India’s first Covid-19 peak may be passing, but infection spreads silently in its vast, rural hinterland, where over 800 million live and testing and healthcare are scant. At the epicentre of the pandemic, the healthcare system is collapsing
Mumbai/Pune/ Palghar/ Beed: On a recent Saturday morning, Medical Superintendent Dr Sunil Darade, 57 and diabetic, was the only doctor on duty at the 30-bed Rui Rural Hospital, a squat building in a tree-lined lane in Baramati, Pune district.
Nearly five months after this government hospital in a western corner of India’s richest state—and the epicentre of its national epidemic—was turned into a dedicated Covid facility, 30 people have died here and the hospital’s workforce devastated by the SARS-COV-2 virus.
Darade listed the staff he lost: “Two nurses tested positive for Covid-19, one X-ray technician tested positive, a dental surgeon tested positive, a pharmacy officer tested positive.”
In addition, two doctors are “absent from duty” owing to age or comorbidity, and two staff-nurse positions are vacant. For a few weeks, the hospital borrowed staff from the nearby sub-district hospital, but with the latter’s Covid facility to be widened, Darade will lose the two borrowed nurses and some volunteer doctors.
The fatigue among rural medical workers in Maharashtra, a state with 21.5% of India’s Covid-19 cases, comes at a time of growing disquiet—even panic—at the rising numbers of cases in villages. Cities may be unlocking, and the first peak of the epidemic may be passing, but in India's richest state by gross domestic product, villages have implemented janata (people’s) curfews, voluntary local lockdowns shutting shops and markets.
In Beed district, where excess rains in September-end damaged thousands of acres of harvest-ready soybean, pearl millet and cotton, farmers avoided gathering as they normally would at local government offices to seek state compensation. “The fear of Coronavirus is worse in the villages,” said Machhindra Gawade, a 70-year-old farm leader in Georai, Beed. “Because we don’t have the hospitals that cities do. People are scared that they could die.”
Across villages in Maharashtra’s predominantly rural districts, very few villages have testing centres, the closest swab-collection facility is dozens of kilometres away, Covid-care hospitals farther still. Article 14 found rural hospitals poorly staffed, available doctors inexperienced, and an acute shortage of oxygen-supported beds, ventilators and critical care equipment.
As India prepares to overtake the United States by most Covid-19 cases—by 12 October, India registered 7.16 million infections, closing fast on the US with 7.80 million—the country now faces a new pandemic challenge: to provide treatment and break the chain of the infection in rural areas where over 800 million Indians live, more than 60% of the population. Through August and September, the number of patients in the country’s rural districts, where health infrastructure has suffered historical neglect, has risen to a third of the total.
The Pandemic’s Rural Surge Across India
The spread of Covid-19 in rural areas is now a pan-India phenomenon, with a second nationwide sero-survey by the Indian Council of Medical Research (ICMR) indicating that a majority of India is still at risk with no peak or herd immunity achieved.
Scant testing facilities in rural areas will adversely impact infection control, said Rijo M John, PhD, health economist at the Indian Institute of Management, Kozhikode. “Already there is a lot of discussion and debate on the extent of under-reporting of deaths in India,” Dr John told Article 14. Low levels of testing in rural communities that have poor reporting and death-recording suggests “many more unreported deaths and undetected cases”, he said.
The National Health Profile 2019 published by the Central Bureau of Health Intelligence concedes that India’s public healthcare system comprises “limited secondary and tertiary care institutions in key cities” while rural areas have “basic healthcare facilities”.
Of the 50 worst-hit districts by number of positive cases as of 12 October, 23 were rural with at least 50% of their population in rural areas. A third of the patients in these 50 districts live in rural districts. This does not take into account patients from rural districts not among the top 50, nor those in rural areas of predominantly urban districts.
Thirteen of the 50 worst-hit districts are in Andhra Pradesh, and 12 of these are rural districts, with East Godavari topping the list of all rural districts at 1,05,682 cases. The other state with a large presence among the worst-hit 50 districts is Maharashtra, accounting for 14 of these, including seven rural districts.
In July, 51% of all new cases were in rural districts, growing to 54% in August, according to an August 2020 State Bank of India study.
