Coronavirus disease (COVID-19) was first identified in Wuhan, China and then rapidly spread all over the world. The World Health Organization declared a pandemic on March 11, 2020 as a result of COVID-19. As it has caused substantial morbidity and mortality, most countries took several measures to control its spread, including India. As of now, India has witnessed three major waves of COVID-19. Several measures like nationwide lockdown, active case finding, contact tracing, home isolation, and vaccination were taken. There was involvement of multiple sectors (including private and government) and community participation. During the pandemic, I was posted at a primary health centre in a rural setting in India. A rural primary care setting has its own limitations. All the steps taken had several challenges at the grassroots level. Therefore, through this article, I highlighted the challenges faced during the implementation of steps taken to battle the pandemic and the outcome.

In December 2019, the World Health Organization learned of reports of a cluster of ‘viral pneumonia cases of unknown origin’ in Wuhan city, People’s Republic of China[1]. On January 30, 2020, the Director-General of the World Health Organization declared the outbreak of a novel coronavirus that was named 2019-nCoV at the time as a Public Health Emergency of International Concern[2]. On the same day in India, Kerala state’s Ministry of Health and Family Welfare reported the first case of 2019-nCoV from a student who had travelled from Wuhan city[3]. On March 11, 2020, the World Health Organization declared a pandemic as a result of coronavirus disease 2019 (COVID-19)[4]. On the same day, the Government of India requested state governments to invoke the ‘Epidemic Act 1897’ to address the COVID-19 emergency, and it was made a notifiable disease[5]. As of now, India has witnessed three major waves of COVID-19 in July to October 2020, April to May 2021, and January to February 2022[6]. India had a total of 44658365 COVID-19 positive cases and 530479 deaths (1%) through November 4, 2022[7].

The Indian health system in rural communities consists of a three-tier system with three levels of health care facilities: Primary level [includes sub-centres/health and wellness centres, and primary health centres (PHCs)]; secondary level (includes community health centres); and tertiary level (includes district hospital and medical colleges). During the period of the COVID-19 pandemic, I was posted as a postgraduate trainee at a PHC in a rural setting of Haryana state (India). The workforce at the PHC includes a medical officer-in-charge, staff nurses, lab technician, pharmacist, health supervisors, and supporting staff for sanitation and security. This PHC is affiliated with an academic institute. Therefore, it has undergraduate and postgraduate students posted for training purposes. Under this PHC there are 12 sub-centres. A subcentre is the most peripheral contact point and has a workforce of two multipurpose health workers [male multipurpose health worker (MPW) and female MPW]. Every village has Accredited Social Health Activists (ASHAs) who are honorary volunteers from the community and act as a link between the community and the healthcare system. This PHC caters to a population of around 50000 residing in the 17 villages and has 47 ASHAs. The medical officer’s role in COVID-19-related activities in a PHC were in planning and execution of active case detection and surveillance, contact tracing, monitoring/management of COVID-19-positive patients, and the vaccination program against COVID-19. I had the opportunity to closely see these steps taken and the challenges faced for the COVID-19 pandemic response at the grassroots level[8]. This article highlighted the issues faced along the journey and their outcomes.

At the grassroots level, we faced several challenges; some were managed and some were not. Initially many of the MPWs and ASHAs were hesitant to visit the households of any COVID-19-positive case. Many of the healthcare workers had comorbidities. The lead was taken by the medical officers and young healthcare workers in the field. Initially, to reduce the exposure we reduced the number of staff by half, and workdays were changed to alternate weeks. As the understanding of the disease improved, the involvement of the healthcare workers and the cooperation from the community increased. There were steps taken to protect all healthcare workers from COVID-19 such as the use of chemical prophylaxis (hydroxychloroquine tablets), PPE (gown, face shield, N95 mask, shoe cover, gloves, and head cover), and the introduction of the vaccines. Despite all these measures, the number of positive cases among healthcare workers rose substantially. This caused an acute shortage of staff. During this period, we learned task shifting and task sharing, which were done by training all the staff in COVID-19-related activities. Sometimes lab technicians and support staff were borrowed for a day from the neighbouring PHCs.

