The Challenges of Frontline Health Managers during the COVID-19 Pandemic in India: A Framework Analysis Study

Coronavirus was rst ocially reported in Wuhan city of China in December 2019. As this novel coronavirus spread rapidly throughout the world, health care workers faced many diculties addressing the pandemic. In the present study, we explored the challenges faced by front-line health managers on human resource management, execution of the central policies, training and in formulating innovative approaches during the covid-19 pandemic in India. Methods: A qualitative study was conducted using framework analysis among front-line health managers concerning covid-19 management at the district level. We conducted 120 in-depth interviews (IDIs) among eight states with the use of an Interview guide. Results: The results are described under ve sections: First: 'challenges of front-line managers in policymaking and its execution' 'human resource management' 'gaps in local execution of central policies' 'challenges in training workforce and data management' 'innovative approaches adopted during COVID 19'. Conclusions: We observed that a centre-down approach was not appreciated much. Many participants felt that there was a need to understand the local context and appropriate amendment. The private system is a part of the Indian health system and can never be ignored, thus all guidelines should include the private system.


Introduction
Coronavirus was rst o cially reported in Wuhan city of China in December 2019. (1) As of March 2021, there were 117,644,542 con rmed cases and more than 2,612,360 deaths globally. (2) As this novel coronavirus spread rapidly throughout the world, health care workers faced a lot of di culties to address the pandemic. During this pandemic, frontline managers faced signi cant challenges on Covid testing due to inadequacies of test supplies, personal protective equipment (PPE), inadequate staff, logistic support, changing guidelines and nancial support etc. However, there are some other challenges associated with covid management for front-line workers such as lack of preparedness to respond to the new pandemic due to the absence of strategic policy, anxiety and fear among healthcare professionals and enforcing guidelines, etc.(3) (4) (5) (6) The coronavirus pandemic has the biggest public health challenges in this century, and it makes a dramatic loss of human life globally, as well as economically also. (7) As, India is the second-largest populous country, so it is a major challenge for those who are serving as front-line health managers to manage this pandemic effectively. (8) So in a country like India where there are still areas of unmet need and non-uniform public health infrastructure, this pandemic and the consequent response had certainly strained for the health care administrative system. (9) Problems in managing the pandemic in such contexts were extremely challenging for frontline managers like district health o cers, district surgeons, taluk health o cers, and other members of the District Task Force. There was a need to understand issues and challenges from their perspective including their priorities and the need for support to create knowledge that can be used to improve overall health system functioning. We, therefore, explored the challenges faced by frontline health managers on policymaking and execution, human resource management, execution of the central policies, training of front line workers and innovative approaches during the covid-19 pandemic at the district level.

Methods
We conducted a qualitative study, using framework analysis to explore the perception of frontline health managers concerning covid-19 management at the district level. We divided the country into four categories like North with Delhi, East with North East, West with Central India and South India. Two states in each zone with a selection of Delhi and Rajasthan as North states, Tripura and Orissa from East, Maharashtra and Gujarat from West. Kerala and Karnataka from the South were speci cally selected states. When we looked into the vulnerability index too these states represent all different vulnerability indexes. Three districts that fell in very high vulnerability/high vulnerability, medium/ low vulnerability and very low vulnerability were included. (10) This consideration of 2 states in each zone comes to 8 states and on an average with 30-35 districts in each state. The total numbers of districts of all these states were around 250. As per the thumb rule, if the total population is more than 100 and less than 500, so we took 10-20% of the population. So, we intended to take 10% of the district in each state. Making it 3 districts in each state. These districts are considered to include 1 very high vulnerability/high vulnerability, 1 medium/low vulnerability and 1 from very low vulnerability. As the total frontline line manager in each of the selected states will be around 60-70, we intended to take 20% (as per thumb rule, if the population is between 50-100, we need to take 20-30% of the total population) of the total Frontline managers. That is 20% of the district Frontline managers. It was ensured that in 3 districts, there will be at least 1 DHO, 1 DS and 1-2 others in the district task force who represent district administration other health care system was included. A total of 5 front line managers was selected in each district. We have also included 1 block-level manager to investigate their challenges, assuming they may be more complicated than those at the district level. So we consider ve managers in three districts and eight states which will make 120 samples in total with a 95% con dence interval and 50% heterogeneity the qualitative sample will be 100.
Data Collection: We conducted 120 in-depth interviews (IDIs) among eight states through the use of an Interview guide. (Table-1). The study was conducted between August to November 2020. Interviews were conducted in both local and English language and the duration was an average of 30-40 minutes. The in-depth interview had stakeholders mainly from the health system but also included 1-2 prominent people in district task forces who were part of decision making. After obtaining permission in-depth interview in person or on zoom or telephone were conducted by senior faculty. Since it was a multicentric study, so interviews were conducted by all authors among eight states. The authors have a variety of professional background, including public health and medicine.
The frame work were prepared looking into the situation by the expert committee for operational research of ICMR as follows: 1. How do stake holder ( manager at local) in uence the policy-the local manager needed to make the amendements based on local need and act aptly at the local level 2. How did the local manager manage the crux of the less of manpower. The local authority had to be oinnovative in management of human resources.

