We conducted a cross-sectional study among supervisors and managers of primary health care facilities attached to medical colleges and institutions anywhere in India, either in the government or private setting. We collected the data for 7 days from April 24 to 30, 2020, through means of a web-based survey for self-assessment by PHC managers and supervisors. The preparedness domains assessed were infrastructure availability, health worker safety, and patient care [13].

We collected data through a rapid survey using a pretested Google Forms online digital questionnaire (Multimedia Appendix 1). A nonrandom convenient sampling method was used to select the study participants. A list of 60 faculty involved in the management and supervision of PHCs affiliated to the community medicine departments of medical colleges and institutes across India was compiled from an accessible private organization member database. These members were sent an invitation to participate in the study through email and instant messages containing the Google Form survey link. Since the sampling unit was a medical college or institution, we selected only one potential respondent from each site to prevent duplication.

Operations (functionality) of any specific health service through outpatient clinics conducted at the PHCs was assessed in terms of continuity of service provision to patients and beneficiaries at the time of the survey. Pre-COVID-2019 refers to the period of service delivery at the PHCs until February 2020. Post-COVID-2019 refers to the period of PHC service delivery at the time of the survey. Adequate ventilation refers to the availability of cross-ventilation with separate doors and windows at the site of service provision to the patients. Adequate handwashing facilities refers to the availability of running water and soap for patients. Adequate hand hygiene facilities refers to the availability of alcohol-based hand sanitizer for health staff.

The Google Form data was exported into Microsoft Excel 2013 (Microsoft Corporation) software and cleaned and analyzed using SPSS version 25 (IBM Corp). Results were expressed in frequency, proportions, and 95% confidence intervals for categorical variables, and mean for continuous variables. The significance of the difference between proportions was assessed using the chi-square test. A P<.05 was considered statistically significant.

The study was approved and exempted from full review by the Institutional Ethics Committee (F.1/IEC/MAMC/(73/01/ 2020/No68). The consent of the participants was implied as participation in the study was voluntary.

The maintenance of essential care health services on an outpatient basis during the aftermath of the COVID-19 pandemic is a major public health challenge. Our study findings indicate that the provision of essential outpatient health care service were disrupted in a significant proportion of PHCs across India with the onset of the COVID-19 pandemic and the rapid escalation of cases. Furthermore, suboptimal infrastructural capacity at most PHCs, poor ventilation, negligible airborne infection control measures, and constraints in achieving minimum physical distancing requirements among patients needed to reduce the risk of COVID-19 transmission [14] possibly precluded the expansion of screening and referral of presumptive COVID-19 cases at these sites.

The public health measures undertaken for containing the COVID-19 epidemic in India significantly contributed to the decline in the provision of essential services at the PHCs. First, India enforced a strict nationwide lockdown from March 23, 2020, onwards (which is continuing at the time of writing), including ceasing all public transport, resulting in diminished health care accessibility [15]. Second, there was a diversion of health care staff, especially doctors and nurses, for COVID-19–related duties. Moreover, even frontline community health workers, including the accredited social health activists, were engaged in the surveillance and contact tracing activities related to COVID-19 [16]. This resulted in the absence of community mobilization of women and caregivers for continuing with immunization and regular ANC services at the PHCs. Third, the feasibility of separating waiting areas for immunization services from curative services and adherence to physical distancing at the health facilities as recommended by the WHO [17] was not possible at several sites due to infrastructural limitations. Fourth, parents of immunization eligible children and antenatal women possibly refrained from visiting primary health facilities due to increased risk perception of contracting the coronavirus infection from other patients.