Later we trained our staff nurses in conducting rapid antigen tests and sample collection for RTPCR. The available trainees (students) at the PHC became involved in contact tracing and follow-up of home-isolated patients via telephone. Healthcare worker burnout and anxiety was real during the pandemic. To tackle this issue, a telephone helpline handled by a professional psychiatrist and psychologist was launched by the state government. This helpline also helped the staff, patients in isolation, and citizens to mitigate stress through online counselling. This was a commendable and well-appreciated initiative to provide psychosocial support. The government of India launched an insurance scheme for healthcare workers fighting COVID-19 (Pradhan Mantri Garib Kalyan Package) to provide comprehensive personal accident coverage of INR 50 Lakh (USD 60446). The healthcare workers included community healthcare workers (ASHAs, MPWs), hospital staff (doctors, nurses, paramedics, technicians), and supporting staff of sanitation and helpers. This scheme was extended to private healthcare workers who may have been in direct contact or at risk of COVID-19[25].

After a few attacks of healthcare workers in India, there was the promulgation of an ordinance to amend the Epidemic Diseases Act of India, which was approved on April 22, 2020 to protect the health workers and property including their living/working premises against violence[26]. To boost the morale of healthcare workers, they received appreciation from the community, national leaders, and compliments from the media.

During community surveillance, we did receive a few false alarms raised by people. We started verifying the calls by the MPWs and ASHA. In a few areas, we did face some resistance to active case-finding surveys from the community. Help from the police and sarpanch were required to resolve the issues. Contact tracing and active case finding were highly resource-demanding activities, which were not useful in the later phase of the pandemic as community transmission had occurred. Despite knowing the fact that a substantial proportion of COVID-19 cases are asymptomatic[27], we continued the practice of symptomatic screening and contact tracing for a very long time. Moreover, the number of symptomatic cases during the peak of the COVID-19 wave were overwhelming for our healthcare workers to trace.

Home isolation also had its own challenges. In the villages, isolating a homemaker was a challenging task as women in villages are primarily involved in taking care of children and livestock. Isolating them for 1-2 wk was a major concern for their children and livestock, which are solely dependent on them. Furthermore, it was difficult to keep farmers away from their farmland because they needed to go to the field daily for irrigation and crop management. Thus, we asked for help from the village sarpanch, the patient’s neighbours, or relatives to provide food and basic needs to the dependents. Our MPWs also frequently visited the patient’s house to check on the dependent’s health. Not only that, but a daily phone call was made at the PHC to check the patient, and their family’s daily health status was updated over the phone. Home isolation was also challenging in cases where a patient did not have a caregiver, did not have a separate toilet in the house, had mental illness, or was experiencing homelessness. Hence, facility-based isolation was most suitable for these kinds of patients. Strict isolation was enforced by the head of the villages, police, and higher authorities as some of the quarantined patients and contacts were not following the isolation order.

We also found that a few patients provided the wrong address and mobile number during the COVID-19 testing, which caused problems in contact tracing later, if the result is positive. To tackle this, we started checking the address with a valid identity card at the time of testing. It was also found that COVID-19-positive patients were tested at multiple health facilities to get a negative report as soon as possible due to requirement to go back to work, double confirmation of diagnosis, a fear of COVID-19, and to confirm recovery. This also increased the burden on the healthcare system as their names were duplicated in the computer systems. Then, the government issued new guidelines stating that the retesting of COVID-19 was not required at the end of the isolation period. This solved the issue of multiple testing for COVID-19 and reduced the workload.

We faced a limitation of space at the PHC due to the creation of space for donning & doffing area for PPE as well as an isolated area for COVID-19 testing. Eventually, after a discussion with the higher authority, a separate COVID-19 testing booth was provided to overcome the limitation. With limited space, it was difficult to maintain physical distancing for the inpatient services and at the sites of COVID-19 testing and vaccination. We faced another challenge of training all the healthcare workers to use smartphones and various applications (like Co-WIN and WhatsApp), which were used for official communication/reporting, sharing the geo location, and vaccination details. For this, we conducted several training sessions for them at the PHC. In the initial period, there were various guidelines related to testing strategy, isolation and quarantine, clinical management of COVID-19, etc. issued by multiple institutions or organisations that created confusion among healthcare workers. Then there were national guidelines released, but all of these guidelines kept changing rapidly with advancing knowledge of the disease. We found it quite challenging to implement the newer guidelines in the community in a short period.