In Uttar Pradesh, predominantly rural districts Jaunpur, Deoria, Barabanki, Ballia, Saharanpur, Lakhimpur Kheri, all districts with large populations of returning migrant workers, have more than 5,000 cases each, according to data from a nationwide Covid-tracker.
In Chhattisgarh, which more than doubled its total count of positive patients in two weeks between 31 August and 15 September, four rural districts have recorded more than 6,000 cases each. Dantewada district and its town head that has a population of less than 14,000 according to the 2011 Census, had 2,455 cases on 1 October, a 179.6% rise in a fortnight.
In Andhra Pradesh, where 60% of cases were found to be in rural areas by September-end, Guntur District Collector I Samuel Ananda Kumar was quoted as saying the surge in cases in rural areas was “alarming”. New containment zones in the district included a series of villages.
In Epicentre Maharashtra, Rural Resources Stretched
Since reporting its first Covid-19 positive case on 9 March, Maharashtra has consistently remained the epicentre of the pandemic in India with 1.52 million positive cases until 12 October. Its health minister has acknowledged concern over a growing rural surge.
An Article 14 analysis of daily reporting by the state’s medical education and drugs department shows that on 1 July, more than three months into the nationwide lockdown, as many as 87% of all Covid-19 cases in Maharashtra were reported from 27 cities governed by municipal corporations. On 1 August, 79.77% of all cases, or four in every five cases, were still in these cities. On 12 October, this percentage is down to 63.09%, meaning at least every third patient is from outside these cities where the state’s best health infrastructure is clustered.
In a presentation made to Chief Minister Uddhav Thackeray on 22 September and accessed by Article 14, the state’s public health department projected shortages over the coming weeks, shortages that persist despite urgent initiatives over six months to upgrade health infrastructure. For example, of 35 districts, 15 would be short of ventilators, the projections said.
Pune district, which includes the urban agglomeration around Pune city and a large agrarian region, together home to 9.4 million people, would be short by 381 ventilators, Chandrapur district by 120 and Yavatmal by 81.
Seven districts are short of ICU beds — Chandrapur by 174, Yavatmal by 118. The districts of Pune, Satara, Chandrapur, Nagpur and Nanded also face an acute shortage of oxygen-supported isolation beds, a basic requirement even for mild cases. Pune would be short by 6,646 oxygen-supported beds, Satara by 2,780, Nagpur by 1,325 and Nanded by 1,191.
Pune district (including Pune and Pimpri-Chinchwad cities), with 3,15,774 cases on 12 October, is India’s Covid capital. At the Rui Rural Hospital in rural Pune’s Baramati taluka, Medical Superintendent Dr Darade finally took a lunch break after a Saturday morning manning the 30-bed hospital as the lone doctor on duty.
Krishna Kamble, an accountant with a local school, waited outside the hospital for Dr Darade to return, to check if his wife would need to be shifted out for specialised tests that the hospital does not offer. She is pregnant.
His entire family had tested positive and only recently returned home from a Covid facility. “We finally all tested negative, but my wife developed some pregnancy complications so we brought her back here.”
The Rui Hospital is now only for Covid patients, and Kamble’s wife had to be admitted here despite testing negative and despite the staff shortages. No other facility will admit her.
Staff vacancies are almost the norm in rural healthcare in Maharashtra. State-run medical colleges and facilities run by the public health department in the state had nearly 14,000 vacancies before the pandemic struck.
The state government is now set to enforce the one-year rural service bond signed by medical students, and has advertised for contractual doctors and offered ‘walk-in interviews’ in some districts.
In Pune, according to a senior government official, a desperate administration tried to mine the city’s civil service exam coaching institutes for doctors — many MBBS degree-holders are known to be aspiring IAS officers. But the students had all left for their hometowns.
Wherever doctors could be recruited on contracts, a practice that pre-dates the pandemic in Maharashtra, those hired earlier want a pay hike to match the Rs 1 lakh monthly salaries being offered now, said officials. Also, contractual positions could be filled mostly in the cities.
