In conversation with Shama Karkal, CEO, Swasti Health Catalyst around the need of strengthening the healthcare system in India

● In response to COVID-19, what are the initiatives undertaken by Swasti to strengthen the healthcare system in India?

In early 2020, our in-house experts on pandemic response and epidemiology alerted us to COVID-19 and afforded us critical foresight into the times that awaited us. We rapidly geared up our systems and formed agile teams across the length and breadth of our work to respond to the crisis.

We first set up a Command Centre at Swasti, to protect and support our communities, our 400+ colleagues across our partners within and beyond the Catalyst Group, staff and health care providers across different settings - Urban, Rural and in upto 300+ Factories to provide guidelines and advisories (much before the government ones were released), conducted capacity building and close comfort and hand-holding support.

Then, in order to support and scale the national response to COVID, we co-founded the Covid Action Collab, a network of multidisciplinary organizations representing the public, private, civil society, academic and other sectors who pool their expertise and resources to support the most vulnerable survive and thrive during humanitarian crises. The Collaborative addresses the COVID-19 crisis by driving comprehensive and co-ordinated action with people at the very centre - preventing new infections, mitigating impact for those affected, facilitating resilience building for communities to thrive and a dynamic humanitarian response system. In FY 2019-2020, the Collab through 100+ partners found active presence in 18 States reaching 10,814,004 people among the most poor and marginalized communities.

From the beginning of the COVID-19 response in India, Swasti has been a member of different task forces at local, State and National government levels to strengthen the health system’s response to COVID-19.

Our frontline health workers have supported ASHAs, ANMs and PHC workforces across all our locations in COVID-19 prevention and work with local governments - Panchayat and District level to support efforts - be they for relief, health or impact mitigation. We have worked to strengthen Community Organizations and Community Institutions to strengthen preventive and promotive practices in community settings therefore sharing the load with the healthcare system in India. In addition to this, Swasti has worked with networks of Private Hospitals and associations Private Hospitals and Nursing Homes' Association (PHANA), to support their work in setting up Fever Clinics and put in place a range of Standard Operating Procedures and guidelines. Swasti’s Community Based Testing and Tele-Care - HelloSwasti™ initiatives for COVID-19 are now under scale up. We are currently working towards bringing together Positive Partners - people who have been COVID positive or affected to learn from and better inform the healthcare systems and policies on COVID-19 response.

● With increasing no. of COVID-19 cases, what are the challenges and gaps that should be immediately addressed and how can these be tackled for better healthcare facilities?

We need to first acknowledge that this period is an opportunity for us to recognize and acknowledge systemic gaps including critical resource gaps in healthcare. This is the chance to build back better.

Our challenges lie in 3 critical areas and therein lies the opportunities to create better healthcare facilities -

1. Our human resources for health at every level - The demand-skill gaps along with shortage of frontline workers across the country became evident during the pandemic. The shortage in other essential skilled professionals was critical even before. India has one medical doctor for every 1,404 people1 and 1.7 nurses per 1,000 people2. With an increased need for preventive and promotive health care, we cannot focus on professionals within health care facilities. Health and well-being is essentially an outcome of a range of different preventive and promotive practices done right with multi-disciplinary teams working across different levels of care. Investing in people for health will eventually result in better health for all.

2. Our systems of procurement and logistics, supply chain management for everything - ranging from PPE to food - need re-thinking to make it more agile, meaningful and responsive. This is the opportunity to bring the power of technology and capacity from the private sector (including social entrepreneurs and civil society) into health care. We have seen significant improvements in the last 15 years, but there are still siloed or niche systems which need to be interoperable and become future ready.

3. Enabling people to increase control over and improve their health

a. Good health is a combination of different factors - it requires people to take responsibility for oneself and ones families complemented by social determinants of good health being addressed at community and societal levels. Clearly we haven’t been able to inculcate the right behaviours through our education systems and institutional structures. We often work in silos and our policies and interventions remain misaligned to the overall mission of well-being of all - including those at the last mile, the most poor and marginalized. To enable people to be truly empowered to take charge of their health, we cannot treat them as “beneficiaries” but as partners and agents of change. This is a paradigm shift in the way we execute on ground and also calls for an integrated interface for people.

b. COVID-19 related stigma and discrimination, which in turn has led to individuals not self-reporting symptoms, attempting escapes from institutional quarantine and not seeking treatment indicates that we have not been able to implement lessons learnt from other interventions such as HIV, Leprosy etc. An increased sense of collaboration and trust between citizens and providers, nuanced social-behaviour-change-communication and the health system is essential to address the issue.

● What kind of collaborative efforts are needed to make sure that people living in rural areas are less impacted as there is very limited capacity for critical care?

