Plot: Problem Statement

The most marginalized and vulnerable communities were the worst hit during COVID-19 where their long standing struggles with access to health services such as testing became a chasm so large that it led to communities fearing testing and the possible consequences if they tested positive - ranging from being further pushed into poverty to becoming stigmatized. As the COVID-19 outbreak continued to impact the country, the need for dedicated, focused and sustained efforts to protect and serve the most vulnerable in India remained a priority.

Community Based Testing engages and screens vulnerable populations for COVID-19 risk through trusted community champions. It operates across the care continuum and creates service awareness and a database of individuals who are at risk of COVID-19 and need regular followup and support.

Those at high risk of COVID-19 were referred for testing through our mobile clinics and those at moderate risk and pre-existing conditions will have regular follow ups. We partner with local governments and NGOs to ensure referral to health or quarantine facilities for the COVID-19 positive and with individuals so they are empowered and cared for.

Our anti-stigma initiatives generate demand, de-stigmatize COVID and ensure early detection so that transmission can be curtailed efficiently.


Plot: Problem Statement

Limited access to facility based covid tests affected the prompt detection of cases and increased the risk of community spread of COVID especially among vulnerable populations like urban poor, who are already living in conditions that exacerbate the risk of COVID-19.

Affordable, safe to use and easily available point of care diagnostics that empower communities, facilitate access to testing and subsequent adoption of other IPC measures would be a great value add for controlling pandemics - current and future. With the onset of third wave of COVID pandemic with the highly infectious omicron variant in India in early 2022, the use of self-administered RATs were approved by ICMR, the apex body as a way to curb the spread of the pandemic as well as ease the burden on already stressed health systems.

Key to delivering this public health response effectively means there is a need to ensure the availability and feasibility of these self-testing kits at the community level.


The Solution

We took healthcare to the doorstep of our communities. Community based symptom surveillance and antigen testing was rolled out in high density urban slums where there was high risk of COVID outbreak due to the migrant nature and occupation of the population, poor sanitation facilities and overcrowding. In addition to COVID testing, for those who come back positive a tele-medicine platform was used to support home or community based isolation and care for mild to moderate cases.

Tele-care was leveraged to provide both mental and physical health support for patients and identify cases that needed to be escalated to health facility level care early.

A comprehensive package of care including support for COVID screening and testing, home isolation, referral and transport to hospitals and tele-consultation was put in place. This included providing home care kits with basic equipment, PPE and medications. Back up oxygen concentrators were made available for moderate COVID patients who could end up needing these. In addition, those individuals for whom home isolation was not practically possible, temporary quarantine and isolation locations within the locality such as schools, rooms in primary health centers or rented rooms or houses were identified to support community based isolation.


What is a playbook?
A playbook includes “process workflows, standard operating procedures, and cultural values that shape a consistent response—the play.”

It borrows from some of the Aristotelian elements of the play -

Plot - The arrangement of events or incidents on the stage. The plot is composed of “clearly defined problems for characters to solve.”

Character - The agents of the plot. The People

Theme - The reason for the play. The Purpose.

3 of the 6 Aristotelian elements of the play

Over the month of April 2021, a deadly second wave of COVID-19 has


Self Testing in Communities : Highlights

This intervention can lead to:
  • Reduction of overburdened hospitals
  • Increased comfort for accessing care and reduced stigma of COVID-19 among community members
  • Reduction of hospital visits for low-risk individuals
  • Increased awareness among community members
  • Reduced rate of COVID-19 transmission to vulnerable community members
Why self-test?
  • Rapid Antigen Tests which can be done at home are easy to perform as compared to RT-PCR.
  • It gives quick results within 15 minutes and can help in containing the infection with ease of accessibility and availability of the tests.
  • Self-testing can become a powerful tool to increase rates of early testing, isolation and care for our communities.

The Problem

As COVID-19 has struck low-income urban communities, they face a range of problems that hinder access and utilization of COVID-19 services from prevention to treatment.

