Amidst India’s unfolding Covid disaster, the southern Indian state of Kerala has been lauded for its effective response to the Covid-19 pandemic, particularly in controlling mortality.
What are the factors that help explain Kerala’s record? This two-part analysis attempts to unravel the secrets of Kerala’s impressive performance against Covid, based on extensive interviews with key officials involved.
This is the first of a series of special reports to be published by Covid Response Watch to understand the social, administrative, historical and political factors behind the way different parts of India have tackled (or not) the Covid-19 pandemic.
Reproduced from www.countercurrents.org
“It’s one thing to talk of numbers, but what really distinguishes the Kerala model is the quality of care you get, which directly translates to lives saved. The public health infrastructure has rightly earned praise, but what has really made the difference is the competence of the personnel that runs it. This was possible only because of extensive capacity building; it ensured that each person knew his role and how to go about it,” says Vinay Goyal, presently the District Development Commissioner of the state capital Thiruvnananthapuram, and part of the team that led the state’s Covid response.
Intensive training programmes were held for health department staff and other officials across the board. Dr. Shinu, who as the RRT member in charge of capacity building, helped set up training teams in all 14 districts, says, “The training programmes were initiated in early February 2020, when there were only a handful of cases in the state and the country. All staff, down to the receptionists and helpers, were made aware of the special nature of the disease, and how to handle visitors and patients while ensuring their own safety. Clear guidelines were issued on treatment protocols, clinical pathways and patient management. The training was conducted in coordination with LSG members and field staff, who are more familiar with the situation on the ground.”
However, the training was so effective, and the learning curve shorter, thanks to the efforts invested in capacity building by the state government over decades, which ensured a shorter learning curve for Covid. Dr. Shinu cites the case of the Aardram Mission, a scheme launched by the state government in February 2017 to improve public health at the grassroots level, in the backdrop of the United Nations’ Sustainable Development Goals (SDGs) 2030.
“The Mission had managed to create a sense of ownership among department officials through its capacity building programmes held over the last few years. This change, which was very evident in the department’s response to the floods in 2018, and during the Nipah outbreak in 2019, proved very useful in meeting the challenge of Covid. To mention just one aspect, even senior officials, who would otherwise issue orders from the state capital, took a hands-on approach, often spending days on end at Covid hotspots to manage the situation,” he says.
Sadanandan echoes this, saying, “The team spirit of health officials and workers were commendable. Whenever I would follow up with staff who I knew to be overworked, I would never get a negative response. The attitude will always be “We are winning this battle.” Similarly, the remarkable competence of the state’s nursing staff contributed tremendously to the success of the effort. In many instances, due to a paucity of doctors, nurses were managing patients, and quite successfully. In fact, it was the overall competence of Kerala’s health system as a whole – and I say system and not department – that saved the day.”
Kerala’s five-tiered Covid-management strategy was based on, and benefited tremendously from, the decentralized structure of the state’s governance and public health infrastructure, says Goyal. While health facilities distributed more or less evenly across urban and rural areas helped the authorities manage the epidemic locally, decentralized governance ensured that Local Self-Government bodies (LSGs) provided critical ground support.
Says Goyal, “Unlike most parts of the country, here the LSGs have the funds, manpower, the capacity to marshall resources and for decision making. They are accountable to people, and so enjoy a high level of trust. In fact, many of the winning ideas – such as community kitchens to supply nutritious food to those placed in isolation – came from LSGs and were later implemented statewide. But let’s not forget that none of this was built in one day but is the result of decades of investment in decentralization and empowerment.” The community kitchens ended up providing critical nutritional support to poor families as well as the state’s large migrant worker population that was stranded due to the lockdown.
Even the public health interventions, usually implemented top-down, benefited from this decentralized approach and empowered personnel. For e.g. The ‘route map’ method used in contact tracing of cases during the first wave was devised by Dr. Amjith Ravindran, a district-level doctor who holds a diploma in public health. This was later adopted statewide, after it proved to be effective in tracing cases.
