Strategic planning

For want of a plan

Print edition : June 05, 2020

Health workers sanitising a designated red zone area in Vijayawada, Andhra Pradesh, on May 11. Photo: V. Raju

India failed to ramp up public health infrastructure and spending during the lockdown period and it does not seem to have a strategy in place to deal with the continuing rise in the number of COVID-19 cases.

The blanket lockdown announced in India without so much as a day’s notice in order to handle the COVID-19 pandemic has had visible consequences. For one, the strategy to contain the overall morbidity and mortality ensuing from the infection and the collateral effects of the lockdown has been more of a knee-jerk response rather than a calibrated one.

The fourth phase of the lockdown, which began on May 18, has been more or less on these lines though with a major difference. The decision to allow States more autonomy did not appear to be guided by the incidence and spread of the infection. If anything, both in the days after the lockdown took effect and in May there has been an alarming jump in the number of confirmed cases even though the case fatality rate continues to be low compared with the Western democracies.

In many States, the spurt in cases had to do with the large numbers of migrant workers heading home in sheer desperation because of the mismanaged and shortsighted policies of the government. Unfortunately, some of them may have been inadvertent carriers of the virus. On May 21, the District Magistrate of Ghaziabad, Uttar Pradesh, tweeted that the district was in the “red zone” (where more than 10 COVID cases have been found) because of the high influx of migrant workers and that the decision to open shops had been deferred. The district borders Delhi on the east and is a major confluence point for migrant workers from Delhi and Haryana. Its industrial areas were home to a sizeable migrant population from Uttar Pradesh.

Law and order approach

From day one, the government’s approach to the epidemic has been to deal with it more as a law and order problem rather than as a medical and humanitarian crisis. “The lockdown has to be strictly implemented and State governments have been instructed to follow the guidelines” was the refrain of the Union Home Ministry spokesperson at COVID-19 media briefings. The spokesperson of the Ministry of Health and Family Welfare on his part would reiterate how “social distancing and the lockdown” had to be observed by all if COVID-19 was to be “defeated”. The onus was, therefore, put squarely on the people.

When reports emerged of migrant workers getting killed by trains and being run over on highways, which was bad optics for a very image-conscious government, the Central government’s response was to instruct States to ensure that no one was found walking on the roads. District Magistrates were to be held responsible if migrants were found on the roads. The approach to the pandemic was primarily along these lines in the first few weeks of the lockdown. The shortfalls in the supply of masks and other personal protective equipment (PPE) were met with imports that generated controversies over the issues of bidding and overpricing. Even if these issues could be set aside as there was a global shortage of PPE and the government had taken steps for the domestic manufacture of the same, the dependence on the private sector network of medical colleges and hospitals was huge. In many States, there was a “takeover” of private health facilities to set up COVID-19 hospitals and level one and level two care centres, but there were as many instances of people being refused treatment for non-COVID-19 ailments at private hospitals and nursing homes, which had shut their outpatient and inpatient departments.

“People come to the hospitals with asthma and various breathing problems. But the OPDs [outpatient departments] are not functional. One doctor I contacted told me to pay the appointment fees online and that he would give me advice only then and that too on the telephone. I was told to explain my symptoms on the phone. How is it possible for a doctor to prescribe without seeing the patient? Not everyone is capable of explaining their ailment. What if the wrong medicine is prescribed?” a medical sales representative in Ghaziabad told Frontline.

Several State governments had to repeatedly issue orders and warnings to private sector health care facilities not to refuse treatment. Malini Aisola, co-convener of the All India Drug Action Network (AIDAN), told Frontline that a high-level group (HLG) was set up under the Fifteenth Finance Commission in May 2018 to evaluate the regulatory framework of the health sector. It comprised a sizeable section of private health care players. It was reconvened recently because of COVID-19.