Ayush Prasad, Chief Executive Officer of the Pune Zilla Parishad, explained why Maharashtra’s rural healthcare model is broken. Primary health centres (PHCs) are no more than a basic OPD, while rural hospitals are simply large OPDs, with the addition of an X-Ray machine, other diagnostic equipment, an Operation Theatre for deliveries and for other extremely basic surgeries.
Secondary care, including a paediatric ICU, neonatal ICU, caesarean-sections and some specialised surgical procedures, are available only in the sub-district hospitals. “In the PHCs, sub-district hospitals and rural hospitals across the state, we had 70% vacancies when the pandemic hit,” he said.
Class IV staff, for example, are what he called a “dying model”; these vacancies are never filled as the system migrates slowly to outsourcing menial jobs. The Class III posts, such as auxiliary nurse-midwife, are filled by promotion and are therefore heavily litigated and face continuing vacancies, Prasad said.
As a consequence of the long-standing shortage of doctors in rural Maharashtra, rural Covid facilities now have a paucity of skilled and experienced medical professionals. Prasad said young doctors in rural hospitals, overwhelmed by the situation, are treating patients only for the infection even when there are comorbidities. The professor-doctors at the state’s medical colleges are stretched thin.
The shortage of other staff is equally tricky.
“We can’t do tests on Sunday. Or rather, if we have to do a swab-collection on Sunday, we’ll have to call in our lone lab technician. He would take about 90 minutes to get here from his hometown,” said Dr Snehal Kshirsagar, the medical officer at the Ter Rural Hospital in Osmanabad district.
During the early spurt in rural cases, Ter conducted almost 100 swab-collections daily. The number has now settled around 35 daily tests, and 30% eventually test positive. As of 12 October, the state recorded 20.70 positives for every 100 tests, a positivity rate that is among the highest in the country.
That, combined with low levels of testing as the infection spreads to rural areas, will be challenging, said Dr John, the health economist. “Overall, to a passive observer, it appears that the state is going for herd immunity,” he said. Maharashtra’s tests per million as of 21 September were 48,400. For the same date, Andhra Pradesh has tested 98,824 people per million, Tamil Nadu 86,601; Telangana 67,687 and Delhi 1,30,147.
If testing levels have been low in cities such as Mumbai, Pune, and Thane, they may be worse in rural areas that are now sharing the caseload. Anticipating a severely burdened rural health infrastructure, Dr John said, “I wouldn’t be surprised if Maharashtra’s deaths from Covid rise in coming days if this trend were to continue.”
The only course correction policy-makers can make, he said, is to slow the spread by increasing testing and quarantining as many positive patients as possible, even though exhaustive contact-tracing may not be possible with every fifth test emerging positive. “If you give up on testing, this is only going to spread further,” he said.
None of that urgency is visible in Maharashtra’s rural hospitals. In the second and third centuries, during the rule of the Satavahanas, Ter was located along a trade route to the West, and artefacts from archaeological excavations here are displayed at the modest Ramalingappa Lamture Museum along the main road, closed for public since the start of the lockdown.
Modern day Ter, 25 km from the district headquarters of Osmanabad city on a severely damaged road, has four positions for government doctors, but one is vacant. Of the remaining three, one was transferred to Osmanabad Civil Hospital to fill more pressing gaps in staff strength there.
Dr Kshirsagar lives in Tuljapur, 40 km away, while the other doctor lives in Latur, 50 km away. Each does a 24-hour shift before being relieved by the other. The off day in between is spent commuting home.
The Ter Rural Hospital is not a Covid facility, and Covid-positive cases are referred to Osmanabad Civil Hospital, 25 km away. Most patients make their own arrangements for the journey - ambulances are in short supply.
At rural hospitals and sub-district hospitals, a steady stream of people enquires about tests during the morning hours. Most hospitals conduct swab collection only during the first half of the day, owing to staff shortages. Patients arrive from villages in a 30-km radius, most often three on a motorbike, the most commonly available transportation in villages.
“There’s no testing facility in the villages, so our Primary Health Center (PHC) refers suspected Covid-19 patients to one of two government hospitals nearby, one is 15 km away, the other is 30 km away,” said gram panchayat member Santosh Gavhane at Dawadi village in Pune’s Khed taluka.
