, needles among others.
- Expansion to include pharmaceutical items will be done based on need and after assessing capacity for regulatory compliance and adherence to quality standards
- Support govt in the distribution of the procured material at different level
7.2.2.7 Ambulance Facilities
Priority: Immediate
Ambulance will play a very critical role in giving timely treatment support to the COVID 19 infected patients. This includes the ability to transport critically ill patients from PHCs to tertiary care centers with life support and is in addition to the normal requirements of ambulance like transportation of pregnant women for delivery and other critical illnesses. Thus there is an immediate need to mobilize additional ambulances for the transportation support to COVID 19 infected patients while ensuring better coordination mechanisms to ensure lean usage of the much needed ambulance / transportation resources. Govt has already issued a SOP for such ambulance and transportation of COVID 19 infected patients which is mentioned in Appendix A5.
Areas where Civil Society Organizations can help:
- Support govt in mobilization of additional ambulances at different levels.
- Training of ambulance staff on the SOP issued by the Govt.
- Operationalization and management of ambulance call centers
7.2.2.8 Capacity building of Doctors & Medical Support Staff
Priority: Immediate
Capacity building of doctors and medical support staff on the treatment protocols for COVID-19 infected patients as well as how to handle such patients keeping them safe will be an important step in the fight against this pandemic. This is especially true for doctors who will be involved in treating critically ill patients under respiratory distress in places where they do not have the support of consultants or intensivists. AIIMS has already developed an online training module for such which needs to be popularized among doctors and other medical staff. There can also be quick classroom training in this regard.
Areas where Civil Society Organizations can help:
- Support govt in the development of training plan and training calendar.
- Technical and logistical support for conducting such training.
7.2.2.9 Testing Kits
Priority: Immediate
Testing is the key strategy in the fight against COVID-19 pandemic. As of today, ICMR supplies test kits to a subset of approved government laboratories while the remaining approved government laboratories and approved private laboratories privately procure their reagents and kits. These kits are approved by ICMR, DCGI and the MoHFW. Currently all laboratories that test for COVID 19 have to be registered with ICMR and have to update the national line listing on a real-time basis. However, increasing expansion in the testing for COVID 19 in both public and private hospitals may be necessary as the number of cases increase. Thus, the number of approved labs need to increase and also there should be an adequate supply of authentic and quality COVID-19 testing kits at these labs. ICMR has already approved a list of testing kit manufacturers.
Further, for pre-screening and quicker identification and preventive action in a wider geography, there will be a future requirement for serological testing kits (not currently used for diagnosis) to assess the seroprevalence (community spread) of the disease. This will help in strategic and operational planning (subject to government regulatory mechanisms). There is a requirement of assessing the requirements of testing kits. Accordingly, order needs to be placed for supply of testing kits from the ICMR approved testing kit manufacturers. A detailed list of ICMR approved testing kit manufacturers and their prices are mentioned in Appendix A6.
Areas where Civil Society Organizations can help:
- If needed procure testing kits for the ICMR approved govt labs.
- Logistical support in timely distribution of the testing kits at different levels.
- Training of the medical support staff on method of using the testing kit.
- Help setup COVID 19 sample collection units in govt health clinics/ hospitals, following govt guidelines and in logistics of sending them to approved labs
- Procure pre-screening kits and make it available to distant and remote areas from where the samples will take a long time to reach the approved labs
7.2.2.10 Creation of Additional Hospital Beds
Priority: Immediate
Most of the experience till date, seems to suggest that around 20% of people who are infected will need hospital care. If the infection rate of the virus increases during the community spread stage, the number of people who need hospital care will be very high. Thus preparation with respect to sufficient number of bed availability at the Block (CHCs) and District (District Hospital) for treating COVID-19 patients will need to be undertaken urgently. The requirement for additional number of beds will be based on the projected patients flow. Accordingly infrastructure needs to be augmented. Guidelines of how to develop makeshift separate hospital facilities for COVID-19 patients is mentioned in Appendix A8.
Areas where Civil Society Organizations can help:
- Support govt in quick procurements of beds and other related infrastructure for setting up of the special/temporary hospital for COVID-19 patients.
- Support govt in the general management of the special/temporary hospital for COVID-19 patients.