Testing in the community, especially within hard to reach and extremely vulnerable populations, remains difficult. Limited access to testing leads to delayed identification of COVID-19, leading to both poor health outcomes for the infected individual and increased transmission in the community. Furthermore, having a test alone is not enough- unless testing is integrated with referral systems for compassionate care, home isolation, institutional quarantine and hospitalization where needed, healthcare will remain fragmented and inefficient and the likelihood of an explosive epidemic increases. Effective testing is also constrained by the fact that there is a palpable fear of getting tested, especially amongst vulnerable communities, due to:

  • Lack of trust in institutional quarantine and fear of forced institutional quarantine away from their communities
  • Loss of livelihood and ability to survive in quarantine
  • Stigma from the community and care providers

In addition the challenges of COVID-19 testing in communities, ensuring that individuals who are COVID-19 positive are able and willing to isolate and receive care poses another problem. For those from these communities who do test positive, home quarantine is virtually impossible as most of them live in houses with a single room and/or lack of access to water and bathing facilities within the house. With hospitals across the country overwhelmed and the pressure showing no sign of reducing amidst the second wave - there is an urgent need for interventions to serve COVID positive patients from vulnerable communities in order to ensure these patients are cared for and to reduce the burden on the healthcare system.

So far, the inability to control spread of the virus has led to a massive burden on the health system, leading to loss of life. The shortage of healthcare professionals and supplies both contribute to the inability to cope with the influx of cases. Many cases arrive late at hospitals, already in need of critical care that could be avoided by early intervention. The number of patients with severe cases continues to rise, and hospitals do not have enough ICU beds in some cases or even simple oxygen support therapy and equipment to manage the demand. In order to address this challenge, there is a need for innovative solutions that can support the healthcare system.

Agency and Self Testing

The most poor and marginalized communities often struggle to navigate the formal healthcare system perceiving it with a fair amount of fear, trepidation and labeling it unfriendly, or costly, or both. The systems and processes of health care service delivery often means loss of a days’ wages for the poor in attempting to navigate the same. On the other hand, health is not a priority for the poor, unless it affects their work, and generally only symptomatic relief is sought.

This results in repeat episodes of preventable illness and also drug resistance to treatment. The poor lose one to two months of productive time a year due to illness in their family, and nearly 50 60 percent live with some form of undiagnosed illness and die earlier than those economically better off. In India alone, about 50-60 million people in the last decade have been pushed to the brink of poverty because of health-related expenditures.

The central problem is often agency of the human being over their own health and access to testing. Self-testing is bringing that agency back to the people to a large extent where they can test themselves in the safety of their home - or wherever they feel safe. It does not require a long turn around time for receiving the test result and they can then work with a community health worker to navigate their next steps around the health concern. It also takes away the fear of possible consequences of a positive result - instead ensuring that with the test in their hands and them in their own safe space - they take the agency and responsibility of the right next steps.

In the context of a situation like COVID-19, self-testing allows people to decide whether to go out or self-isolate at home or seek care. The term “going out” would include work, socializing, shopping, and eating out. The decision making is no longer a diktat but a conclusion arrived at by oneself based on ones’ own self testing.

The Thoughts Behind The Solution Action of Self Testing in Communities

Test and isolate early to break the chain:
Detect early symptomatic cases of COVID19 among poor communities using active screening and community based testing in project areas identified as hot spots or potential hot spots for COVID
Treat at home and intervene early:
Detect early symptomatic cases of COVID19 among poor communities using active screening and community based testing in project areas identified as hot spots or potential hot spots for COVID

The theory of change is that using trust capital within the communities and creating safe alternatives for testing and isolation will remove hesitation for early testing and isolation, curbing the spread of outbreaks within these vulnerable communities.

