People Centred Governance: How Kerala Tackles COVID-19
TM Thomas Isaac
Kerala has a total of 394 positively tested cases and interestingly 245 out of them have recovered indicating a nearly 60% recovery rate, by far the highest in India. Although it leaves about 147 cases still active, there have only been two deaths so far. The average death rate internationally is around 6% while it is less than 1% in Kerala, a most remarkable achievement indeed. Typically a secondary transmission as per the Indian average is 2.8-3% however it is only 0.4% in Kerala. In other words, a primary source of coronavirus, coming from outside, China, Gulf or Europe, normally should have infected 3 percent in Kerala, but we have been successful in limiting it to maximum one percent. This points to the effectiveness of our health system and intervention.
Recognition for the Kerala Model
The Kerala governance system and process of development in the context of combating the COVID-19 pandemic has garnered widespread attention and appreciation. Kerala’s experience has received international attention. Our success is being reported in International newspapers and MIT is making a case study of how Kerala is dealing with the pandemic. National media is also discussing the success in Kerala. So, this fight against COVID-19 has brought to limelight Kerala’s perhaps unique development experience itself.
Kerala’s Health System
Kerala has a very robust, three-tier health system. Formally that is present in every other state of India. But unlike other states, we have a very active network of primary health centres which covers all the villages in Kerala. The total number of primary health centres in India is around 100 and 68 of them are from Kerala. All the top 12 best PHC’s in India are from Kerala. So we have a network of Primary Health Centres at the village level, and intermediate community health centres, and at the top you have tertiary institutions like Medical colleges, district hospitals and so on. Most of this can be accounted as a legacy of the past. Such a full-fledged health care system did not emerge in the past five years rather it’s a historical legacy. Even before independence the health performance of Kerala, particularly Southern Kerala, was much better than the rest of India. By 1970s, Kerala had achieved the best life expectancy, much higher than the rest of the country, infant mortality rate was very low, at present it is around 11 percent or even lower, maternal mortality is the lowest in India, and sex ratio is in favour to females. So, if you take any health indicator, Kerala is so much superior and therefore it came to be widely discussed in the 1970’s on how Kerala was able to achieve this. This success raised a new question- how did this come about and why does Kerala have such an effective public health system? Was it the benevolence of the kings who ruled Kerala? Well, there has been a number of researches by Prof. TN Krishnan and others which has revealed that in addition to the role of governments there was a very important factor- a demand from the people. That was a prime mover – the demand generated from the people for health services, just like education. Such a demand was generated because of social movements starting from social reform movements, then agrarian movements, and the Left movements. Powerful social movements and popular mobilisation exerted demands on the state for better health sector, educational services, etc. Therefore, the successive governments have been forced to respond to these demands from below, and the health sector, education sector and others expanded.
This is a development story spread over nearly a century. And during the post-Independence period, the successive Left governments have been nodal points when major measures and steps were made in protection of the public health system as well as the public education system. The whole ideological framework of Kerala is such that once such steps are taken, it’s not rolled back. It is very difficult to do that in Kerala. Hence we have a progressive movement forward. For example, the present government in Kerala has invested 4000 crores in the public health system to expend on medical equipment and infrastructure. At every Taluk Hospital, we have 20 dialysis machinery, every general hospital at the district level has a cardiac department, and every medical college has an oncology department with around 5775 posts of doctors, nurses and paramedics. This kind of investment has definitely been an impetus for the improvement of the health structure and health establishment.
Identification and Primary Intervention
Once a patient is identified, immediately we would set about drawing his or her route map for the last fortnight and then identify everybody who might have had come into contact with them and we would put them all under house observation, test them, and if they report to be positive, we move them to isolation in a hospital and then prepare the route map for that individual. This is continued until the chain is broken. This has been very effective and the lockdown has certainly helped us to contain the COVID-19 spread but in addition Kerala also puts emphasis on intensive testing. It is not enough to have a lockdown, it is equally important to have intensive testing. Observation, tracing, testing, and isolation- these are prerequisites to winning this battle. Cooperation of people with the government is also of significance in order to make this exercise work and that’s the big success of Kerala. We have been able to move ahead with the commitment of our health workers. The videos of the cured patients leaving the hospital is quite heartening. They are given a big send off with all the health workers clapping. It’s an indication of the morale of the health workers which is in sharp contrast to many of the leading hospitals in India, AIIMS included, where there are complaints about having not enough equipment, protective suits and so on. Therefore, Kerala government has been able to rally the people also into this fight and we seem to be winning the fight.
