What Explains COVID Disaster in Rural India? How Can We Fix This?

With the focus being on the urban healthcare collapse amid COVID-19, rural areas’s suffering has been overlooked.

Image used for representational purposes.

(Photo: Altered by Erum Gour / The Quint)

The ongoing COVID-19 crisis is nothing short of apocalyptic. The severe underreporting of cases and deaths — especially in rural areas — is not just worrisome but frightening. Entire villages have been locked down; people are going to the Primary Health Centres and Community Health Centres at the village cluster level and block levels, only to succumb to their breathlessness — as there is no oxygen and essential supplies.

While most of the coverage has been limited to how COVID-19 is ravaging hospitals in urban centres, it is rural India which is bearing the brunt of the public health crisis as the disease has spread to interiors — further reiterating the urban-rural divide of privilege.

Under Disaster Management Act, What Role Can District Authority Play to Save More Lives?

Everything is happening at such a breakneck speed that there seems to be no time to pause and reflect. The district administrations are doing all they can to fight the pandemic and the gory situation at hand.

The question though is whether the district administrations are merely acting as implementation bodies or are they actually using the decentralised power they have under the Disaster Management Act of 2005 (DM Act)?

Prima facie, it seems that district administrations have been cornered into being merely implementation and monitoring bodies, and are not involved in actual policy design apart from imposing curfews and lockdowns. The examples of Madurai and Nandurbar districts postulate the fact that a more robust policy-centric approach at the district level yields positive results.

The moot question in this health crisis which has engulfed us is: what role can the district authority under the DM Act play to ameliorate conditions at the grassroots level to save more lives (apart from imposing curfews and lockdowns)?

The DM Act provides ample powers to the District Authority to formulate both preventive and response strategies. Recognising these powers under the DM Act, and the necessity of a strong intervention at the village level backed by the experience of our team working at the grassroots in Gujarat, Jharkhand and Chhattisgarh, we made some policy recommendations to the District Collectors in our field areas, as well the state governments.

These recommendations were backed by precise anecdotal and testimonial evidence and years of experience in disaster response.

What We Recommended for District Authority

These recommendations were backed by precise anecdotal and testimonial evidence and years of experience in disaster response.

The Primary and Community Health Centres at the village cluster and blocks respectively, are facing severe shortage of oxygen and beds. Since oxygen is not available at these centres, the patients are breathing their last at PHCs and CHCs without even getting tested. In our experience, tackling rural distress first in disaster prevents undue pressure at the district level.

We recommended that the District Authority issue requisition orders under Section 33 and 65, to take control of all suppliers and manufacturers of oxygen in their jurisdiction, and supply the same equitably to rural health centres.

This would save crucial lives, as the time taken to travel from the villages to the main hospitals in the district is causing umpteen people to die on the road itself.

By the time ambulances arrive, it is too late. When the administration of oxygen happens at the latter stages, recovery becomes harder, as the lack of oxygen starts affecting the kidneys and brain.

Paucity of Ambulances, Beds, Essential Supplies

Paucity of ambulances is another major problem. To solve this, requisitioning school buses and state transport vehicles and equipping them with basic supplies was recommended. While requisition orders often seem arbitrary, the times are such that these powers need to be invoked. The problem of lack of beds and space can be solved by converting schools, community halls and colleges into COVID care centres (which was ordered in the Gujarat government notification), something which has been happening in an ad hoc manner, but a systematic policy needs to be designed by the district authority around it. Lack of personnel can be addressed by engaging with voluntary groups / NGOs who are working tirelessly on the ground.

The situation is inexplicable. Entire villages have been locked down. Knowing that these cases have the potential of getting serious, the hospital needs to go to these villages. These villages need to be mapped, and essential supplies in medicines and oxygen need to be sent to the sub- health centres and PHCs in their cluster.

No Discussion Around Strengthening of PHCs and CHCs

It is mind-boggling that the discussion is being restricted to medicine supplies, beds and oxygen in district and city hospitals. Does this come from the position of privilege of people and journalists setting the discourse residing in urban centres with access to hospitals? The conversations limited to beds and oxygen supply only in hospitals and not Primary Healthcare Centres needs serious reflection on the part of not just the government but journalists, policy-makers, and most importantly, the technocratic think tanks who think inclusive and robust policies can be made sitting in Delhi without setting foot in India’s villages.

The Indian Public Health System Guidelines for Primary Healthcare Centres, 2012 clearly mandate the presence of oxygen cylinders among other essential facilities.One PHC is supposed to cover a population of 30,000 in non-tribal areas, and 20,000 in tribal areas. 

Our experience from the grassroots is nothing short of heartbreaking.

The massively under-equipped sub-health centres, PHCs and CHCs have been, in our observation, leading to huge pressure on the hospitals in district headquarters and other urban centres.

The ASHA workers and the rest of the staff are overworked and underpaid massively. The summer heat does not help either. There is no doubt about the fact that the Centre and the states were underprepared, but this fact does not absolve the district administrations throughout the country, who are mandated to have a District Disaster Management Plan to be implemented by the District Authorities. The District Authorities have sweeping powers when it comes to not just requisitioning but creating an entire framework for tackling disasters.

It is Indigenous People Who Bear the Brunt

As always, it's the people in the tribal areas suffering the most. They live in hilly terrain, far away from the hospitals which are mostly in the district headquarters. Had simple clustering of these villages been done through COVID care centres with the supply of essential kits and medicines, so many fatalities at the village level would have been prevented.

Section 32 of the DM Act mandates that every department at the district level have a district disaster management plan. This is again non-existent.

The powerful nature of the DM Act and its decentralised nature is failed by the institutions at the district level, who, it seems, look at themselves as mere administrators and implementers rather than policy-makers.

The funds allocated to the Gram, Taluka and District Panchayats, through the Fifteenth Finance Commission were released last year, which was the highest allocation ever.

Knowing that the pandemic was raging and not going anywhere (since cases kept rising), it was recommended by the Panchayati Raj Ministry that this money be used to generate employment at the local level. 50 percent of this fund was tied, meaning, to implement government schemes, but the other 50 percent was available to be used as the local bodies preferred.

Some part of the other 50 percent could have been used to integrate strengthening health services and creating employment at the village level. This money, along with other funds available at the Taluka and District levels, could have easily tackled the shortage of oxygen, beds and essential medicines at the PHC level and CHC level —preventing the dire situation we find ourselves in.

(Arvind Khuman, Renuka Kasta and Aditya Gujarathi work with the Centre for Social Justice. This is an opinion piece. The views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.)