Chennai: The scale of disruption in routine health services in the wake of the COVID-19 pandemic in India is even larger than was earlier estimated, new official data show. April 2020 saw a higher fall in immunisations, maternal health interventions and treatments of conditions including kidney failure and cancer than in March 2020, while some indicators showed signs of revival in May and June. These delays could lead to long-term health effects, experts say.

The National Health Mission’s Health Management Information System (NHM-HMIS) tracks indicators on utilisation of health services from over 200,000 health facilities, from primary health centres to district hospitals in every district of the country and is updated nearly every day. These health facilities are predominantly in rural areas and in the public sector. Earlier this year, March 2020 data, after just a week of the lockdown, showed that health services were severely curtailed in the country as compared to previous months in 2020 and to March 2019. Subsequently, the NHM stopped publishing these data. This week, the NHM published updated data for April, May and June.

Fewer women accessed maternal healthcare in March and April 2020, when the lockdown was at its strictest, data show. Routine checks on pregnant women and tests that are vital for the health of the mother and child were missed, and the number of institutional deliveries fell; there were over 580,000 fewer institutional deliveries in April than in January, which could indicate that many more women had potentially unsafe deliveries at home. The number of women who received benefits that they are entitled to under the Janani Swasthya Suraksha Yojana [Mother’s Health Protection Programme] has also declined to under half of its January level, the data show.

Source: National Health Mission’s Health Management Information System data

The NHM-HMIS numbers also point to a disruption in immunisation services, which if not restored, could have potentially lifelong impacts on children, experts said. The number of children who got the Bacille Calmette-Guérin (BCG) vaccine--which prevents severe tuberculosis--in April was half that of the number for January--that is, 1 million fewer children got the vaccine that month.

Source: National Health Mission’s Health Management Information System data
Note: Pentavalent 1 is the first dose of a vaccine that protects against diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenza type B (Hib). Rotavirus 1 is the first dose of a vaccine that protects against the rotavirus which causes diarrhoeal infections

Even at the risk of infection, “we cannot delay polio, DPT [Diphtheria, Pertussis, Tetanus], hepatitis and pneumococcal vaccines”, Ravindra Chittal, consultant paediatrician and neonatologist at Hinduja Hospital and Lilavati Hospital, Mumbai, had told IndiaSpend in May 2020.

Outpatient attendance in April fell to half its January levels, NHM-HMIS data show, with 69 million fewer outpatient visits. This included outpatient treatment for serious conditions including cancer and acute heart disease. Doctors who have been observing this decline in their outpatient departments (OPDs) are aware of what this implies--a coming storm. “What we are already seeing is that when patients start to return to OPDs, they will have a much more dangerous and unmanaged form of the disease they were suffering from,” SP Kalantri, medical superintendent at the Mahatma Gandhi Institute of Medical Sciences in Wardha, Maharashtra, warned.

Source: National Health Mission’s Health Management Information System data

In April, inpatient treatment of serious communicable diseases declined by 60% over January levels, and the decline was greater among women than men, the data show.

Source: National Health Mission’s Health Management Information System data

Other worrying indicators from the data include a 45% decline in the number of patients registered for TB treatment and a 60% decline in the number of men being screened for HIV in June 2020, even as the lockdown was opening up, as compared to January 2020. The number of surgeries--both major and minor--also fell by over half in June as compared to January.

The NHM numbers do not show any sharp increase in deaths from any other disease or cause, but these immediate numbers do not show the long-term impact of, for example, a person missing dialysis treatments. Terming this disruption as “worrisome”, Madhukar Pai, director of the McGill International TB Centre at Canada’s McGill University, said in an email: “Every immunisation dose missed during this crisis might be a TB or a measles case in the future. Every patient not diagnosed with TB now, might end up with advanced disease with higher fatality in the future. If institutional deliveries have gone down, that increases the risk of maternal and newborn mortality.”

India will be lucky if it ends tuberculosis by 2035--a decade later than targeted--Pai had told IndiaSpend in May, pointing to an 80% drop in monthly notifications of TB because of COVID-19-related disruptions.

For public health and development experts, the potential harm to Indian health that these numbers indicate suggest reconsidering India’s COVID-19 response.

"Recent sero-survey evidence of COVID's low fatality rate in India calls for a reconsideration of some of the harsher measures that have been imposed, including those that contribute to the disruption of health services,” Jean Drèze, a development economist, told IndiaSpend.

“India cannot just focus on COVID-19,” Pai said. “Every effort must be made to resume routine health services, and build surge capacity to deal with all the morbidity that has been missed during the past few months.”

"Can the children who have missed immunisations be given booster shots? Are we at risk for disease outbreaks for measles and diphtheria because of missed immunisations? Have the mothers who had to deliver at home come through safely?” asked Keshav Desiraju, India's former health secretary. "They need to be immediately checked on. They’re going to have to take stock at the block level to see what has happened to all the people who missed their medications and treatments,” he said.

(Rukmini S. is an independent journalist based in Chennai.)

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Rukmini S

    An independent data journalist based in Chennai.