The above steps taken were to break the chain of transmission and to assess the extent of COVID-19 infection in the community. Frequent estimation of seropositivity was a crucial indicator[28]. In our rural setting of Haryana state, the seropositivity during April to May 2021 (the initial phase of vaccination against COVID-19) was 59.3%[29]. The seropositivity among vaccinated and unvaccinated groups during July-August 2021 was 65.4% and 57.8%, respectively[29]. When we look at the national level, the seropositivity in India during May-June 2020 was found to be 0.73%[30], and it increased exponentially to 20.7% in the first wave and to 69.2% during the second wave of COVID-19[31]. Even during the nationwide lockdown there was a substantial increase in the test positivity rate[32].

The major steps included nationwide lockdown and COVID-19 vaccination. The nationwide lockdown may have been effective in enhancing the preparation (procurement of resources and preparedness for logistics and health infrastructure) and capacity building. The collateral consequences of lockdown were seen in a few unpublished research studies that were conducted in our setting and found a significant reduction in the coverage of routine immunisation for children and a substantial reduction in the utilisation of maternal care services during the lockdown. It also affected the follow-up and medication adherence in patients with tuberculosis or non-communicable diseases. Vaccination against COVID-19 may have been effective in reducing the severity of the disease in an unexposed person. Currently, the evidence suggests a pressing need to revise this COVID-19 vaccination strategy in India[33]. In the race of the COVID-19 vaccination drive, the single best vaccine against COVID-19 was not selected. Acknowledging the effectiveness of natural immunity was not accomplished. The COVID-19 pandemic had a short-term positive effect on the environment[34] and was a boon for promoting digital platforms/interventions. Mass-level promotion of health and hygiene could have a direct or indirect effect for controlling other infectious diseases.

Despite taking various steps to combat COVID-19, we may have not been able to prevent or control the waves of COVID-19. COVID-19 exposed the weaker links of our healthcare system, which provides us with an opportunity to strengthen the rural healthcare system for the future. The subject of public health in India is dealt by the state, therefore there could be variations across the states of India. However, the strategy remained the same across the whole of India, which was a five-fold strategy of test-track-treat-vaccinate and COVID-19-appropriate behaviour. Perhaps a concurrent evaluation of each step/strategy would have provided better learning and understanding.

The COVID-19 pandemic affected all levels of healthcare. We witnessed the brink of the breakdown of the health system, especially during the second wave when there were shortages of medical oxygen and beds in hospitals. We faced several challenges but never stopped healthcare services and fieldwork. We saw a huge and active collaboration of multiple sectors to combat this disease. During the COVID-19 pandemic, we saw an approach involving an empowered community, and multisectoral coordination, which are said to be the pillars of primary health care. COVID-19 has taught numerous lessons to everyone.

Due to the selective focus on COVID-19-related activities, other routine healthcare services for maternal and child health and major illnesses like tuberculosis, and non-communicable diseases were affected. The pandemic affected physical health and other domains of health (psychosocial, spiritual). COVID-19 has also affected the education and financial system of our society. It does provide a picture of the extent a disease affects human life.

The current healthcare system of rural India was not adequate to contain the transmission of COVID-19 and was not able to manage the load of COVID-19 patients. There is a paramount need to strengthen the infrastructure, laboratory services, regional surveillance systems, medical care, and skilled workforce. Currently, the healthcare system in rural India is heavily dependent on grassroots workers like ASHAs and MPWs. During the pandemic, ASHAs played a pivotal role in the management COVID-19 pandemic in rural areas. Furthermore, improving the support and recognition of grassroots workers are needed.

I would like to thank my teachers and colleagues. I would like to express my gratitude to all the staff of the primary health centre and all the grassroots health workers.