According to a Press Information Bureau release, the HLG was asked to review its original recommendations in light of present developments. According to the commission, there was an immediate need to reassess the requirement of health manpower (medical and paramedical) and the estimated requirement of resources for 2021-22 to 2025-26 in relation to the shortfall in hospital infrastructure, medical equipment, PPE, and so on. The mechanism to fund these requirements will need to be critically examined, including the enhanced role of the private sector. The commission was of the opinion that the Rs.15,000 crore financial package announced for States would increase the investment at the grass roots and would lead to the setting up of infectious disease blocks in all district hospitals and public health laboratories at block levels. These, it noted, were “important first steps” in a series of measures that would be required.

Speaking on behalf of the AIDAN, Malini Aisola said that health was a State subject and the delivery of health care rested with State governments. “The States are free to make decisions about the terms of engagement of the private sector during the pandemic. They must utilise their constitutional power to frame policies and enforce legislation to curb unethical practices by the private sector. An oversight mechanism must be developed and enforced strictly. The reality is that the private sector is better equipped to deal with critical care. The immediate need therefore is for governments to devise mechanisms for utilising the private sector without pinning any financial burden on people,” she said.

India is far ahead of both China and Africa in terms of the number of confirmed cases and the mortality rates. On May 20, the government claimed that the low death rate was due to timely case identification and clinical management of cases. It said that it was focussing on upgrading COVID-19-dedicated infrastructure. There has been little self–criticism about the state of the overall public health infrastructure in the country, the intransigence of the private health sector in either denying treatment or being reluctant participants in COVID-19 treatment and management or the government’s own callous mismanagement of migrant worker populations and how that may have contributed to the spurt in new cases in May.

Fresh cases were reported in Maharashtra, Tamil Nadu, Delhi, Gujarat, Madhya Pradesh, Uttar Pradesh, Andhra Pradesh, Punjab, Bihar, Telangana, Karnataka and Kerala. But there is a wide variation in the numbers and in recovery rates. States such as Kerala have much better rates of recovery and an almost negligible number of new cases. Maharashtra continues to lead with the largest number of cases, including fresh cases, and deaths followed by Tamil Nadu, Gujarat and Delhi.

Even though Tamil Nadu accounts for 11.81 per cent of the national caseload, a little more than Gujarat’s 10.92 per cent, and is in second place after Maharashtra in the list of confirmed cases, in terms of fatalities, only 95 people have died there compared with 773 in Gujarat.

Stung by the criticism that it had not utilised the lockdown period to ramp up health infrastructure, on May 21 the government (through Health Ministry media releases) declared that it had a high recovery rate of 40 per cent and had initiated a community based sero-survey to estimate prevalence of the disease. Twenty meetings of the National Task Force were held, it said. While 3,027 dedicated “COVID-19 hospitals” had been identified and 7,013 care centres set up (converted from existing public and private facilities), the fact is that no new hospital supported by the Central government has come up in the public sector. The only reason hospitals are not overcrowded is because of the enforced lockdown, the restrictions on movement and the lack of all means of transport. It is not because people are not falling sick.

There was nothing in the Union Finance Minister’s financial package announced in May, almost a full two months after the lockdown began, that could bring immediate relief to the lakhs of workers in the unorganised sector who had lost their livelihoods. Even the package on health was in the form of a slew of announcements that will come into effect later. Yet, the decision to go easy on the lockdown appeared to be motivated not so much by the COVID-19 caseload but by the pressure of industry to reopen economic activity.

Labour laws tweaked

The lockdown has been used as the perfect opportunity for employers to sack or lay off staff. Factories were eager to restart operations employing fewer people working in 12-hour shifts. To make this possible, several State governments tweaked their labour laws with the full backing of the Union government. The apprehension that the influx of city dwellers into the hitherto insulated rural hinterlands would lead to a fresh wave of cases there was not something the Central government seemed overly bothered about.

