Averting a Crisis in Preventive Healthcare

Date

June 1, 2020

4 min read

As various regions of India now begin to emerge from lockdown, an important step will be confronting the consequences of disruptions in routine services provided by government health workers, including immunisation, antenatal checks, and nutrition drives. These preventive healthcare services form the backbone of India’s aspiration to be a healthy country with low rates of infant, child, and maternal mortality and morbidity, and systematic measures to correct for recent disruptions are essential.

Unsurprisingly, the COVID crisis has taken a toll on the already weak government health infrastructure, especially in rural India. Data released by the National Health Mission, covering a majority of sub-centres, primary health centres, community health centres, district hospitals, and sub-district hospitals, as well as some private facilities in rural India, shows a worrying trend related to use of preventive healthcare services. For example, there is a sharp decline in children receiving basic vaccines, and in medical interventions performed on pregnant women, indicating a potential increase in home births.

One may see this as a short-term blip due that will correct itself once the overall situation improves. However, our predictions need to account for the sobering reality that even in the pre-COVID era, India struggled with utilisation rates of preventive health services. For example, only 62% of children between 12 – 23 months in India are fully vaccinated (NHFS-4).

The recent drop in use of healthcare services caused by COVID may be longer lasting and threaten the achievement of India’s health goals if those who only recently began utilising preventive healthcare services fall back into their previous pattern of not using the formal healthcare system.

Central and state government health departments must therefore start planning to reverse this trend quickly. And here, rigorous evidence on what works to improve take-up of preventive health services can come in handy to inform the government’s health strategy in the short to medium term.

Health system strengthening

Once the acute phase of the COVID crisis is over, the government should consider strategies to restore the motivation of overworked and overwhelmed healthcare workers, especially those on the frontlines. To augment existing salaries and monetary incentive schemes, governments can consider non-monetary incentives to further leverage the intrinsic motivation of health workers.

For example, research has shown that providing volunteer health workers with social incentives can improve their performance. In Zambia, non-monetary rewards in the form of public recognition improved the performance of volunteer health agents by 31 percent. While non-monetary incentives should not be used as a substitute for financial incentives, they can be an option to complement financial incentives.

Generating demand for essential preventive care

Small incentives for parents, such as a kilogram of lentils per immunisation administered, coupled with reliable services at convenient mobile clinics, have been found to generate a sixfold increase in full immunisation rates when tested in Udaipur, Rajasthan. The addition of the incentives also caused these immunisation clinics to be more fully utilised and therefore twice as cost-effective as identical clinics that did not offer incentives to parents.

Another innovation for boosting demand for immunisation is to identify and mobilise community ambassadors, namely individuals who are effective at sharing information through word-of-mouth. J-PAL affiliated researchers conducted a randomised evaluation in Haryana in which they asked households to help identify people in the community who are good at spreading information, and then sending monthly text messages about vaccination to both these nominated “ambassadors” and the caregivers of children who need immunisation. This intervention was found to increase full immunisation rates by 25 per cent.

Thus, state governments that are grappling with the challenge of low immunisation rates in specific pockets of the state can consider interventions such as leveraging community ambassadors and giving small incentives to parents for each immunisation dose received by the child.

While the Indian healthcare system continues to reel under the pressure generated by the COVID-19 pandemic, it would be good to identify quick win solutions that can help prevent a complete derailment of our health targets. Cost-effective and scalable solutions that have been rigorously tested can play an important role in informing the health strategy of state governments.

The application of evidence cannot be a blind copy-paste but will need to be assessed on the basis of its suitability for answering local challenges, and then adapted for the context. Globally informed and locally grounded solutions may be the need of the hour to allow us to remain on track for achieving our health goals.


About Author
Shagun Sabarwal
Shagun Sabarwal Director of Policy, Training and Communications J-PAL South Asia

Shagun Sabarwal is Director of Policy, Training and Communications at J-PAL South Asia, and Director of the CLEAR South Asia Centre.

She leads the advancement of J-PAL South Asia’s partnerships with governments, donors, civil society organizations, and J-PAL affiliates to establish new research, disseminate policy lessons, and scale up successful social programs. She also provides strategic and technical leadership to J-PAL/CLEAR South Asia’s capacity building engagements, working closely with public, private, and social sector stakeholders to build a strong monitoring and evaluation ecosystem in South Asia. She is currently a principal investigator for research on the adaptation of the Graduation approach by governments, and on enhancing frontline health worker motivation and performance in India.

Prior to joining J-PAL, Shagun was an Evaluation Specialist with 3ie and a Postdoctoral Fellow at Population Council. Her previous work has included research on maternal and child health, adolescent health, and intimate partner violence. She completed her doctorate in public health from Harvard University.