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Observational Study
. 2022 Jul 27;17(7):e0269674.
doi: 10.1371/journal.pone.0269674. eCollection 2022.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

Rasmi Avula  1 , Phuong Hong Nguyen  1 , Sattvika Ashok  1 , Sumati Bajaj  2 , Shivani Kachwaha  3 , Anjali Pant  1 , Monika Walia  4 , Anshu Singh  5 , Anshuman Paul  6 , Ayushi Singh  7 , Bharati Kulkarni  8 , Deepak Singhania  9 , Jessica Escobar-Alegria  10 , Little Flower Augustine  11 , Madhulika Khanna  12 , Maitreiyee Krishna  7 , Nandhini Sundaravathanam  13 , Prakash Kumar Nayak  8 , Praveen Kumar Sharma  10 , Prerna Makkar  7 , Puspen Ghosh  14 , Sadhana Subramaniam  11 , Sai Mala  2 , Rakesh Giri  11 , Sameeksha Jain  15 , Santosh Kumar Banjara  11 , Sapna Nair  16 , Sebanti Ghosh  10 , Suman Das  14 , Sumeet Patil  6 , Tanmay Mahapatra  14 , Thomas Forissier  10 , Priya Nanda  17 , Suneeta Krishnan  17 , Purnima Menon  1
Affiliations
Observational Study

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

Rasmi Avula et al. PLoS One. .

Abstract

Background: Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

Methods: We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2.

Results: In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges.

Conclusions: Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Phone survey in India: State and sample size.
ANM: Auxiliary Nurse Midwife, AWW: Anganwadi Worker, ASHA: Accredited Social Health Activist. BR: Bihar, CG: Chhattisgarh; MP: Madhya Pradesh; OR: Odisha; TG: Telangana; TN: Tamil Nadu; UP: Uttar Pradesh.
Fig 2
Fig 2. Anganwadi worker service delivery during the COVID lockdown in April 2020 and in July/August/September 2020, by state.
A. Service delivery: Opening of village center, food supplementation, home visits, and conducting VHND. B. Service delivery: Counselling, micronutrient supplementation, growth monitoring and support for immunization. BR: Bihar, CG: Chhattisgarh; MP: Madhya Pradesh; OR: Odisha; TG: Telangana; TN: Tamil Nadu; UP: Uttar Pradesh; VHND: Village Health, and Nutrition Day, IFA: Iron-Folic Acid. Note: Anganwadi workers were not asked about distributing IFA supplements in Uttar Pradesh.
Fig 3
Fig 3. Services disruption and restoration during the COVID pandemic: Results from health management information system data.
VHND: Village Health, and Nutrition Day; ANC: Antenatal Care; IFA: Iron-Folic Acid.
Fig 4
Fig 4. Adaptations made to provide services during COVID-19 pandemic (April 2020).
VHND: Village Health and Nutrition Day; FLW: Frontline workers; ANC: antenatal care; PNC: postnatal care; IFA: Iron-folic acid. Note: Data on adaptations to provision of IFA are based on Auxiliary Nurse-Mid-Wife reports in Uttar Pradesh.
Fig 5
Fig 5. Challenges faced by Anganwadi workers (AWWs) in delivering services during COVID-19 (April 2020).
Note: Anganwadi Workers: Frontline workers in India’s Integrated Child Development Services Scheme.
See this image and copyright information in PMC

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