The village, which has had more than 30 cases and one death, undertook days of voluntary lockdowns. The village’s PHC is actually a sub-centre, and its newly purchased pulse oximeters and blood pressure cuffs have come from gram panchayat funds.
A team of Accredited Social Health Activists (ASHA) was fanning out into the stone fortifications that mark the boundaries of the Peshwa-era village, to conduct door-to-door surveys under the Maharashtra government’s new programme ‘My Family My Responsibility’, an ambitious effort to reach every single family in the state.
“We do have PPE sets at the sub-centre, but not for use during surveys,” said medical officer Dr Bhagyashree Panhale. The ASHAs conduct surveys with only a cloth mask for protection, not even gloves or face shields.
In Short Supply: Staff, Equipment, Skill, Experience
It has been 15 years since the National Rural Health Mission (NRHM) was launched in 2005, to provide “accessible, affordable and quality health care to the rural population, especially the vulnerable groups”.
In 2013, the NRHM was subsumed into the new National Health Mission. Despite various improvements, it failed to reduce the wide disparities between rural and urban healthcare.
In November 2019, a government report analysing NSSO data on social consumption did indeed show improvements across states’ rural areas on various health parameters.
But according to independent public health researcher and member of the Jan Swasthya Abhiyaan Ravi Duggal, this improvement in access to and use of public health centres and rural hospitals was from a “low, insignificant point”.
Duggal told Article 14, that community health centres and primary health centres had been neglected, and up to 70% of permanent positions in these across many states were vacant.
Maharashtra’s current struggle to bridge the gap in rural health infrastructure is a good example, he said, of how an early achiever state in the Eighties fell back in later years.
Having met the target of one PHC per 30,000 people set by the Minimum Needs Programme in the 1980s, Maharashtra has not been able to take care of these assets or equip them with resources such as diagnostics, Duggal said.
With a few exceptions, such as Mizoram and Goa, which spend more on health in their budgetary allocations, many states suffer on account of chronically low investments in rural healthcare. Maharashtra has among the lowest levels of spending on health, with its health budget barely 0.6% of Gross State Domestic Product (GSDP), Duggal said. According to the National Health Profile 2019, Mizoram spent 4.2% of GSDP on health in 2015-16; Arunachal Pradesh spent 3.29%; Nagaland spent 2.97%. Andhra Pradesh, Telangana, Delhi, Gujarat, Haryana, Punjab, Maharashtra, Tamil Nadu and Kerala all spent less than 1% of GSDP on public health.
The impact of the long-term neglect of public health financing was visible before and at the start of the pandemic across rural India, through staff shortages in Gujarat, resource shortages in Uttar Pradesh, strained medical professionals in Telangana, and hurried recruitments in Chhattisgarh, among others.
P V Ramesh, independent health professional and former bureaucrat who was once Andhra Pradesh health secretary, said his personal opinion was that India had never resolved the matter of whether public health delivery is to be seen as a public good or not. While the British set up a post-War National Health Service, India had no similar parallel.
The tendency in India is to sanction buildings and “confuse hospitals for healthcare,” Ramesh told Article 14. As for human resources, a skewed policy led to India producing more doctors than nurses, later permitting the private sector into nursing education without adequate regulations, he said.
An early example of investment in providing real health outreach services was Andhra Pradesh’s Arogyasri insurance programme later renamed the YSR Arogyasri. Ramesh said he foresaw at the time a strengthening of public healthcare, a regulatory system where learnings would loop back into improving the system. “But very little of that has happened,” he said. “I used to dread the idea that we would not have the wherewithal to manage a pandemic because the system has neither the resilience nor the manpower trained to undertake management of a pandemic of this nature.”
His fears are reflected in the rising fatigue felt by health workers, who also battle infections in their ranks, on the frontlines in far-flung districts and remote villages.
S P Kalantri, medical superintendent at Kasturba Gandhi Hospital in Wardha, in the Vidarbha region on Maharashtra’s eastern edge, said in an interview that the district witnessed a sharp spurt in rural cases mid-September, with positivity rate among those being tested as high as 40%. Alongside, there was fatigue among health workers now battling the pandemic for six months. “And as quite a few healthcare workers also have got infected, there is now a fair amount of fear and panic among healthcare workers as well,” he said.