Analysis:
A framework analysis was carried out in this study. This approach is often used in applied qualitative research to in uence policy. The qualitative data has been analyzed deductively using a previously prepared framework which is based on the speci c objectives and speci c sub-domains. The analysis includes the following ve stages.(11) (12) 1. Familiarisation: In this step, all the recorded interview was transcribed and we read the eld notes, data set as well as related literature on covid management.
2. Identifying a thematic framework: In this step, we developed a framework analysis diagram on contest policy management, human resource management, training and data management, Gaps in local execution of central policies and Innovative approaches 3. Indexing: In this person, we applied the developed framework to the entire dataset.
4. Charting: In this stage, the relevant information was extracted and added to the thematic framework.
5. Mapping: In this last person, we explored the developed framework and revised it thoroughly. Ethical: Ethical clearance was taken from the nodal centre and each centre had the liberty to submit for expedited ethical clearance. During the interview, Participant consent was recorded and permission was sorted from the local state PI. The participant consent form was signed whenever there was a physical interview. As the nodal centre investigator is involved along with the other site PIs during the interview, exemption from the local ethical body was also possible.

Results
Two states form each of the 4 regions of the country taken up for the study are grouped based on the emerging themes. The column depicts the key thematic areas which arose after an iterative code categorization. Segregation and a tabular depiction show that maximum code contribution towards the key thematic areas was by the western region (33%), followed by the eastern (24%) and southern (23%) regions respectively. Moreover, the broad thematic contribution of responses of the frontline health managers towards the pandemic scenario and the situational factors which arose as an indirect consequence of the scenario; was the maximum as compared to the other themes. The summation table above broadly categorizes the broad themes into Positive and Negative arenas. The negative themes have been collated to include the Gaps in execution, Barriers, Issues with nance, challenges in managing data, Constraints among FLWs and other situational factors arising out of the Pandemic; although not directly related to it. Out of the total of 608 codes for negative themes, the western region was found to cater to more issues and challenges; which however was least with the southern part of the country. On the other hand, the positive thematic areas which included the reaction (Immediate), response (gradual), Strategic action plan and Surveillance have been better in the Southern and western region but least in North India. Although, there is no direct association between these, however, observation and percentages show that out of the total 1205 codes categorized into 10 broad themes, 608 were negative and 597 were positive.
Positive themes as depicted in green bars show that the representation in south is maximum followed by west; whereas, it is least in the north regions. The negative thematic representation of the blue bars in the backdrop shows a contrast scenario; with southern region having least contribution and western region with maximum.
The radar diagram on the left shows the negative thematic issues and maximum situational factors have contributed to these. Situational factors are those issues which have come up as an indirect consequence of the pandemic and not directly related to the health. The various codes for this are given in the table above. Besides, we nd, the eastern region to be having maximum gaps in execution, be it the guidelines or testing strategies or other deliverables. The western region has been shown to have maximum issues with situational factors and constraints among FLWs as regards to manpower shortage, incentives, over duties, fear, no quarantines etc. the southern region comparatively had higher issues with data management. We also nd that there were least issues with nance and its management among all the 4 regions.
The radar diagram on the right depicts the positive thematic areas and we nd west and southern regions contributing maximum towards the Response in the form of innovative techniques, local amendments and redistribution. On the other hand, the strategic action plan was well in the eastern region which includes good communication strategies, donations, doorstep delivery, use of past experiences, planned division of work etc. Southern region speci cally was able to react well in such situation by immediate decisions, Local level management, relying less on seniors for decision making and action.

