Nexus of Good: Worth replication

In a district like Nandurbar (Maharashtra), imparting health services to the tribal population is a stupendous task because of the poverty, illiteracy, remoteness and unwillingness to mix with the mainstream of society. The lack of proper roads in the inaccessible regions and the mountainous terrain makes the problems more severe. Most of the PHCs lack requisite staff, well-maintained buildings and staff quarters. The number of medical personnel available is below the national average.

Weakening immune system, compounded by underlying medical conditions like Sickle Cell Anemia, heightens the severity of the infection and increases the mortality rate. The spread of COVID-19 among the elders would have put the entire generation at risk.

In the absence of any industry in the vicinity of Nandurbar District which would have been capable of generation and supply of oxygen in the case of urgency, alternative solutions to the emerging crisis were required. The District Collector Rajendra Bharud recognised all these problems. He had the foresight to make the district self-reliant not only in terms of oxygen requirement but also in other necessary preparation to fight COVID-19.

There wasn't a single liquid oxygen plant or tank in the district before the pandemic outbreak the previous year. However, the doctor-turned collector envisioned the Coronavirus threat of the future and the effects of weak health infrastructure in the district.

Nandurbar didn't do what the others did. After a steady decline in the cases in the first wave, as well as the assurance from Central Government regarding the vaccination programme, many district administrations, dismantled their COVID-19 facilities. Bharud kept an eye on events in America and Brazil that were facing a massive surge. He wanted to be prepared in case a similar surge took place in the district. Accordingly, District Planning and Development Council (DPDC) allotted Rs 85 lakh from the DPDC fund for the installation of an oxygen plant. In September 2020, the district administration installed the first oxygen plant with a capacity to produce 600 litres per minute. Forecasting the surge, the district administration went ahead to install another plant of similar capacity at the district hospital by using funds from State Disaster Relief Fund and Corporate Social Responsibility.

When the second wave hit Maharashtra, Nandurbar reported as many as 1,160 cases in a span of 24 hours on April 7, 2021. The district administration installed another plant at Shahada block in few days. At present, with the proactive effort, the total oxygen capacity in the district is 1,800 litres per minute. By adding two more plants at Navapur and Taloda with a combined capacity of 1,200 litres per minute, the total capacity of oxygen generation will reach 3,000 litres per minute by May 20, 2021.

Availability of funds is always a crucial component in setting up a robust healthcare structure including ambulances, ventilators, beds, oxygen plants, vaccines, medicines, staff, a website, and control rooms in every block. Dr Bharud used a combination of resources, including District Planning and Development Council (DPDC) funds, State Disaster Relief Funds, Local Bodies' Cess and CSR to meet expenses.

Apart from setting up oxygen generation plants, many steps were taken by the administration to fight the pandemic. Nandurbar had to depend upon GMC Dhule to get swab samples tested in the initial days of the pandemic. The administration installed its own RT-PCR lab with a capacity of testing 2,000 samples per day. Keeping in mind the second wave of Covid, the testing capacity was augmented with the addition of a second RT-PCR machine of the same capacity.

Schools and community halls were converted into COVID-19 centers. The administration set up 7,000 beds just for isolation and 1,300 beds for active treatment.

During the first wave, the district had faced a massive crunch in terms of frontline doctors. Since there are no medical colleges in the region, finding experts was a challenge. So, all local doctors were roped in and were trained to perform vital procedures of COVID-19 treatment such as intubation and monitoring of oxygen levels.

The health department has to bear the burden of data management, inventory management etc. at DHC, DCHC and CCC. Hence, the teachers, staff from ITI instructors etc. have been made available for the purpose.

Considering the future demand, 27 ambulances have been arranged with CSR funds; four ambulances have been hired with the help of Nandurbar and Shahada municipal councils while 16 ambulances have been purchased from Local Cess Funds. In addition to this, two dedicated hearse vans have been made available to the Municipal Council for transporting dead bodies.

One of the early steps taken by the administration was the creation of a website and control room to help control the panic and systematically guide the citizens. This would also ensure that people were not running from pillar to post in search of beds. The website www.ndbcovidinfo.com is set up and is updated in real-time to let people know about bed availability, COVID-19 test reports, ambulance status and nearest vaccination booth status etc. Due to the user-friendly design of the website, the complaints of citizens regarding the non-availability of information have been drastically reduced.

Control rooms (24X7) had been established in all six talukas in the district under the supervision of the Incident Commander as well as at District Headquarter under Additional Collector. FDA officer was also made available with the control room for mitigating any shortage of medicines as well as oxygen. District administration has provided four separate helpline numbers. A separate logbook is being maintained for calls received and action taken on it.

Railways has turned 21 coaches into isolation wards at the request of the state government in Nandurbar. There are 16 beds in each coach. The isolation coaches have been covered with layered gunnies and a water drip system to lower the temperature, making it suitable for the use of COVID-19 patients.

The ongoing small but effective practice of appointing nurses was started last year in Nandurbar. One nurse is appointed for 15-20 patients. These nurses have to monitor the requirement of oxygen every 2-4 hours, round the clock. They have the discretion to increase or decrease the flow depending on the patient's need.

The district presently has 52 government and four private vaccination centers. Out of the three lakh individuals aged above 45, one lakh have already received the first dose. This is despite the lack of awareness around vaccination. Efforts have been made to reach out to the target group Instead of calling people over for vaccination as a part of 'camp approach'. This way, people didn't have to travel on hilly terrains. Teachers and sarpanches were deployed to spread the word about the seriousness of the situation.

The district has managed not only to control the positivity rate but also slash it by 30 per cent. The single-day spike is reduced from 1,200 to 300 i.e. by 75 per cent by various active interventions at local levels.

With his committed team of officers, doctors and paramedics, Dr Rajendra Bharud has demonstrated that even an unprecedented crisis like COVID can be managed with foresight, meticulous planning and execution. What they have done is eminently replicable and presents an excellent example of the Nexus of Good. This model can be and should be a lesson to other districts in the country.

Views expressed are personal