Adjusting intensity of pushing for Community Based Testing

When there are outbreaks in the neighbouring areas or in the city

High intensity of encouraging CBT - with intentional programming on ground to ensure more and more people have occasion and opportunity to self test - including rolling out door to door campaigns as required

When there are no outbreaks / an epidemic has slowed

High intensity of encouraging CBT - with intentional programming on ground to ensure more and more people have occasion and opportunity to self test - including rolling out door to door campaigns as required

Towards the tail end of the first wave of COVID-19 in India, we experienced the incredible usefulness of setting up similar programs with communities of M-East ward, in one of the most socio-economically disadvantaged areas in Mumbai. With the program, we saw that the community there had access to antigen and PCR testing close to their homes and with quick turnaround times, at a time where the rest of the city was struggling to get tested.

Pandemic Preparedness & Self Testing in Communities

These systems and habits are strongly systems oriented yet agile - where it will remain in place and continue to support people who could come back positive after testing and it can also roll out a a higher level of response in case of rise in cases, ensuring that communities are better prepared as more waves of the pandemic arrive. We also built in surge capacity for times when infections increase and taking a surveillance approach when there is a lull in the outbreak.

Depending on the geography and the outbreak, repeat antigen testing in highly exposed individuals such as community workers, factories, nearby construction sites could be set up to identify outbreaks early.

Purpose and Objective

Stronger Together

The Self-Testing in Communities Playbook offers guidance to help communities explore the suitable options of self testing for vulnerable populations, insights on what works and what does not and communication strategies to address myths and misconceptions. The document outlines the steps required for incorporating self-testing activities that can be undertaken for smooth planning and rolling out of self-testing in communities.

In the playbook, you will find:

  • Set of activities to integrate self-testing as an activity in the community
  • Summary checklist
  • Team role matrix
  • Tips and tricks

The playbook divides the entire process into 3 Acts, which are as follows:

  • Act 1
  • Scene 1 : Planning phase
  • Scene 2 : Pre-roll out phase
  • Act 2 : Roll out of self-testing phase
  • Act 3 : Post self-testing phas


The Main Actors!

Trusted community members are employed for surveillance, mobilization and demand generation and are nested within the programs, these will be the point of entry to the work.

These individuals have local knowledge on the needs of the community, context, and barriers to care which will inform the package of services.

They also help in identifying key people who could then be trained to support in various services from the ground level.

Utilising existing local workforce like community health workers, volunteers would be crucial for the success of the program that would enable, empower the local team to care for their own communities.

Who are the people?

Program Manager


  • Develop the testing strategy for the communities based on the risk assessment and information gathered from communities
  • Orchestrate training and orientation for the clinical and non-clinical team involved in testing
  • Facilitate and ensure availability of resources required for testing

What does the Program Manager need to know?

  • Information regarding the community spread of COVID
  • Access to and information on referrals and linkages to care
  • Technical support for the team of healthcare workers

Field Notes : On the role of the Program Manager

The Program Manager could be the manager of the community health workers themself.

So either they manage the program of introducing and sustaining self testing in communities or they’re the supervisor of the community health workers or working at a community health centre.

This individual is a central focal point who can manage the administrative bit in the sense of determining :

  • How are the tests getting distributed?
  • Where are the tests being conducted?
  • Who are the people who are positive and need help?
  • Who are the people who are concerned about their status due to exposure but are testing negative? Do they need help with a repeat test?

And manage administrative responsibilities such as maintaining inventory of tests, understanding insights around self testing behaviour and addressing any hurdles to uptake, making sure that social behaviour change communication is appropriate.

Community Health Workers

Who are they:Community Members

Community Health Workers are community members who take lead in the program and train to become frontline workers anchoring health and wellbeing initiatives in the community, engaging with their community to facilitate their wellbeing journey - as individuals and families.

They may be part of government programs or programs run by community institutions or non governmental institutions.

