In Conversation With Shama Karkal
Why is there a need to invest in primary healthcare to power the Indian economy?
A robust Primary Healthcare system is crucial to introduce and hold in place preventive health measures. It improves access to preventive and promotive health among the population including the marginalized, prevents underlying health conditions being experienced by the community members from getting potentially fatal by early identification and diagnosis therefore helping appropriately triage and reduces the burden on health systems and is a key determining factor in protecting from long term illnesses.
When we invest in primary healthcare, we can reduce total hospitalizations, avoidable admissions, and allow for optimal investments and utilization of resources.
A combination of gaps in primary healthcare and marginalization and poverty affects health-seeking behaviors, which results in little or no preventive health measures being practiced by individuals. This often further results in repeat episodes of illness, undiagnosed conditions, resistance to treatment, early death, high burden of morbidity and significant out of pocket expenditure (OOP), as high as 60% in India.
The inability to practice health-seeking behaviors, in turn, exacerbates the risk of myriad health issues with or without COVID-19 for the most marginalized. With COVID-19 this plays out in terms of severity.
For the Indian economy to flourish, it is imperative to invest in primary healthcare. The economic case for it is quite simply put - a combination of health system efficiency and protecting the citizens so they are able to function as contributing members of the Indian economy - breaking out of chains of ill health and poverty.
Primary healthcare improves equitable access to health care and equitable health outcomes including powering the Indian economy. Afterall, healthy citizens make a healthy economy.
Importance of partnerships and collaborations across the board to strengthen community systems and primary healthcare
Partnerships are central to our success in creating systems innovations for change and delivering outcomes to positively impact the most vulnerable communities. We have always built and sustained partnerships with community organizations, donors, and brands; academia, technology firms and venture networks; and media and cross-sectoral experts. Leveraging these collaborations have ensured effective and efficient use of funding, programs are evidence-informed and technology-enabled, and platforms are built for cross-sectoral convergence.
Could you please share details about Swasti’s ongoing partnerships with the government, public health agencies, corporations and other organizations?
Some examples are the partnerships created with Indrapradtha Institute for Information Technology Delhi (IIIT-D), Azim Premji Unviversity, Oregon State University, Fu Jen Catholic University, Institute of Rural Management, Anand (IRMA), Patient-Centered Medical Home (PCMH), Swathi Mahila Sangha, Catalyst Management Services, Vrutti; corporates like Marks & Spencers, Levis, Inditex, Walmart, Amazon etc. We work with district, state and central govt departments of health, social protection, women and child health and social justice and empowerment. as well. Swasti is represented in International bodies too.
We work in the community with and through local people as volunteers, outreach workers and staff. They are able to connect with primary and secondary stakeholders in the same geographical areas in a better way as there is an existing established relationship.
We work in a collaborative manner with local institutions - be they civil society, private sector or government through formal, informal engagement based on the needs of the community.
We work closely with the government at various levels from Panchayat/cities to State and National Ministries. We are currently in the process of formalizing our relationship (MOUs) with different Govt. Departments for various activities that we undertake.
Role Swasti is playing in making diagnostics & vaccination accessible and affordable to the marginalized community in India?
In order for marginalized communities to have access to diagnostics & vaccination, we have a 4 pronged approach
1. Foster a collaborative response.
2. Ensure safe and affordable transportation to access healthcare services - in this case, COVID-19 vaccination centers ; as well as use of the most appropriate point of care diagnostics.
3. Use vaccination camp to conduct regular health checkups and referrals
4. Community Systems Strengthening for Health Systems Strengthening
In response to COVID-19, Swasti and the Catalyst Group co-incubated the #COVIDActionCollab - The COVIDActionCollab (CAC) is an all India collaborative, united to provide relief, recovery and build resilience among the most vulnerable communities. The collaborative consists of Organizations and Networks working together to support these communities during the period of crisis and enable them to secure their future.
And, here are some glimpses from the activities on ground:
Improving access to COVID-19 vaccination camps for marginalized communities:
To improve access to COVID-19 vaccination camps for marginalized communities in far-flung areas in India, teams from Swasti partnered with local Community-Based Organizations (CBO) and Non-Governmental Organizations (NGO) to develop tailored approaches and set up the camps too.
When the COVID-19 Vaccination Drive in rural and peri-urban India was being undertaken solely at Primary Health Centers - state-owned rural health care facilities - ground CBO and NGO teams mobilized 5 to 10 community members, hired the first available local small to medium-sized transport and shared rides to the Primary Health Center.
However, this solution was not workable for individuals who had accessibility and mobility challenges or were at enhanced risk due to health conditions - such as older adults, people with disabilities, people living with HIV and ground CBO and NGO teams used two-wheelers / access modified vehicles to ply as transport for them.