Participation of People, Local Governments and Social Workers
On top of all this, is an element which is a very distinct flavour of Kerala- mobilisation of people around these institutions which is possible only due to the presence of very vibrant local governments in Kerala, a product of the People’s Planning Campaign of the 1990’s. These local governments, primary health centres are transferred institutions, and therefore there is a lot of local ownership about it and they also have the liberty to spend the allocated amounts. The last two decades witnessed the emergence of palliative networks. Every village, every panchayats, has a number of palliative societies, belonging to different organisations and different networks which is a big mass movement. Now, the government of Kerala has attempted to tap these mass energies through a special mission – the ‘Ardram Mission’, which is responsible for the improvement in the health facilities and also try to link them with the mobilisation from below.
Foresightedness and Contingency Planning
This was the existing condition of the Kerala health system and so, when the COVID-19 outbreak happened, we were prepared. And preparedness is the key word to Kerala’s success. Why were we prepared? We were taken by surprise when the Nipah virus plagued the state in 2018. We didn’t know how to cope with such an unforeseen introduction of an epidemic. 17 people died and we learnt a lot of lessons from that. And therefore, the moment we heard about the Wuhan crisis, a control room was immediately opened in Kerala because there are a large number of Kerala students who are there in Wuhan and China who were expected to return home. The control room was opened, mock drills were made in every district, and then special teams were prepared with adequate training. We began identifying isolation wards and prepared Plan A, B and C for different contingencies. So when the students began to come back from China, there were three cases and that was it. We successfully prevented a secondary spread. So the key was the preparedness of the system for this eventuality. Today the whole western world, the USA, maybe one of the richest of the countries was still caught unprepared. Their private health system and insurance based profit motivated system, as is evident, cannot handle this kind of epidemic. It’s a case of market failure. It’s a market oriented health system and the market fails during a crisis just like in an economic crisis. So, in Kerala, we were prepared. But things spiralled out of hand at the end of February when returnees from the Gulf and Europe landed. Some of them dodged our restrictions and the spread began. And we faced a period when the number of people with confirmed COVID-19 cases in the state was rising faster than the national average, and the incidence of sick persons in the confirmed cases was highest in Kerala, higher than any other state. But over time we were able to take hold of the situation firmly and the condition began to improve. We quarantined the house of over two and a half lakh persons. We were able to do that with cooperation from the people because we were supplying food, sending all necessary services to the houses, and anybody who developed a symptom was tested and if positive, they were immediately moved to the hospital. The new cases that are emerging are all from people who have been quarantined. There has been no spread outside in the society as a whole which is a significant achievement. Kerala is steadily recovering and it is now standing 12th in the number of active cases. Number of cured cases is now much higher than the new cases that are emerging. The curve is slowly depreciating and in some period we’ll be really flattening it and soon we will be able to create districts where there are no active cases at all.
Break the Chain Campaign and Relief Assistance
We were able to successfully run a campaign- Break the Chain, which really caught on. Keralite’s would be privy to this-that we are big spitters. That is a habit which arose from our tradition of betel chewing. But now we don’t find anybody spitting in public spaces of Kerala. We are teaching everybody to wear the mask. Physical distancing has been successful. But most important is, after the lockdown, the central government gave some paltry amount of 500 rupees to Jan Dhan account owners, some money to the construction workers from the Construction Welfare Fund which are state funds and 5kg rice or wheat. Apart from all these, there has been no money transfer. A sum of 2000 rupees under the PM Kisan has also been promised. But in the state of Kerala, 8500 rupees has been given to every aged, differently-abled and disadvantaged people as welfare funds. All other workers are being provided 1000-3000 rupees per person. A food kit consisting of 15 kg rice, pulses, condiments, etc. are distributed to every household. Such a concerned and humane approach to those who are in lockdown brought forth the best cooperation from the people which explains the Kerala success. We are bracing for the next round of challenges that we must encounter once the lockdown is lifted. There will be a mass insurgence of people from the Gulf and other parts of the world. It will be of prime importance to quarantine them for 21 days. Our estimated expectation is that around two and a half lakh Keralites will return from abroad, and we have already found the accommodation for them. When that phase arrives, we plan to strictly implement another decision which is to house quarantine all the elderly people in Kerala, all the vulnerable sections in Kerala, and monitor them. Because a healthy individual is less prone to be severely affected by COVID-19. One may fall sick but is most likely to recover. However for vulnerable people mortality rate is much higher. And therefore they have to be protected. This is a big challenge, a big experiment now.