The spread of the epidemic to places that had not reported a single case or in areas where the epidemic had been successfully contained earlier is evidence that the lockdown has not worked. In fact, in the third week of May, the daily increase in the number of cases ranged from 3,500 to 5,000, and in the 24-hour period between May 18 and 19, it went up to 6,154 in one single day.

Amulya Nidhi, a public health activist in Madhya Pradesh, told Frontline that the lockdown was meant to buy time so that the government could ramp up health infrastructure to make it possible for the country to handle the pandemic. “However, there has been no reliable and in-depth assessment of the social, economic and health situation, and instead of strengthening the public health infrastructure, in many States the dependency on the private sector to handle the pandemic has been increasing. By this time, tests should have been made more accessible and easier for all segments of the population. But this is not the case in the majority of the States today,” he said.

Talking about Madhya Pradesh, he said that the State lagged far behind in testing capacities. It had just 20 testing laboratories, whereas States with a comparable population, such as Gujarat and Tamil Nadu, had increased the number of testing laboratories. Gujarat had a total of 37 laboratories and Tamil Nadu 67. Madhya Pradesh, he said, was nowhere close to achieving even a minimum number of testing laboratories necessary to gear up for the increase in cases when the lockdown was lifted.

“The lockdown is being touted as the golden solution. At the same time, the lockdown is being declared a success. However in the case of M.P., this is not at all the case. The State government’s strategy was to “Identify, Isolate, Test and Treat”, which it has failed miserably to implement. In the last two weeks, as lockdown 3.0 was coming to a close, the infection spread to 11 new districts. Today, 49 out of 52 districts have infections. On March 19, the government published data on 25 dedicated COVID-19 category 1 hospitals spread across just 13 districts…. When citizens paid the economic price for the lockdown, with lakhs losing livelihoods, why didn’t the government use this time to strengthen public health care infrastructure?” he said.

A senior official associated formerly with the health department in Haryana told Frontline that at the Panchkula Civil Hospital, a doctor had been hired to run the intensive care unit (ICU). No routine surgeries were taking place. Neither was the OPD open for people. “There has been no planning on how to run an ICU. If there had been too many cases, they would not have been able to manage. A typical ICU is not only about having ventilators. It is a complete system. We need trained staff as there are ventilator [-operating] protocols. There are ICU guidelines but [these are] not followed. I doubt if district hospitals in India have ICUs,” he said.

On May 15, the government issued an advisory for the management of health care workers in COVID-19 and non-COVID-19 areas of hospitals. It seems that a large number of health personnel and their contacts were found infected and had to be isolated because of which the health service delivery in hospitals had been adversely affected. It is clear that the situation can hardly be described as optimistic. Initially, the number of such personnel who were infected was made public, but later these figures were not released despite repeated queries by the media.

The World Health Organisation declared COVID-19 a pandemic on March 11. India took a full fortnight to react to it. Although it had begun screening passengers at airports early on in January, only those from China and Hong Kong were screened. Whether the lockdown was necessary at all is a debate that will continue to rage for years. Its disproportionate effect on the vulnerable sections—exemplified in the images of migrant workers being humiliated, being beaten by the police, being reduced to beggary and getting killed on roads and rail tracks—is not going to be forgotten easily.

A letter from the Editor


Dear reader,

The COVID-19-induced lockdown and the absolute necessity for human beings to maintain a physical distance from one another in order to contain the pandemic has changed our lives in unimaginable ways. The print medium all over the world is no exception.

As the distribution of printed copies is unlikely to resume any time soon, Frontline will come to you only through the digital platform until the return of normality. The resources needed to keep up the good work that Frontline has been doing for the past 35 years and more are immense. It is a long journey indeed. Readers who have been part of this journey are our source of strength.

Subscribing to the online edition, I am confident, will make it mutually beneficial.

Sincerely,

R. Vijaya Sankar

Editor, Frontline

Support Quality Journalism
This article is closed for comments.
Please Email the Editor