Once the Government allowed for Vaccination Camps to happen in Villages and within Community Spaces, the CBO and NGO teams scheduled fixed time periods for community members, mobilizing them and working extensively on community-level myth-busting and stigma reduction.
Given that in villages and peri-urban areas, the local CBO and NGO teams and the community representatives played an active role in facilitating vaccination, they were able to partner with the Frontline Health Workers at Vaccination Camps to improve access for individuals who were bedridden or were unable to access the Vaccination Camps in their community spaces for reasons such as old age, disability, pregnancy. This was prior to Har Ghar Dastak - the Government Of India's campaign for door to door vaccination.
At Self Help Groups, members were motivated to convince others in the group to seek vaccination with late evening or early morning camps to ensure the timings did not cause a loss of daily wage.
These approaches were not limited to people interventions only. In Urban Poor settings, the local Community Health Institution partnered with Design Innovators to put in place plastic barriers in Auto Rickshaws owned or operated by community members. This is the preferred local transportation of the community for safe transportation to access clinical services. This helped protect the Auto Rickshaw drivers as well as the passengers - while making it a COVID-19 safe and comfortable transport to access health institutions.
Improving COVID-19 diagnostics for marginalized communities:
Community-based surveillance and testing for COVID-19 as a solution to the challenge of delayed identification of COVID-19 among vulnerable populations was deployed by Swasti across all locations at the onset of the pandemic.
During the initial months of the COVID-19 pandemic, the Swasti team conducted both door-to-door and telephonic surveillance in the communities they serve to assess risk of infection, possible severity by also screening for predisposed health conditions, exposure and contact tracing.
Across India, Swasti partners with marginalized community leaders and their organizations to improve uptake and understanding of self testing for COVID-19. I want to share with you two stories of our work in this regard:
Shivaji Nagar, Mumbai
Swasti launched the Community-Based Testing initiative in one of the most densely populated urban slums of Mumbai: Shivaji Nagar, Govandi in the month of January 2021
The initiative offered a safe, door-step screening and testing option to the community which had very limited access to the same. The team on the ground not only screen people for symptoms but also able to collect swab samples for Rapid Antigen Test (RAT) and RT-PCR tests with a quick turnaround time
The initiative also includes pre and post test counseling as well as primary health care services for other non-communicable and high burden co-morbid conditions which affects the severity of COVID-19, along with pre and post-test counseling
Between January 2020 and December 2021, we were able to maintain a low positivity rate (<2%)for COVID-19 in partnership with Doctors For You and SBI Foundation.We did this by conducting daily doorstep surveillance and testing for the community, covering over 1.5 lakh individuals and 15k+ tests
The community-based RT-PCR lab continues to run in the community, providing free tests to the most vulnerable
Taking Self-Testing to Factories
Safe return to workplaces amidst the ongoing pandemic is a key concern for both employers and employees. Factories can be particularly high risk environments for large outbreaks as they have a large number of workers working in close proximity. With self tests now being available in the Indian Market, regular, repeat antigen testing can be used as an effective surveillance tool to identify and curb outbreaks early in factories along with other protective measures. However not much is understood on how to operationalise this.
We have partnered with Foundation for Innovative New Diagnostics (FIND) and factories in Peenya Industrial Area (ACWA and a Shahi garments unit) to implement a pilot for peer assisted self testing. This includes a usability and acceptability study to understand both comfort and accuracy of testing by factory workers.
This pilot study will help develop operational learnings on how factories can implement testing surveillance systems to protect their workers which will be useful for both domestic and international organizations.
With recent govt. announcement about the launch of a national tele-mental health programme to provide 24x7 free counselling and care to people, do you think tele-care services can also help in supporting vulnerable communities in India (from mental health, social protection to primary healthcare services)?
It is indeed a welcome move. In our experience, here is a list of things that TeleCare has been instrumental in
1. Conduct community surveillance to understand the needs of the community.
2. Help the community connect to telecare services by correctly identifying those individuals whose symptoms can be managed over the phone.
3. Accurately and quickly navigating those with emergency symptoms go to the hospital.
4. Follow up with those individuals who don’t respond over the phone.
5. Helping the nurses and doctors by assisting patients while they are receiving consultations
6. Helping communities access social protection schemes
7. Correctly identifying those in need of emotional well-being support and encouraging them to reach out to the counselors.
Tele-Care counseling supports prevention efforts by ensuring that verified information reaches the last mile. When Tele-Care is layered on trusted service providers and networks of the community, the information is deemed more acceptable to the community.
Telecare is a solution so that the community can access healthcare easily, quickly and in an affordable manner. By picking up the phone and talking to a nurse, up to about 80% of the health issues faced by a household can be addressed. The nurses and doctors can even send them prescriptions over the phone.
However, health is not the only service available on telecare; people can also access emotional wellbeing services and get information about social protection schemes.