The Adversities of Lockdown
Lockdown is most certainly necessary. We must accept that there is no other solution. But those who are responsible for giving leadership to the lockdown appear to have forgotten that you are locking down people from their subsistence, from their jobs and their income. It was most shocking when the Chief Justice of India asked ‘if the Government of India is providing ration to the people, why should they be agitated?’ The salaried of India must meditate for a moment, suppose you don’t get your salaries for almost two months how will you survive? Sixty to seventy percent of Indian workforce is constituted by daily wage labourers or daily earning self-employed, and we are locking them out of their jobs for two months. How do they live? In some sense, we can conclude that this lockdown is also a crisis as big as the Pandemic. In fact, people are afraid of this economic crisis more than the virus. That’s the reason why hundreds of thousands of migrant workers in Mumbai, Delhi, Surat, and so on are restless. They want to get back to their village, where at least even if the virus catches them, they will have some modicum insurance, food and social security from the community. Therefore a good section of the population definitely perceives this crisis to be much more serious than the virus itself. Because the virus catches you at some future date, characterised by probabilities but hunger is an everyday experience.
Possibility of replicating Kerala Model in Other States
If a state is willing to devote sufficient funds, it is very much possible to replicate a Kerala model health care system elsewhere. As previously mentioned, the demand for quality health care service comes from the people. There is a very interesting paper by Professor Joan Mencher. She was one of the foremost anthropologists who wrote a paper on EPW from the early 1980’s. She studied and compared the agricultural labourers in Kerala and Thanjavur. The paper is very evocatively titled ‘The Lessons and Non-Lessons of Kerala’. So what was the lesson? In Thanjavur, the village she was studying there was a PHC but no doctor, no medicine and nobody is bothered. But in Palakkad, the village she was comparing in the study, there is a PHC, if the doctor doesn’t come for a few days there will be agitation. If there’s no medicine there will be agitation. So this is the demand from below, popular vigilance, which may be lacking in other states. But take the case of Tamil Nadu. Tamil Nadu is a very interesting case where supply has resulted in creation of health infrastructure which has met the health needs of the people, so much so that this is one state after Kerala where you can find very rapid and significant improvements in health indicators during the last four decades.
How can the Kerala model implementation be carried out in other states? In the Indian scheme of things, state governments are constrained. They cannot independently borrow, revenues are limited, and therefore you may not have sufficient funds to make a big investment in health infrastructure. That is the reason why the Indian government has decided that we can’t spend even 2% of the GDP on health. It is much less than that today, and therefore India governments decided to go for an insurance programme. It has no fixed investment but only insurance payments made otherwise the private people will set up hospitals- something based on the American model. The Kerala model is very different from the American insurance model- it’s a public supply of health facilities. Now, the key reason is lack of investment funds. But the Left government in Kerala has ensured that the health infrastructure must be in full, education infrastructure must be in full, and of course other physical infrastructure like roads, buildings, industrial parks, and so on must be built.
We have to pump in something like two lakh crore rupees into Kerala infrastructure which is a huge amount of money. We cannot obtain the money from the budget since the FRBM Act does not permit that. Therefore we are using many interventions outside the budget available at this infrastructure. A key instrument of this has been Kerala Infrastructure Investment Fund Board. This fund is intending to borrow 50,000 crores of rupees, and then finance agencies who will invest and thus build up infrastructure. Now how will they borrow this 50,000 crores of rupees? It’s a small financial innovation. The legislation which created this KIIFB also mandates that the government pay half of our motor vehicle’s tax as grant every year to this institution. So they are assured of a future buoyant every year increasing income flow, revenue from the government. Half of every rupee coming into the government from motor vehicle tax, i.e. 50 paisa would go to KIIFB and 50 paisa to the treasury. Now, therefore this fund is able to borrow. They can just say anybody releases our future income flow. Now we will securitise it. 15 years from now we will have enough funds to repay whatever you lend us with interest. There are models which can demonstrate that. And we have a model which shows that 50000 crores borrowing now with a moratorium period, 15 years, the government grant to them will be sufficient to repay it. So having assured of this money, we are giving, allowing administrative sanction for the infrastructure. That’s how we have invested 4000 crores in health infrastructure, constructions of things are going on, and equipment are coming. Look, we have digitised all the school classrooms in Kerala. It has transformed the education pedagogic methods. Then every higher secondary, high school is getting new buildings. This is a big transformation of public education, public health financed through a method which is very innovative. So if you ask me is it possible to do it, yes it is possible to do it. But you must be convinced of the need to do that, you must have a politics which defends the public health system and public education.