1. Our Panchayati Raj Institutions need to be supported to utilise the full range of their authority, to ensure local infrastructure meets the needs of rural communities including investments in health infrastructure. Leveraging existing community institutions to outreach and serve people locally requires coordinated efforts. Collaboration amongst all agencies at the Panchayat and district level with a focused agenda on equitable access to care and services needs to be the aim. Safe water, better sanitation, improved hygiene and safe food for the communities along with social safety nets and health care services are essential. This will require localized collaborations and health and well-being champions from within the community to take the lead.

2. Ensuring preventive and care information reaches the last mile - The understanding of Social Behaviour Change Communication has grown immensely in the last few decades with a combination of heuristics that borrow from neurobiological understanding of communication as well as psychological and sociological. The prevention of COVID-19 requires adapting practices of everyday health well-being. This is a collaborative effort to strengthen on ground knowledge and support systems for these behaviours to be more effective.

3. We must bring together the power of the State, market, people and the right enablers to make sure that livelihoods of the vulnerable are protected. This has become more critical because of the pandemic and requires collaborative efforts to create common good. The growing income inequality in the country requires that we find new solutions and look at system change efforts rather than addressing the symptoms.

● What are the core HSS functions that need to be advanced to ensure sustained health outcomes for the poor?

All of them actually. Core HSS Functions are typically seen as (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance and these are interwoven.

● Do you think tele-counselling can play an important role in HSS? If yes, then please explain how?

Yes, Indeed. Infact, I would term it as Tele-Care, which is broader and offers a larger range of services. Poor populations lacking access to health services in normal circumstances are left most vulnerable at the time of crisis. Coupled with a burden of both acute illnesses and chronic diseases, social determinants and limited access to health care, they end up seeking health care only when they are seriously unwell or faced with catastrophic illness. The uncertainties and anxieties that come with a pandemic have not only led to an increase in stressors but have also restricted the ways in which it is generally dealt with. There is a higher risk of abuse and gender-based violence. While these are prevalent across socioeconomic status, it is largely unmitigated in the lower economic strata, where the resources, services and the space are constrained.

Besides the existing challenges of accessibility and affordability of healthcare for the underserved, the COVID crisis has precipitated additional barriers to accessing healthcare for chronic conditions, including the digital divide. To amplify this lack of access, people experiencing an influenza-like illness (ILI), which could be SARS-CoV-2 (COVID19) are afraid to seek care due to fear of stigmatization. Now our health systems are typically are ill-equipped to address these concerns.

With Tele-Counselling, these concerns, along with say mental well-being concerns or menstrual wellness concerns, or gender based violence - which are all critical social determinants for health and well-being - can be discreetly addressed. Now with Tele-Care, we take it a few steps further.

Swasti recognized the need for a platform that can support chronic medical conditions with immediate needs of basic essentials and support to protect from violence. There is also an urgent need to bust myths around Covid-19 and de-stigmatize testing. The Tele-Care platform has been conceptualized and designed as a trust-worthy and robust platform, where community members can dial in and access the required services. It is layered on to an offline component that serves a range of requirements - from referrals to social protection help desks to financial inclusion services and more.

Tele-Care when combined with actual on-ground support services can not only ease the burden on the health system but also become an easy to use, accessible and affordable partner in health at the last mile.

● How have the vulnerable communities been impacted due to COVID-19?

The most vulnerable are also the most at risk during crises such as this pandemic. At Swasti we work with some of the most marginalized and vulnerable communities - the urban poor, the rural poor, women in factories, women in sex work, transgender people, men who have sex with men, people living with HIV (PLHIV), adolescents and young people. Each of the communities have been struggling in different aspects of survival, health and well-being. From being locked up with their abusers as lockdown came to force to losing their livelihoods and falling deeper into loan traps - their stories are equally harrowing and inspiring as they continue to work through ways to rise above their situations. For PLHIVs, the food donation drives often did not meet their nutritional needs and this combined with loss of livelihood only augmented their despair. Many of the communities have been pushed deeper into poverty with many becoming homeless. Children in the urban and rural poor families have missed out on mid-day meals as schools shut down and education has taken an unsure future. And this is just the tip of the iceberg. For these communities who had made significant progress in the last few years to stay protected from situations such as HIV, TB, Malaria and had been working towards finding ways to invest in their family’s future to break the poverty-ill health cycle, COVID-19 has set them back significantly.

● Since it has been over 10 months of COVID-19 outbreak, do you think the situation has changed for vulnerable communities in any way?

We need to recognize that our communities have shown extraordinary resilience during these times. They geared up to be health champions and partnered with frontline health workers to keep their members safe and protected while also partnering with organizations like ours through their community organizations and community institutions to secure social protection services and initiatives that are effective and efficient. Over the last 10 months we have also seen increased participation in the health response at the community level by these community champions. Yet critical concerns like livelihood, access to health care remain.

● Anything else that you would like to emphasize on?

“In the midst of every crisis, lies great opportunity”, said Albert Einstein. The opportunity now is for us to work together to create a more equitable society.