Challenges in policy making and execution at district level
In majority of the states, the centre down guidelines were followed as provided mostly because of lack of autonomy for local decision making. However, Rajasthan was one such state where delegation of decision making was bestowed on the district o cials. The many confusions due to repeated change of guidelines posed an issue almost everywhere as the same had to be communicated till the grassroot level workers time and again.

Challenges with human resource at district level
Human resource was constrained not only owing to the fact that it could not meet up to the huge need that arose during the time but it also showed the dearth of health care workers as against requirement. The existing system was being strained with the workload and the situation also got di cult when staff themselves turned positive. The non-involvement of private sector from the start was also seen to pose a huge challenge in involving them later as many either refused or showed no interest to shoulder the burden.

Challenges in training and data management
Training was generally not considered as a major issue at almost all site. The concerns were mainly centred around the frequent change of guidelines. The fact that the local needs of the states were not taken into consideration especially with regard to management of tribal population, quarantine rules in high populous areas, containment issues etc posed a challenge to the frontline managers. There seemed to be data duplications at many sites as there was no clear guidance on the same. The most important observation as pointed out by frontline managers of various states was the fact that the IDSP needed rejuvenating in terms of manpower and resources.

Gaps in local execution of central policies
As local considerations were at a minimum in the central guidelines that were disseminated, it did pose a huge task to the district to go on with COVID activities with ease. From restricting the public against panic buying to allaying their fears, the district frontline managers found it a humungous task to take into the consideration the local needs as well execute the guidelines. Especially areas that were surrounded by both airport and seaport which saw doubling of workload alongside managing the migrants and community at large, it was indeed a requirement to have the necessary norms in place. At certain sites, alongside the main issues, the bureaucratic involvement posed a hinderance in ow of work.

Innovative mechanisms
These situational factors contributed to putting up some strategies of management i.e., reverse quarantine of individuals like the elderly thus preventing them from getting infected, formation of COVID armies for better surveillance and watch over activities, conduction of mock drills so as to better deliver the guidelines to the grassroot workers, involvement of local leaders which thus helped to gain better trust of community, regular media usage by interviewing the COVID survivors so as to allay fears and myths that developed around the infection etc. Usage of polio surveillance teams and their experience at certain sites helped to manage COVID related activities in the community in a better way. Such mechanisms put in place thus paved the way for better management of infection.
The workload during COVID however saw a distribution across various departments other than health majorly. The departments involved included the police, teachers, revenue department, NGOs, panchayat etc. While the direct health related workload was managed by the staff from public health sector, the other COVID related activities were managed by the rest of the involved departments ex: Food delivery was taken up by NGOs, contact tracing by teachers and police, revenue department for isolation and noti cation etc.
The digital platform was used to its maximum with regular online trainings for the workforce. At certain sites, training modules for various cadres was made so that it could be simpli ed and delivered effectively to various levels of workforce.
Evolving many technical committees at the district level helped for better distribution and management of workload. Experiences gained from management of health during oods and outbreaks such as Nipah were taken into consideration and similarly acted upon. Price capping was immediately brought up to ensure that it does not exceed buying capacity of individuals.

