Written by Vrishali Shekhar and Pooja Haldea
India is facing a health crisis, which isn’t to do with COVID-19. Factors such as the nationwide lockdown and re-routing of resources towards the curtailment of COVID-19 have caused a severe disruption of non-COVID essential health services that are indispensable towards maintaining progress in health indicators.
In the month of March alone, there has been a disturbing drop in maternal health services with a decrease in attended skilled home delivery and institutional delivery by 16.2 per cent and 7.7 per cent; child immunisation in BCG and MMR by 7.5 per cent and 34.3 per cent, and outpatient treatment of major non-communicable diseases such as oncology and heart ailments by 64 per cent and 51.8 per cent respectively. Unchecked, these are bound to have long-term consequences on non-COVID mortality and morbidity.
While supply side issues such as inadequate health facilities, over-stretched human health resources and insufficient funding strain the health system, we cannot overlook the behavioural tendencies of individuals and communities in influencing their demand for health. Fear and threat perception, social norms, choice and cognitive overload and scarcity of resources are some of the heuristics that play a key role during a health emergency like COVID-19.
One of the central emotional responses during a pandemic is fear. Negative emotions resulting from threat can be contagious, and fear can make threats appear more imminent. Negative emotions get accentuated by misinformation and rumours on social media that scandalise the number of deaths as opposed to recovery rates. The fear of physical contact is replacing the traditional handshake with “namaste” even in the Western countries as the new social norm. Similarly, conforming to herd behaviour by staying indoors due to the fear of virus transmission may cloud out individual needs and demand for healthcare such as rescheduling vaccination appointments.
Conservatively, five million estimated children have missed out vaccination since the pandemic in India. This is a disturbing trend in India, where the two leading causes of child mortality are due to vaccination preventable diseases such as pneumonia and diarrhoea, thus stressing the need for prevention and management of child health protection.
The problem of choice overload becomes pertinent today where people are forced to use their limited cognitive resources to process pandemic information. Pregnant and lactating women are mentally burdened with multiple child birth and rearing practices. Crowding her intellectual space with COVID-19 information could act as short-term barriers and tunnel her limited attention towards dealing with the emergency rather than adhering to preventive health practices.
A study estimates a 10 per cent decline in the coverage of maternal health services during COVID-19 in low and middle income countries resulting in a worrying additional 28,000 maternal deaths and 168,000 newborn deaths. MMR at 122/100,000 live births in India must focus on the continuity in the demand for preventive maternal services.
Another widespread reason behind cognitive overload is poverty. The lockdown has resulted in the loss of livelihoods for the disproportionately large informal workforce in India. People faced with economic hardships and scarcity find that the struggle to survive consumes their attention, often leading to unhealthier behaviours and accentuating health inequalities. For example, the health crisis has all the makings of a perfect storm for exacerbating the malnutrition amongst the most vulnerable, i.e women and children. The disruption of food supply chain and the inadequate food safety relief packages explain the supply side issue of the nutrition crisis.
However, the struggle to survive with scarce means has an income and substitution effect of demand for cheap calories rather than nutrient-rich foods. Moreover, in these times of economic despair, the intake of micronutrient supplements for women and micronutrient-fortified products for children may be forgotten. Additionally, mothers may be concerned about passing the coronavirus to their infants through breast milk, an essential ingredient to combat malnutrition. This is significant in India where 69 per cent of children under five die from malnourishment and every second woman is anaemic.
Policymakers should focus on designing solutions that help people achieve long terms goals of health and wellness. Policies must focus on minimising the efforts and barriers while making a choice about healthy behaviour. During pandemics where people are less inclined to make an active choice about their health, it is important to make their “default” option an easy and healthy one. The focus must be on using choice architecture that leverages the propensity of humans to stick with a decision that is already made, particularly by a trusted source such as a health practitioner. Hence supporting a physician communication strategy that presents vaccination as the default and structuring the vaccination discussion as an opt-out, not an opt-in, may help to minimise parental autonomy on child’s health.
Further, reducing administrative burden and simplifying processes for accessing health services is also critical. The pandemic has resulted in a disturbing trend in the rise of mental health issues and suicide rates. Creating “friction costs” by making it more difficult to obtain large amounts of over-the-counter drugs can be effective in reducing overdoses and suicide rates.
Amid the coronavirus outbreak, regulatory guidelines were issued by the Ministry of Health and Family Welfare and NITI Aayog to promote contactless telemedicine in India. Odisha has been the first to offer free teleconsultation to decongest the healthcare facilities, reduce the barriers of poor accessibility and minimise the exposure of viral transmission. As an example, practicing social distancing may be difficult for pregnant women, most of whom require weekly to monthly prenatal visits during pregnancy and may experience severe coronavirus symptoms due to their state of relative immunosuppression as compared to their non pregnant counterparts. Use of telemedicine may be a good way to limit her exposure while ensuring antenatal care.
Further, frontline workers can be trained on how to counsel using digital media. An example would be making available WhatsApp videos on critical health behaviours that they can forward or show to the community members.
Lastly, we need to find share of voice for other critical health behaviours amidst the COVID noise. We must look at how we can make risks of other diseases more salient (for e.g., highlighting that the chances of a child dying of measles without the MMR vaccine is higher than the risk from COVID-19). We should also look at how we can build on the risks and behaviours that current pandemic has made salient, such as germ theory, mask wearing and handwashing, and use it to improve behaviours and outcomes in other diseases.
The need of the hour is to ensure that an episodic pandemic doesn’t dent the goal of “health for all”. The torturous future course of action must look towards integrating behavioural insights to mainstream health policymaking and care provision while countering the COVID-19 pandemic.
Shekhar consults with the World Bank on Social Protection, Health and Nutrition issues. Haldea is senior advisor at Centre for Social and Behaviour Change, Ashoka University
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