Why decentralized structures exemplified by Kerala manage worst health crises better

By Abhinav Alakshendra, Soumyadip Chattopadhyay, Arjun Kumar*
We are witnessing a humanitarian and economic crisis of unprecedented proportions due to the novel coronavirus pandemic. In India, apart from a fiscal relief package of $23 billion to provide relief to the poor, the Central government has announced a nationwide lockdown which is backed up by additional measures and relief packages of varying nature and scale from the state governments.
Clearly, frailty of India’s health care system, e.g. characterized by 8.5 hospital beds and 8 doctors per 10,000 populations as compared to the 120 to 130 beds per 10,000 populations in Japan and South Korea, has made the management of this outbreak all the more difficult. So far, over 90 doctors, nurses, and paramedic staff have tested positive in India which is having serious regressive impacts on the already stressed supply of healthcare workers.
Covid-19 is creating havoc in the labour market as the recently released the Centre for Monitoring Indian Economy (CMIE) report has indicated an overall unemployment rate of 23.4 percent, with the same for the urban areas being as high as 30.9 percent. Prof Pronob Sen, the former chief statistician of India, has roughly estimated job loss for 50 million workers in just two weeks of lockdown.
The Centre for Policy Research (CPR) reveals that migrant daily wage workers of Delhi lack money to buy food and are facing a hunger crisis. Indeed, the trade-off between containment of the disease and risking the economic consequences is extremely difficult, and India has decided to opt for mitigation procedures.

Coordination and management fiasco

As of now, the policy makers face two clear-cut challenges – (a) to ensure that all citizens are saved from hunger and destitution and (b) to palliate the spread of the pandemic. The 21-day lockdown had caught various wings of the central and state government off guard, worsening the plight of informal workers and virtually making a mockery of the much required ‘social distancing’.
In essence, apart from the allocation of budgets and announcement of fiscal stimulus, effective coordination and management among different levels of government in the form of decentralization is required to respond to the twin challenges.
To manage the looming threats of the Covid-19 crisis, widespread tracing, isolation, testing and treatment strategies are extremely crucial. However, zeroing down on the emerging hotspots and secluding new patients is proving to be a herculean task. Given the population density and lack of awareness, even the simple task of making people understand the need for testing if they are symptomatic is a daunting challenge. Stigmatization of migrant people returning to their native places would only make the matter worse.
Local governments and their elected representatives can better comprehend the needs and priorities of common people and make the governments more responsive in terms of speed, quantity and quality of responses.
These representatives, being the first responders in governance structure, can be a vital node for connecting government health facilities and economic assistances to the people. They can also play a vital role in disseminating information or imparting good habits of social distancing and washing hands and fructifying the battle against Covid-19.
Furthermore, for isolation of infected people, proper quarantine facilities, are needed. The initiatives of the Odisha government in the form of allocation of approximately $6,500 to each panchayat (village council) to get similar infrastructure in place should be replicated at the national level which would cost the Indian exchequer an amount of $1.3 billion.

Setting up of Corona Care Centres, as operationalized in Kerala involving village panchayat, is an important policy intervention, to be scaled up nationally

A speedy mechanism of such funding would help facilitate spending in accordance to the needs and priorities of common people. Setting up of Corona Care Centres, as operationalized in Kerala involving the village panchayat, is another important policy intervention, to be scaled up nationally. The Uttar Pradesh government has already put all village panchayats on alert and has required them to host of preventive measures such as putting soaps at all the hand pumps. 

Serious challenge

Providing food to the poor including migrant and homeless population during this lockdown phase is another serious challenge. The Kerala state government has involved the local government in running community kitchens to supply food to the locked-down families. The local governments are also entrusted with the responsibility of preparing a list of families who cannot afford the meal cost and of delivering food at their doorstep for free.
Importantly, India has enough food to feed it’s entire population, albeit such food might not be reaching them in the crisis times. Here also the local government can be engaged either to provide or deliver the specified quota of wheat/rice and pulses to any citizen who approaches the public distribution system (PDS).
In Indian cities, people are facing difficulty in practicing two basic preventive measures of frequent handwashing and social distancing. Nearly two-thirds of the households do not have access to water within the house and even the available water is insufficient and irregular. In Dharavi, Asia’s most densely packed slum, 80 people share a public toilet on an average.
Multiple agencies including city governments are in charge of providing these basic services in India. and Lack of synchronization of responsibilities among them often contributes to poor service delivery. Infirm financial health of the city governments, especially of the smaller cities in India, further limits their capacity to provide basic services.
Essentially, the cities often get entangled in a vicious circle where paucity of resources causes poor service delivery, leading to poor revenue generation. Urban poor are badly hit as lack of access to basic services exacerbates their existing vulnerabilities, leading to their health and livelihood being compromised in times of public health catastrophes like Covid-19.
Due to lack of genuine autonomy, cities prioritize short-term projects and overlook the strategic approaches that would otherwise prove to be more effective in dealing with health emergencies. City governments should be granted full autonomy to allocate funds to the levels of Market Welfare Associations (MWAs), Resident Welfare Associations (RWAs) and ward committees. They are the closest to the common citizen and can better address their daily needs of cleanliness, hygiene, sanitation and water and, thus, can mitigate the impact of Covid -19.
In some states, local governments are provided with some funds to spend during an emergency situation, e.g. in Jharkhand, Gram Panchayats (GPs) have an emergency fund of $ 130 to help anyone who is at risk of starvation.

Way forward

The bottom line is that the availability, quality and accessibility of health care facilities are necessary but insufficient to ensure an effective pandemic response in India. Now, in fact more than ever, the importance of close as well as robust collaboration between governments at the state and local levels and decentralization of basic responsibilities is being felt.
Not surprisingly, the states with robust decentralized structures, as exemplified by Kerala, are in a better position to manage this worst public health crisis. In the mid-19th century, the city of London was suffering from recurring epidemics of cholera. The metropolitan authority responded to the crisis by constructing a sewer network connecting most of London and carrying out street improvements.
The lesson is far-reaching. As part of a long-term strategy, we should utilize this opportunity to strengthen our local governance systems and empower the institutions as well as their representatives as new frontline warriors in this crisis.
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*Abhinav Alakshendra is assistant professor and Director, Center for International Design and Planning, University of Florida, USA and senior visiting fellow at Impact and Policy Research Institute (IMPRI), New Delhi. Soumyadip Chattopadhyay is associate professor of economics at Visva Bharati University, Shantiniketan and senior visiting fellow at IMPRI. Arjun Kumar is Director, IMPRI and China-India visiting fellow, Ashoka University