Community Health Workers are truly at the frontlines where they implement projects as per project design and have powerful valuable insights for behaviour change communication and trainings for communities to lead healthier lives. They are often tasked with review and pre-test of programs, documentation of the feedback using tools as appropriate, and are tasked to incorporate changes in order to respond to community urgencies and actively scale-up programs - ranging from immunization to mobilising for testing for communicable and non communicable diseases - based on community requirements. They often co-design and develop appropriate behaviour change display and training aids/ props that are cultural and language sensitive.

What do the Community Health Workers need to know?
  • How to demonstrate self testing efficiently and help community members learn the same
  • Importance of providing respectful instructions, informations and link to care
  • Digital literacy for those doing data entry
  • Understand how to escalate any concerns including quality issues with the kit to the clinical team
The following functions are imperative for the community health workers to carry out in this context:
  • Assuage all doubts with the help of the clinical team
  • Arrange for self test kits from the clinical team / program manager
  • Be prepared to demonstrate and help
  • Support data entry on the apps

Community members mentioned that the trust in the community health worker was the key factor that motivated them to undergo self-testing resulting in was their trust in the health workers and positive experiences from the program. They felt that the unwavering support offered by the health workers helped them overcome the initial fear and hesitancy from their family which prevented them from accessing these tests. Continuous sensitization campaigns and mass capacity building sessions conducted by the program induced a mindset change among the larger community thereby increasing the overall acceptance and willingness to test among communities.

Clinical Team

What does the Clinical Team need to know?

It is important to have sensitisation sessions on the importance of providing respectful care and its impact among vulnerable populations. At the outset it is important for the clinical team to skip any assumptions that the community has all the information or would be able to find it by themselves. Communities, particularly marginalized and vulnerable communities, may have poor experiences interacting with health systems historically and specific health-related questions that, clinical teams should be briefed on answering most sensitively.

During COVID many people did not access general care, even when they needed it, due to health systems being overloaded. So if testing initiatives for vulnerable populations are implemented during a pandemic, clinical teams may also use these occasions to address the communities’ general clinical concerns.

The following functions are imperative for the trained clinical team to carry out in this context:
  • Provide pre- and post-counsel on what to expect.
  • Actively assist the community members in conducting the self-test
  • Ask if there are any questions and respectfully answer any questions or concerns, however basic they may seem.
  • Help community members read the test results and address the concerns of treatment and stigma if tested positive while deploying the protocol on positive test results.
  • Request community members to repeat the test the next day if they test negative and are experiencing symptoms.
  • Explain the importance of attending routine testing program when selected for random testing for those who test negative.

Field Notes :: On the role of the Clinical Team

Self Testing can be uncomfortable and scary for communities - especially those who come from marginalized communities.

Most Self Testing tests come with paraphernalia that looks complex and can be confusing - the booklets although much improved - come with written text often in very small font and the steps need to be explained patiently to community members attempting self testing - be it the first time or repeatedly.

The fear associated with the result can also be a cause of major anxiety.

And therefore it is critical for the clinical team to be able to practice empathy while playing the role of the expert for the community and help decode the results and the next steps.


Accessible | Affordable | Available

How to choose the right place to set up health worker-assisted self-testing?

In partnership with peers, choose the location for peer-assisted self-testing that is most convenient and safe for them. Identify a location to conduct testing in the community. This could be a at wellness centers, during house-to-house visits, or during NCD camps. Following are some examples of places where you can conduct testing for your community members:

  • Homes of the individuals
  • Clinic or Medical room
  • Isolation room
  • Self-help group meetings
  • Dedicated kiosks set up at NCD camps
  • Community events
  • At the community member’s workplace (if it allows for privacy)
  • Outside the workplace
  • Open space with a shelter/roof
  • Kiosks set up outside or at the entrance

If there are multiple sites/locations within the community ensure that all the sites meet the following criteria.

The testing location should be:

The place should also have an accessible drinking water facility, medical care, privacy and washroom. Ensure that the self-testing space is accessible for people with disabilities. If that is not possible, alternative arrangements need to be made - this may involve discussing with the Medical Officer at the vaccination centre to explore alternatives such as Mobile Vans.