Gondia, Wardha, Chandrapur, Bhandara and Amravati, all backward districts in Vidarbha, are witnessing a spurt in cases. Between 15 September and 1 October, these districts recorded a rise in total cases by 80% to 118%.
If doctors and nurses are facing burnout, the flag-bearers of the NRHM, the ASHAs, have spent the last two months in a nationwide struggle for more dignified working conditions.
“The ASHAs are not even treated as workers. When they started in 2005, they were expected to work two to three hours a day. What we’re seeing now is complete exploitation of their labour,” said Ranjana Narula, convener of the All India Coordination Committee of ASHA Workers, affiliated to the Centre of Indian Trade Unions. The ASHA unions across India have been agitating for protective gear, minimum wages and social security benefits.
Across rural India, 600,000 ASHAs conduct door-to-door surveys to check for symptomatic patients. They are central to contact-tracing in villages.
“Nobody asks about our mental health,” said Archana Ghugare of the ASHA union in Wardha district. “One ASHA’s mother died of post-Covid complications in Kolhapur. Others have faced violence for going door to door. There is tremendous fear and insecurity among ASHAs.”
The ASHAs are also usually the first to identify mental health complaints among villagers, a responsibility they’re now unable to fulfill amid the widespread anxiety, Ghugare said. In many district hospitals, the psychiatry and deaddiction units have not been able to function during the pandemic or have functioned sporadically.
Traditional condolence meets and grief-sharing, including the practice of an entire village’s menfolk gathering for a cremation or burial, have been jettisoned. Village squares in Beed, Osmanabad, Pune, Palghar and Raigad bear flex-board hoardings in various sizes, announcing deaths and the 10th day post-cremation rituals, some politely requesting villagers not to attend.
Racing To Get Equipped Amid A Pandemic
As India raced to buy and install ventilators, rural hospitals had more mundane shopping lists — computers, generator-sets, additional oxygen tanks, central lines for oxygen, ambulances.
Pune’s PHCs and rural hospitals received 97 life-support ambulances, purchased from receipts of funds devolved to Gram Panchayats this August-September under the 14th Finance Commission recommendations for Panchayati Raj Institutions. State-owned ambulances in rural Maharashtra were mostly purchased under the NRHM in 2007-08. Other districts are getting new ambulances too. According to officials, the state government will spend Rs 75 crore only on new ambulances with the bulk to be delivered to the ill-equipped district areas.
Mid-July, when tribal-dominated Palghar district’s M L Dhawale Memorial Trust-run Rural Homoeopathic Hospital was added as a dedicated Covid hospital by the state government, the hospital had already spent more than three months serving the local community through its continued OPD services, free dialysis, extending its long-stay facility for those admitted into its geriatric care and mental health wards.
Palghar, with the west coast on one side and forested hills on the other, is one of Maharashtra’s most backward districts, carved out of Thane district only in 2014. Its public health facilities are so poor that residents access healthcare in neighbouring Gujarat.
One Monday morning, about a month after they launched their Covid wing in August, Hospital Director Dr Anand Kapse was awakened by a call at 5.20 am. They were going to run out of oxygen that day.
Palghar does not have a medical oxygen plant, and the hospital sends its large oxygen cylinders to Mumbai, 100 km away, for weekly refills, in batches.
This August and September, however, as a serious shortage of medical oxygen affected all of Maharashtra alongside a spurt in Covid-19 cases in rural areas, the Dhawale Hospital had one batch waiting in queue in central Mumbai where the supplier had run out of stock, and another batch almost empty.
Across rural Maharashtra, hospital staff have dramatic tales about refilling of oxygen cylinders—truck break-downs, major suppliers running dry, 400-kg cylinders being manually hauled out in the absence of hydraulic platforms.
“I called the Food and Drug Authority (FDA) Commissioner, the FDA nodal officers,” Dr Kapse told Article 14. By the time an industrial oxygen cylinder was arranged, the hospital was down to its last cylinder, with 35 minutes of oxygen left.