Depletion of Tourism and Alternate Economy Stabilisers
The Kerala economy has been growing faster than the national average from late 1980’s until now. In the 1970’s Kerala’s per capita income was much lower than the national average. In 1957 it was 20% lower. Then it went on decreasing. But now, you know, Kerala’s per capita income is 60% higher than the national average. So we have been growing faster than the national average. Two things need to be taken into account- we received one major blow in 1990 when the opening up occurred, imports increased and the prices of all our commercial crops failed. So, agriculture which had started to grow at an astounding rate of 4% per annum now is negative or stagnating. However this didn’t affect the economy very much for the simple reason that our investment in education and healthcare produced better human resources who could then exploit the opportunities that were emerging in Gulf countries and the rest of the world. So outward migration increased and they sent back remittances. Remittances are now around one third of Kerala’s GDP. And therefore the buoyant economy continued. But more than the tourism, what is more worrisome is what would happen to our migrant workers outside. A world recession means, particularly a recession which involves the Gulf with depletion in oil prices which will further result in a lot of people losing their jobs. Earlier when the Gulf was shaky, a lot of people jumped to Australia, Canada, and Europe. Even that is not possible this time. And therefore return migration will increase, remittances will go down and then there will be serious trouble. Take a scenario of two lakh people coming back. How do you reintegrate them with the economy here? It’s a big challenge. So a very important concern is to formulate a viable strategy for the same. In fact the first budget presented by me in 2016, beginning of the term of this present government, the first sub-heading of my budget speech was ‘The new anti-recession package’. And everybody wondered why I was calling it recession. India has no recession and Kerala’s finance minister is saying anti-recession package. That package announced this Kerala Investment Fund Board about which I earlier mentioned. Why did I call it a recession? Already, indigenisation of the workforce was taking place in the Gulf countries, a lot of people were coming back. So we foresaw this possibility of increased return migration and of a regional recession in Kerala- that’s how I had described it. And therefore we would require something special. A state government cannot have an anti-recession package within the federal framework of India from the budget, unless permitted by the Central government. They are not permitting it even now under COVID-19 conditions so how could we expect them to permit in the normal times to have an anti-recession package. So, we invented KIIFB, this 50,000 crore investment. This was present in the manifesto of the Left government and it wasn’t something invented in the budget speech, it was something foreseen in the manifesto of the LDF which had said that this investment in the infrastructure will make Kerala attractive to Private investment, attract investors from outside, into those sectors in which Kerala has higher competitiveness like knowledge industries, service industries, skill based industries, value added industries, and so on. So this was a strategy to prepare the path for investment in sectors which will produce quality jobs so that the people who will come back from the Gulf can be fruitfully employed or the new generation be fruitfully accommodated. Tourism, in my opinion, is going to be still the great engine of growth in Kerala. But tourism is not going to open up. Other sectors will be opening up now by May. We are definitely going to open up the economy. On the basis of strategy I said we are going to quarantine all the vulnerable sections and others will go on work and we will have to be on vigilant guard, but life has to go on. But for now there is no question of opening up tourism until the next season, say in December. December starts the new season. But we have to start marketing now. As soon as the COVID-19 comes down, pandemic comes down in Europe, we will have to go around advertising a resilient Kerala. A whole lot of people who are quarantined in Kerala in the COVID-19 times, the tourists, initially there was a lot of ill-feeling about how we get interned in a third world hospital. But many of them are leaving Kerala with a lot of good will. Many of them said on record we couldn’t have gotten a better treatment. I know of a case in Alappuzha, an American lady who was caught in the lockdown. Of course, she had to be quarantined. She proved to be negative. And after the quarantine period she was told she can go. There were some flights in which American tourists were being taken. But then she asked the Collector, ‘Can I stay here? I am safer in Kerala than in New York’ which is very much true. That’s a good will. So, I think our resilience, our fight is going to be our brand in the next marketing. So we have to imaginatively think how to make the best out of the situation. For instance, Kerala health is a good brand now. Pharmaceuticals is an area where we should invest. We were considering setting up a pharma-park and now is the time. We will start working on that. We have a public sector factory- Kerala State Drug and Pharmaceuticals. We intend to expand it. Organ transplant, once you have that you will have to live lifelong with medicine- five or six pills, it costs 250 rupees per day now. Now this public health factory is waiting for the licence to produce the same pills at 40 rupees. Notice the price difference. Now, this is the time to invest and scale it up. We can have a Kerala generic brand. It’s a generic medicine but we will put a Kerala brand to that. So, this also provides certain opportunities. Look at China, they are opening 80% normal to the factory production under COVID-19 conditions themselves- retooling their factories, using more machines. And the sector that is not leading the charge- it is the health product sector. The test kits, the suits, the ventilators, and so on. So similarly Kerala could also think of strategies for restarting growth.
These are significant excerpts from Kerala Finance Minister and economist Dr. TM Thomas Isaac’s online lecture on Kerala and COVID-19, organised by the SFI-Hindu College Unit at the University of Delhi. The transcript was prepared by Sooraj Elamon and Anagha Pavithran, Masters students at the University of Delhi. The video recording can be accessed here.
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