COVID-19: Lessons from Kerala, a talk by Mr. Rajeev Sadanandan (Ex. Additional Chief Secretary, Govt. of Kerala)
The Institute of Public Policy organised the talk under its COVID 19 Lecture Series, in which issues of public policy are looked at in the current times of continuing pandemic across the country. The talk was delivered by Mr. Rajeev Sadanandan and was titled “COVID 19: Lessons from Kerala”. Mr. Sadanandan was a career bureaucrat hailing from the Indian Administrative Services and retired as the Additional Chief Secretary to the Government of Kerala. He has been involved with developing the state’s health system since the early 90s and was at the forefront in state’s successful fight against the Nipah virus in 2018.
Mr. Sadanandan started his talk by opining that when we look at systems and policies, it is important to step away from the current situation and look at what brought us here. When people admire Kerala’s response, it is important to remember that a lot of it has been built up previously. The systems to handle a crisis cannot be built during the crisis but have to be built much before time. This is the big advantage that Kerala has had in handling the crisis.
Mr. Sadanandan gave a brief overview of the history of healthcare development in Kerala right from the British period. The erstwhile kingdom of Travancore, Cochin, Malabar of the Madras presidency formed the modern state of Kerala. Malabar was hardly different from any other part of British India but fared much better in healthcare. The royal family of Travancore had already established several hospitals in early years of 20th Century. The big advantage for Travancore was that the royal family had adopted the western system of medicine and used their clout to push the system. One of the concepts used by the kingdom to push modern healthcare practices was through social intermediation. In social intermediation, to push an unfamiliar system, other existing systems have to be used. For example, when vaccination was introduced in Travancore, people were wary of the principle underlying vaccinations – i.e., immunity against a disease is best developed by being infected by the same disease. This trust deficit was further aggravated by the practice of untouchability and strict caste divisions. The approach was to deploy vaccinators from different castes to educate and inoculate their own community.
There was already a demand for education and health by the royal family. The introduction of missionaries furthered the reach of modern education and health, as they used these to attract people to their message. Another factor was the rise of social movements in the pre-independence era which demanded equal treatment to backward castes and extended this demand to same modern facilities of health to all. On socio-cultural factors playing an important role in developing progressive policies and robust governance systems Mr. Sadanandan highlighted that the Dewan of Baroda built palaces when he was in Baroda and focused on health when he came to Kerala. The effect of society could be an important underlying factor. These factors provided an enabling environment which set the foundations of a robust healthcare system in the erstwhile state of Travancore and modern state of Kerala.
Building upon the strong foundations
Post-independence the trend continued and while other States invested in infrastructure and large industrial investments, Kerala continued to invest in education and health. This investment in health and education was counted as non-planned expenditure and affected Kerala’s fiscal health. The investment in infrastructure and other capital expenditures tend to start giving returns in the short run but when it comes to health and education the returns are long term with short term fiscal constraints. Apart from deferred benefits, ‘returns’ from investments into health and education capacity building are often hard to quantify, if not unquantifiable, making it hard to justify increased government expenditure.
By the 1970s the state had a robust health system in place. But the ensuing financial crisis led to decrease in health expenditure gradually from the initial 10.43% of GSDP to around 4% in the 2000s when it hit rock bottom.
Changes in the Neo-liberal Era
This drastic reduction in investment on health led to the citizenry’s confidence in public health going down, patently inferred from an NSSO survey which stated that only 28% of Kerala’s population utilised government hospitals for health services. When the government cut back, the private sector came in to meet the shortage, which led to rapid privatisation of the state’s health sector. But the investment in health picked up again after 2005, with the current government especially placing a huge thrust on healthcare expenditure.
From the mid-90s, the policy discourse across India was that government health systems are inefficient, and therefore private players must be brought in. This has resulted in demoralisation and underfunding of government health services in the country. However, this devaluation never happened in Kerala. Since 2016, the government has infused more funds into healthcare, making it more consumer-friendly. Given a choice, the people of Kerala would go for government services due to their credibility.
Role of local bodies in developing a resilient system
Another important factor highlighted by Mr. Sadanandan was the resilience of Kerala’s health systems, i.e. the ability of the health system to respond to a crisis. This has internal and external aspects associated with it. Internal aspect refers to the availability of materials and how well systems are staffed and trained, while the external aspect refers to the support of the society.
Referring to the 73rd and 74th Constitutional Amendments which transferred the subject of public health to local governments, Mr. Sadanandan stated that in 1996, the government of Kerala transferred oversight of all public health centres, sub-divisional hospitals up to district levels to gram and block panchayats, depending on the level and location of institutions. As he was working in the health department at that time, he recalled how the bureaucracy and public at large was shocked by this move as health is a highly technical subject. There was huge resistance from the end of 90s and the new century. The doctors also opposed it, but public health was transferred.
Despite this, maximum flexibility is given to panchayats and activities are routinely handled by government directorate services.
Panchayat hence had a clear functioning in health. In 2011, the Ward Health and Sanitation Committee (WHSC) was empowered which had elected ward member heads. Moreover, there were multi-purpose male workers, ASHA workers, local volunteers that worked in the wards to look after heath, sanitation and nutrition (which was added later).