7.2.2.11 Creation of Critical Care Units with Oxygen & Ventilators
Priority: Immediate
As per the estimate a significant number of the COVID-19 patients who are admitted to hospitals will need oxygen / ventilator support. In the event of an increasing rise in infections as seen in other affected countries, it will become very important to augment ICU capacity to deal with the crisis. Non-availability of ventilators in sufficient numbers turned out to be one of the major causes behind the increase in mortality rate in the pandemic worldwide. Thus proper planning to develop such facilities will be crucial. The requirements of an additional number of CCUs with ventilators will be based on the projected patient flow. A guidelines for setting up such CCU with ventilators along with costing is mentioned in Appendix 9.
Areas where Civil Society Organizations can help:
- Support govt in quick procurements of beds, Ventilators and other related infrastructure for setting up of the CCU at Block/district level for COVID-19 patients.
7.2.2.12 District Level COVID-19 Response Cell
Priority: Immediate
To manage a pandemic of such high scale, there will be requirements of proper coordination of different stakeholders involved/associated with the response along with increased collection of data, analysis and dissemination to aid in strategic and operational planning within the district. Thus there will be requirements of setting up of COVID-19 Response Cell at the District level, especially in the hot spot district. A simple SOP of this COVID-19 Response Cell is mentioned in Appendix A7.
Areas where Civil Society Organizations can help:
- Support govt in setting up of the COVID-19 Response Cell at the district level with logistical support.
- Depute skilled manpower to run the cell in coordination with the Govt dept.
7.2.2.13 Provision of clean drinking water and WASH facilities
Priority: Immediate
Access to clean drinking water is likely to be a critical casualty of the pandemic. Regular sources of drinking water (local well, water pump, water tank) will certainly have been disrupted by the curfew. Ensuring that people (particularly migrants recently returning to their villages and adding to the pressure on resources) have access to clean drinking water is critical. Neglecting this could lead to another public health disaster layered onto the COVID-19 disaster.
Areas where Civil Society Organizations can help:
- Support government in increasing the availability of clean water at healthcare facilities, quarantine facilities and residential areas with high risk.
- Set up safe potable drinking water facilities at the village level.
- Distribute water storage containers so that families can store water for 2-3 days.
- Create and disseminate IEC material on how to keep water safe.
7.2.2.14 Augmenting Biomedical Waste Management
Priority: Immediate
The increasing load of patient care and increased use of PPE by both healthcare workers and the general public has increased the levels of biomedical waste that may be infectious. Therefore measures have to be taken to augment existing mechanisms in the safe disposal of biomedical waste. This requirement is expected to further increase as the number of cases increase and special care should be taken so that the biomedical waste is appropriately treated and does not pose a risk to handlers and their contacts as well as to the general public.
Areas where Civil Society Organization can help:
- This requires specific skillsets and approvals thereby limiting direct participation of Civil Society Organizations.
- Support the government in augmenting existing capacity in the safe disposal of biomedical waste.
- Support government in the creation of autoclave, incineration and landfill facilities for the expected rise in biomedical waste.
- Support the government in the dissemination of guidelines on handling of biomedical waste to newly established and rural facilities along with capacity building of personnel.
7.2.2.15 Augmenting Cold Chain Facilities within the Health System
Priority: Immediate
Since many secondary and tertiary facilities especially in the less well connected districts in India do not have adequate cold storage facilities for sensitive pharmaceuticals and diagnostic reagents, it is important that they be strengthened to accommodate increasing demand during the pandemic. Since an important part of handling the pandemic involves providing critical care to patients with costly and sensitive medications, it is important that these facilities be assessed and gaps be filled to enable seamless functioning of the healthcare machinery.
Areas where Civil Society Organizations can help:
- Supporting the government in setting up prepositioned stocks of essential medicines especially for critical care of SARI patients.
- Supporting the government in establishing cold chain solutions including time sensitive transportation of sensitive medicines.
- Supporting the government in establishing a database with inventory of available medicines and diagnostics with various stakeholders to enable availability.
7.2.2.16 Fill Vacant Posts related to Health Care
Priority: Subsequent
Medical and paramedical staff are the biggest weapon in the fight against COVID-19 pandemic. Situation analysis of the present healthcare infrastructure mentioned above will give us exact data of the vacant post of medical and paramedical staff at different levels. These posts need to be filled quickly. Recruiting final year MBBS students is a possibility. Calling upon some retired functionaries who are in good health and able to work could be another.
Areas where Civil Society Organizations can help:
- Support the government where possible.