Trust and social capital
The success of any public health strategy is determined by society as much as the state, says Sadanandan. “The most critical factor that determines the success of a strategy during an epidemic, when panic levels are already high, is trust. The authorities in Kerala largely enjoy considerable trust of the public, something we have seen repeatedly in the past, be it during the 2018 floods, in the epidemics that followed in the wake of the floods, or the Nipah outbreak. Secondly, the state’s social capital proved to be an enormous resource. The active role played by LSGs, by members of the public who volunteered in large numbers, or organisations like Kudumbasree (the state’s 4.5 million strong network of women’s self-help groups), the setting up of community kitchens, the care extended to migrants workers, all reflect the power of this social capital.”
Kerala, is well known for its welfare-oriented policies, and its educated and empowered citizenry and an alert media which didn’t shrink from criticism or asking pointed questions of the administration. The state government also did its part in building trust by ensuring transparency. The RRT, the apex body in charge of the state’s Covid response, would meet at 5 pm every day, and the day’s update would be given to the media in a press conference held at 6 pm by the health minister, and later the chief minister. As it turned out, these daily press conferences provided much-needed reassurance to a public in the grip of pandemic anxiety in the early days of Covid-19.
Sadanadan points out the deep impact of this public trust in the authority, and in state-run health facilities in Kerala. “Everywhere in India, there has been a huge number of private insurance claims on Covid. But in Kerala, these claims are very few in comparison; this is public data that anyone can verify. We have recorded instances where patients shifted from expensive corporate hospitals to government medical colleges. That is the level of trust enjoyed by the public healthcare in Kerala.” Sadanandan, along with the state’s former finance minister T.M. Thomas Isaac, has authored a paper based on the state’s Covid experience, titled ‘COVID-19, Public Health System and Local Governance in Kerala’.
Communication and outreach
Early on, Kerala initiated a successful IEC (Information, Education and Communication) campaign, titled ‘Break the Chain,’ that was designed to create awareness about the importance of social distancing and sanitary practices among the populace. Apart from an intensive media campaign, it involved health department teams fanning out to crowded spots like bus stands and shopping centres, including moving trains, to spread the message. Similarly, public assistance was effectively sought in contact tracing, which played a crucial role in infection control in the early stage of the epidemic.
Civic participation and cooperation
While the Kerala government, and particularly its health department, and even the state’s public health infrastructure has been rightly lauded for its role in managing Covid, the civic contribution to the effort has not received enough attention. “The public – the army of volunteers, especially youth – is the force behind Kerala’s effective Covid-response. Whether it is for call centres, contact tracing, or vaccination, our entire effort was run with more than adequate support from volunteers,” says Goyal.
He further adds, “Similarly, the public cooperated far more with government directives on social distancing etc, than elsewhere. We also received tremendous support from community organisations and religious bodies. Many organisations came up to us voluntarily offering their facilities for Covid treatment. There were cases where individuals offered their second homes to house patients.”
Goyal, who had come up with the idea of creating contactless Rapid Screening Vehicles (RSV), got enthusiastic support from the public. “The idea was to bring testing facilities to the doorstep of potential cases in remote areas or those who were refusing to get themselves tested owing to fear. Not only did members of the public offered their vehicles for this purpose, a team of volunteers worked late hours to make a prototype ready within a week,” Goyal says.
Pointing to the weaknesses of the Kerala’s model, Goyal says while the state has done an excellent job in providing quality care to the majority of patients, and in managing them locally, it can do better when it comes to “apex care,” referring to advanced treatment, where he says facilities and manpower are still inadequate. Dr. Shinu concurs. “Ideally, the ratio of nursing staff to patients in an ICU should be 1:1, but we are often forced to manage with a ratio of up to 20:1, which has a huge impact on the quality of care. This is one area where we have a significant gap between need and availability,” he says.
Sadanandan too points to the shortages in manpower to be the chief weakness in the system’s ability to deal with a crisis of this nature. “We recruited new personnel during the crisis, but the numbers were still not enough. As a result, the staff was completely wrung out by this crisis. People where pushed beyond the point of exhaustion, and we were not always able to provide them adequate support. We are seeing the sequences now, in the form of mental health issues affecting staff. The state is offering some support now in the form of counseling etc., but this is not enough. This is something to keep in mind for the future. Also, because all attention and resources were focused on Covid, we don’t know to what extent other healthcare needs were neglected, and what consequences this has had. This we will only find out in the coming days once the data comes in.”
Sajai Jose is an independent researcher and freelance journalist based in Kerala