The seasonality of epidemics in Kerala is well-known. It starts post-monsoon with diseases like dengue, H1N1 etc., and the WHSCs were charged with better control, allowing them to limit water-associated diseases at source by working with the local population. Traditionally, WHSCs have been in-charge of epidemic prevention. After the 2018 flood, a panchayat disaster management plan also came in.
Lessons from Top Down Health Management
An opportunity Kerala missed is the National Rural Health Mission. It was meant to be planned from village level upwards. It would have been ideal for NHM to be placed with local governments, however, bureaucracy ensured that it was placed as a separate vertical head.
In 2011, panchayats started preparing panchayat health plans. There was also a prize for best planning. So now, planning happens together including the panchayat, NHM, health department plans. NHM is heavily regulated by the central government, often creating a barrier in Kerala’s drive for greater healthcare decentralisation.
Managing the COVID pandemic: Putting all the lessons together
When COVID-19 struck, it was nothing new for the panchayats. They had systems already in place including palliative care. Entirely funded and managed by panchayats, they also had social justice interventions like supporting children with cognitive disabilities and destitute people. The pillars in the COVID-19 response were hence the public health and social justice systems. Moreover, dealing with the population at the local level was already part of the Kerala system through the panchayats.
Today, everyone wonders how Kerala has managed to deal with the ongoing COVID-19 crisis so well, asking them for crisp implementable bullet points. However, the extant response system was not simple to actualise; it is a product of a long tradition of investment in health and social justice and other elements as well.
Managing the ‘infodemic’
Citing the example of the 2003 SARS epidemic, where China hit the radar, Mr. Sadanandan emphasised that in a crisis, mistrust in the government is dangerous. Since then, people working in public health understand that transparency with data is extremely important to build trust.
An epidemic can also lead to an infodemic i.e. false information. The antidote to this is credible information from the government. During the Nipah outbreak the government relentlessly shared updates with the people and clarified false information on the Health department’s Facebook page. Hence a mutual trust between the government and citizens is important.
Tracing the possible cases
Unlike other epidemics, in the case of COVID-19, the epicenter of the virus was known. Hence all the people coming from China and other hotspots were closely monitored. The strategy was to trace these people and use the data available from different departments to track them. Despite such data being available to other states as well, the difference was that the lowest management centre i.e. the panchayat wards were not equipped for the same. On the other hand Kerala has experience from its tackling of the Nipah virus. In case of suspicion, the person is called by health workers, and in case of fever, a dedicated ambulance service is available to reach the patient to the COVID observation centre. In case the person is tested positive, contact tracing to identify possible transmissions is done. And the process is repeated again for all contacts. On the important aspect of self-reporting and the mistrust that crept in the system of self-reporting.
Mr. Sadanandan clarified that self-reporting was not practiced en masse in the state and there were people who violated quarantine causing new clusters. But, the role of the ward committee is important which could not have been handled if left to the police or health department alone. The reason is the awareness among the population about the importance of quarantine which encouraged them to exercise vigilance driven by local people and ASHA workers. It’s not that the compliance is higher, but society is vigilant ensuring compliance.
Transforming human capital to human resource
Mr. Sadanandan mentioned that a health crisis can easily turn into a humanitarian crisis. Kerala used the Kudumbashree network of Self Help Group women who were already engaged in palliative care to support not only migrant workers but all vulnerable groups. He highlighted that 65% of the migrant support – like community kitchens – mentioned in MHA’s affidavit to the Supreme Court was provided by Kerala.
Challenges and hurdles
The issue of opening up the economy was addressed by Mr. Sadanandan and he underlined the fact that since the virus spreads due to social contact, any social meeting can threaten driving it further. However, the economy cannot be allowed to come to a standstill. He proposes that there can be selective restarting of activities depending on their importance – colleges and schools may need to be opened, but wedding gatherings can be avoided. He also opined that if the construction sector was kept alive, the benefits accrued for the migrants would have been far greater than the damage that has been caused.
While calling the data collection intrusive, he suggested that the application data collection from Arogya Setu could be analysed to identify high risk activities and clamp down on them in case there is concern of the cases exceeding the health system capacity.
Regarding the fiscal challenge facing the states, Mr. Sadanandan pointed out that Kerala had announced a huge stimulus package with rations and loans. Due to this, fears of fiscal crisis loom large, making central transfers extremely important. The recent permission to increase borrowing is a relief, however the conditionality associated with it has greatly reduced the potential that such a measure could have realised.
Lastly, Mr. Sadanandan emphasised on how the country has seen excessive centralisation of decision making to the Union government, and how the same goes against the essence of India’s Constitution. Criticising the usage of the Disaster Management Authority to invoke and further centralise power at the Union, he hopes that a strong public health act empowering states would be brought out so that the DMA is not used for epidemics in future. Mr. Sadanandan emphasised on the role of policymakers and analysts in developing better understanding between centre and states in managing crises of this magnitude. A new equilibrium has to be brought about and if federalism has to be preserved, a larger set of deliberations are needed.
(Anjali Nambiar is a second-year student in the Master’s Programme in Public Policy at the Institute of Public Policy, National Law School of India University. She holds an honours degree in microbiology and is interested in gender rights, social welfare and migration. She can be reached at firstname.lastname@example.org)