Primary care providers are known to be at increased risk of getting infected with new infectious diseases, especially when handling patients with acute respiratory illnesses during epidemics [18,19]. The inadequate availability of PPE for health care providers during the COVID-19 pandemic has also been observed worldwide [20]. Under these circumstances, the allocation of PPE has been subject to expert criteria that recommend limiting the provision of N95 masks to only those health care providers who are directly involved in the management of confirmed COVID-19 cases [21]. Consequently, primary care providers in resource-constrained settings, working in enclosed small clinic spaces that lack adequate ventilation and are likely overcrowded, are rendered highly vulnerable to COVID-19 in the absence of effective PPE provision. In our analysis, we found that only 1 in 2 medical colleges and institutions were able to provide N95 masks to the health care providers at their primary health care facilities. However, the adequacy of the supply of N95 masks was not assessed in this study.

According to the report of the National Health Policy (2017), only 1 in 5 Indians in rural India use outpatient services at public (government) health facilities due to perceived deficiencies in standards of care arising from dilapidated infrastructure and nonavailability of essential services and drugs [22]. Considering the deficiencies in physical infrastructure at PHC sites combined with the ubiquitous availability of cheap mobile telecommunication services, the potential role of telemedicine services to maintain continuity of care should be considered in such settings [23].

Finally, the functionality of fever or flu clinics is considered a crucial primary care role in the preliminary assessment, counseling and reassurance, and referral of patients reporting with influenza-like illness during pandemics similar to COVID-19. However, in India, government guidelines have stipulated the functioning of fever clinics at primary care facilities subject to the availability of adequate space [7]. Nevertheless, in this study, we found nearly 3 in 4 institutions were operating fever clinics at their PHC facilities despite the obvious infrastructural limitations.

First, due to the convenient sample, representativeness was limited as a majority of sites were restricted to Northern India. Second, the survey was based on self-assessment, which can be subject to bias. Third, we conducted a cross-sectional survey and did not assess prospective change in the OPD clinic operations and service provisions during the COVID-19 epidemic in India. Fourth, we did not consider factors related to facility preparedness like health education and the monitoring and surveillance of health events due to the absence of objective evaluation through an external observer. Fifth, reasons for nonfunctionality of the OPD clinics, which were either due to logistical constraints or because of nonreporting by patients and beneficiaries were not ascertained in this survey.

Existing PHC facilities in India providing outpatient care during the COVID-19 epidemic are constrained in their functioning by weak infrastructure contributing to suboptimal patient safety and infection control measures. Most PHCs reduced essential OPD services and instead were running dedicated clinics for screening and referral of patients with suspected COVID-19 reporting with symptoms of influenza-like illnesses. However, health care managers must address the risks of nosocomial infection in these settings when operationalizing simultaneous COVID-19 screening and special OPD clinics for NCDs, ANC, and care for children younger than 5 years that cater to populations highly susceptible to COVID-19 [24].

The COVID-19 pandemic is still ensuing, and there are projected second waves and considerable time until development of any effective vaccine, generation of herd immunity, and ultimate pandemic resolution [25]. Findings from this study emphasize the need for effective planning, communication, and coordination between the centralized health policy makers and health managers working at primary care settings to ensure overall preparedness. For instance, the government of India, after 3 weeks of lockdown (April 14, 2020), issued a general guideline to the states to make best efforts toward continuing with essential health services at peripheral health facilities as per their feasibility [26]. Subsequently, on May 20, 2020, the government of India issued a comprehensive guidance note that re-emphasized the need for continuing both facility and outreach immunization services except in the containment zones (areas having a relatively higher number of COVID-19 cases and shorter time to doubling of cases) [27,28]. These lessons are suggestive of the need for maintaining effective channels of health communication between various stakeholders for ensuring continuity of essential services during any future waves of the COVID-19 pandemic.

In the medium- and long-term, governments both at the state and center should considerably invest in infrastructure, capacity building, and the strengthening of primary health care services to ensure their effective functioning during public health emergencies [29]. Under the Ayushman Bharat National Health Protection, the government of India has envisaged the upgrading and developing of 150,000 primary care facilities throughout India [30]. Nevertheless, to strengthen PHC in India and significantly augment their capacities and roles during pandemics, an emphatic focus on infrastructure development, especially in terms of spacing, ventilation, and infection control, warrants high prioritization.