“The logistical challenges are immense, while financial challenges were met entirely through donors’ support,” he said. The hospital received individual and institutional donations, and ran an online crowd-funding campaign, key to providing quality medical care as state financial support for private hospitals turned into Covid facilities is limited to insurance scheme payments. The 44-bed Dhawale Hospital Covid facility is staffed by 35 to 40 care-workers who require 1,800 PPE kits monthly. Soon after they started the Covid ward, a few desktop computers stopped working and had to be urgently replaced. Liquid oxygen cylinders were procured later, also through donations.
Several rural hospitals have asked the state for similar equipment, including defibrillators, multi parameter monitors and high-flow and normal nasal cannulas. The Maharashtra government has projected supplementary expenses of Rs 300 crore on “supplies and materials” including computers, diagnostic kits, PPE sets, and such hospital equipment.
Dhawale Hospital also purchased 100 sets of light-weight, quick-drying patient linen when their industrial laundry service provider refused to continue accepting their linen. The hospital now employs two domestic-capacity washing machines, and a lecture hall serves as a drying room where sheets are hung out under ceiling fans. The laundry problem recurs in several rural hospitals. Even in the peri-urban Pune metropolitan region, one facility has changed its laundry operator seven times over six months.
Nearly 475 km away from Palghar, Lokhandi Sawargaon, a village of less than 4,000 people in the drought-prone Beed district of Marathwada, appears at first glance to be an odd setting for a 1,000-bed hospital.
The village is just nine km from the Ambejogai town that houses a state medical college with a 250-bed Covid facility. But with Covid-19 cases emerging in Dharur, Kaij, Ambejogai, Wadvani and Parli talukas, the district administration repurposed three hospital buildings in Lokhandi Sawargaon lying vacant since being built in 2012.
The complex houses a 225-bed dedicated Covid hospital where 198 beds were occupied by September-end and an 85-bed isolation centre. Nearly 500 beds are in a third building, to be operationalised if cases rise further.
The sprawling facility is retro-fitted with a generator-set, an under-construction liquid oxygen plant that will be the first of its kind in the region, ventilators and a PA system. But the additional infrastructure does not resolve the problem of staffing. Despite hiring staff on short-term contracts, according to one doctor who chose to stay anonymous, there is no permanent physician and only one anaesthetist on contract. This means every patient whose condition appears less than stable is immediately referred to the Swami Ramanand Tirth Rural Medical College, Ambejogai.
Impressive as it is, the Lokhandi Sawargaon Covid facility is also emblematic of the state’s wilful neglect of rural public health. A 2017 report by the Comptroller and Auditor General hauled up the state government for the building lying vacant since 2012.
The administrative sanction to build the hospital was accorded in 2008, as a 200-bed geriatric health and mental health centre alongside a woman’s hospital, at an estimated cost of Rs 9.46 crore. The building was finally completed in March 2012 at a cost of Rs 19.21 crore.
A scrutiny of records showed that no staff was ever sanctioned for the hospital, but in 2013, the Directorate of Health Services in Mumbai purchased medical equipment for the hospital including ECG machines, pulse oximeters, a ventilator, 200 beds, 10 wheelchairs, 10 examination tables, 10 stretchers and more, all eventually diverted to another hospital.
Today, patients arrive everyday at the Lokhandi Sawargaon Covid hospital. It has space for triaging, rooms for donning, and clearly separated residential quarters for nursing and other staff.
For all the efforts to optimise and add more rural health infrastructure, under-utilisation and non-utilisation of existing facilities continue during the pandemic. Almost on the border of Pune and Solapur districts, the Bawada Rural Hospital in Indapur taluka is a spiffy new structure, but it has remained locked since being completed last year. No staff was ever approved for the hospital.
Rural Pune had 69,958 positive cases on 12 October, with the state’s own estimation that the district is short by more than 6,000 isolation beds. At the brand new hospital building in Bawada, there is not even a guard appointed. On a patch of grass outside, a Jersey cow ruminates thoughtfully.
(Kavitha Iyer is a Mumbai-based journalist.)
This reportage was supported by the Thakur Family Foundation. The Thakur Family Foundation has not exercised any editorial control over the contents of this report.