Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19

Abstract

Background In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state’s health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19. Methods A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30–63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts – transliterated into English—were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services. Conclusion Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study

“…The reforms under the “Aardram mission” established additional services such as depression screening clinics (ASWAAS, meaning “assurance”) at the FHC level [ 18 ]. The doctors and nurses at FHCs are trained to screen for mental health issues and manage them using psychosocial counselling and clinical guidelines [ 19 ]. The findings in this study show ways in which emotional issues contribute to illness burden and underscore the need to recognize that individuals living with MLTCs maybe considered high risk or more prone to developing difficulties in coping with their conditions and hence the need to offer better mental health support at FHCs.…”

“…The Government of Kerala introduced localised government-sponsored pilots ( Amrutham Arogyam ) and the Aardram Mission in 2017 to strengthen primary health centres, especially services for hypertension and diabetes, through increased working time and improved staff structure [ 18 ]. Further services such as dedicated NCD clinics, mental health clinics, and respiratory health clinics are also being implemented [ 19 ]. However, there remains a gap in the integrated management of MLTCs within primary care settings in Kerala or elsewhere in India.…”

Obstacles in Basic Health Service When Dealing with COVID-19: A Reflection for Improvement

“…Of course, the experience of every country in reflecting the post-pandemic situation is different, one from another. [10][11][12] Thus, in Indonesia, we need a local evaluation to discover the direct or indirect causes on cases and deaths occurring during the pandemic. The narration from the health workers will really clarify the focus of the problems that must be fixed.…”