Discussion
The issue of COVID was global and there was management problem throughout the world. Most had issues of constraints and gaps in other countries too. [13] Our study also talks how the administration had issues of gaps in understanding and constrains of people and people management. But interesting is the diversity of India where you nd most south states tried to have positive response and north states were stating the problems more. Though as a country every aspect of administration worked to ful l the management of COVID but states with better resource earlier with health care could plan more positive approach as compared to states with not so good health care had to deal with negative form and getting it right was a big task. West region with growing economy and health care being better connected could cope in better way than eastern states. The whole concept was the understanding of health by adminisatrtion and political people, so whenever health had better literacy; the coping strategy as positive comments increased in the state. The different regions set different methods to cope the situations and the was expressed in global publication. [14] In most states some issue remained same but few states had speci c negative themes which were to be handled. So probably they didn't have time in limited period to handle more positive stratergy. This epidemic gave most states an outlook of their health system and made them understand their weak perspective in health system. Most negative themes were with constrains so the health system with constrains in front line worker had lot of issues to be dealt. Most positive themes were response so it is evident that with less contrains more response was possible. So its important as health system to clear the constrains in front line worker and front line manager.
Studies in the past have shown the inadequacies in our existing health system. The main challenges being workforce, infrastructure and out of pocket expenditure. [15] This study gave a deep understanding of various situational factors existing in the health care system that both contributed as well as deterred the execution of various activities. The complexity of challenges faced during the pandemic was vast. A convergence with other sectors not only including the private health sector but other departments as well is evidence to opinions already shared by various other studies. [15,16] Thought there were instances where the private sector did measure up to the requirement, it was evident from most sites that the governments laxity in involving them did pave the path for a widening the gap between the public and private health sector in the country. In a developing country like ours where private sector is playing a major role in provision of healthcare, having a good public private partnership should be a major priority issue. Various other departments were involved to reduce the work pressure thus also ensuring provision of necessary care.
Financing in health sector for health care delivery forms a major crux of adequate health care to all. For Universal health coverage adequate funding under programs is essential. [17] With no speci c guidelines on issues that should have been also placed as priority, like the fund allocation for various COVID activities, issues with logistics etc, delivery of services faced many back logs. Management of migrants as they had to cross borders during the lockdown, management of COVID survivors, non-compliance by the locals etc posed a challenge to the system in place as the newness of the infection and the unpreparedness of the health system became clear.
Workpressure and lack of co ordination are major concerns noticed during this pandemic.
[18] Our study also highlights that there is a de nite need for more workforce in the health sector. A structured planning of activities is very essential. It was also opined that a national representative should be involved at every state in order to understand the local contexts of every state and have guidelines applicable to each of them. There is a need to have clear SOPs on management of tribal areas as these are a sect of community distinctly different from the rest of the community in terms of culture, traditions and practices.
With evolving challenges from the pandemic, many different innovative mechanisms were put in place thus showcasing that such mechanisms need to be in place as a continuum too. The fact that data management was a very confusing and challenging work during COVID, many states evolved digital methods to ease out the process. Line listing of laboratories helped in data gathering from various laboratories. The GPRS mapping of cases helped to know regarding cases and thus take up subsequent measures. Mobile applications that were developed helped keep track of cases and also a watch over the quarantine. Tele ICU facilities helped in better management of critically ill patients. Mobile testing facilities helped in increasing the testing coverage. Some of the states used certain mechanism which helped ease out on the patient load example: zone wise allocation of beds preventing overcrowding at hospitals. Facilities for tele consultations helped individuals to access health related advice even from home. Better monitoring and better surveillance along with improved data management was seen through the various innovations brought out at district level within states. It also became evident that the system of surveillance within IDSP also required to be re looked into.
As studies have time and again emphasized the need for shift of health agenda from merely disease speci c approach to multisectoral approach, [19] this study also showed that there is a need to work in the direction of multisectoral collaborations in order to provide health care in a feasible manner. [19,20]

Conclusion
The study very well showed us the uni ed response of an ethnically diverse country with diverse resources. Stress exposes us and our response to it depends on those unintentional traits which we inculcate during our growth. The COVID pandemic exactly did this. However, the different regions of India responded in a different manner. Where the southern part of the country responded to it in a very positive manner with strict regulations for testing and management; the northern regions saw more of problems which needed the policy interventions. Western region had more of innovations and techniques to manage the same level of problem; whereas eastern part of the country did well as far as the communication and information management is concerned. The learning experiences; more than fault nding also teaches us the uni ed front which was put up based on the bare minimum availability. It also gives all the option to imbibe the positivity of dealing with a pandemic with what best is available instead of just shouting out the problem. Figure 2 Diagrammatic depiction of contribution towards the categorized themes as per region.

Figure 4
Framework analysis of human resource management and innovative approaches adopted during COVID 19