Blog 7 | HEaL Institute & IJME Covid-19 Insights | May 11, 2020
The first case of Covid-19 in India was reported in Kerala on 30th January 2020. But Kerala was able to contain the spread of Covid-19 to only 503 cases as of 8th May 2020. Moreover, 483 of these patients were able to recover and only three deaths were reported. Kerala’s unique outcome in dealing with the Covid-19 pandemic provides for an interesting analysis.
The World Health Organization’s (WHO’s) constitution states “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”. Kerala’s healthcare governance model attempts to translate this concept of right to health into practice. We provide brief insights into this model to appreciate its strengths responding to pandemics and also challenges involved.
Decentralization in health governance and policy
Kerala is well known for its unique model of development. Under the state’s decentralized governance structure implemented through the People’s Plan Campaign, the Public Health Centres (PHCs) and their referring sub-centers were brought under the jurisdiction of panchayats/municipalities. This has helped the state health infrastructure to engage more closely with the community to identify health care needs, and thereafter implement effective changes to these needs. Kerala had embedded and empowered the local self-governance institutions, in matters of health, via various legislations including through the Kerala Decentralisation of Powers Act, 2000. The decentralization has led to the continuous interface of doctors and community members working together to evolve needy and timely health care facilities to address community problems and priorities.
The recent aims to provide universal, affordable, and quality health care for everyone, which is approved by the State cabinet in 2019. The policy proposes a primary health center in each panchayat with all the facilities, including laboratory services. The healthcare landscape in Kerala is ahead in many parameters compared to other Indian states, achieved mainly due to effective primary healthcare.
The decentralisation of health governance in Kerala ensures the availability and accessibility of healthcare. The community health workers together with other community members cater to the health care requirements at gram sabha level. This helps in a strong community network to bring governance close to people. Thus, it might not be an overstatement to say that decentralization enabled a rights-based approach to health care.
Kerala’s effort to bring governance close to people has served it well during the Covid-19 crisis response. For example, a strong participatory approach in health care decision making at local level enabled community-based support in quarantine and monitoring measures. In the Covid-19 crisis scenario, the effective monitoring of home quarantine, as well as identifying the essential needs of the quarantined was possible through a strong community network.
The effective manner in which Kerala could respond to the Covid-19 health crisis, as well as to the earlier Nipah virus outbreak, highlights the success of its health governance policy, political will and commitment to its effective implementation. Kerala’s successful system of health governance is characterized by its decentralised functioning and its reliance on universal healthcare access. It has invested in strengthening healthcare institutions especially at the primary level. Also as seen in Kerala’s Covid-19 response, the state has laid a remarkable emphasis on transparency in communication, and community trust-building.
Securing public trust: Salience and strategies
Maintaining public trust during the times of pandemics remains foundational to pandemic response strategies both for practical and ethical reasons. The World Health Organization has also mentioned about the significance of building public trust. This has salience since it also determines the extent of people’s compliance with the containment strategies developed by the government in consultation with the representation from people and communities. We list three strategies which helped the Kerala government to achieve this compliance.
First, , the state government adopted contact tracing, which was the most effective strategy to control the outbreak of Covid-19. All the health personnel in the state were asked to undertake surveillance, monitoring, and contact tracing. The strong and robust network of Accredited Social Health Activists (ASHA) workers helped in effective implementation of this strategy.
Second, Kerala provided timely dissemination of surveillance data and updates about the outbreak’s control to keep panic under check and gain the confidence of the people. The regular transparent communication by the Chief Minister and Health Minister of Kerala, via daily press conferences, helped in this regard. This was a unique approach to gain public trust when compared to other states in India. Transparency, an important element of good governance, was also achieved through this exercise.
Third, the Government of Kerala enacted the Kerala Epidemic Diseases Ordinance, 2020, an ordinance for revamping the archaic Epidemic Diseases Act, 1897. The ordinance consolidates laws on the prevention of epidemic diseases. It allows for special measures including quarantine or isolating people based on their travel history, restricting movement. This helps in contact tracing in case of virus spread. The Ordinance also empowers the state to seal borders and restrict public transport as preventive measures and issue guidelines for social distancing. Overall, it restricts essential services and makes the breaching of these measures a punishable activity. This thoughtful and prompt response should serve as a torchbearer for other governments to take the necessary steps to contain the spread of the epidemic.
Challenges and Way Forward
Though considered a model for other states, Kerala’s health governance system has recently faced several challenges: the epidemiological transition towards chronic disease, reduction of public health funding, and the enhanced presence of private health sector providing care at a much higher cost. The shift from the public to the private sector is a concern because individual household spending on health expenditure is increasing while many public facilities are underutilized and understaffed due to migration of doctors in public service to higher-paying jobs in the private sector. Another challenge being faced by Kerala is the lack of a cadre of specially trained public health professionals for tracking infectious viral diseases. Lack of adequate infrastructure and facilities for testing of diseases is yet another major constraint.
The following pertinent measures are suggested for maintaining the robustness of Kerala’s health governance system:
- More investment in the public sector is needed to revitalize the health care system. There is a need to revamp the system in a way that the public and private sectors effectively co-operate and complement each other to meet the health needs of people.
- More emphasis must be given to protective health care, as done in the past, rather than focusing more on curative care. The Directorate of Public Health proposed under the new Kerala Health Policy, 2018 must effectively care for the administration of hospitals and works related to public health.
- The quality of healthcare services by the private sector must be ensured. The strict enforcement of The Kerala Clinical Establishments (Registration and Regulation) Act, 2018, that provides for the registration and regulationof clinical establishments, both public and private, should ensure minimum standards of facilities and services by such establishments.
- There is a need to develop standard treatment guidelines and protocols binding on all medical professionals. The national guidelines for infection prevention and control in healthcare facilities should be strictly adhered to.
- Adequate number of medical labs with mandatory accreditation and improvement in quality services must be set up. There should be mandatory accreditation for medical labs as laboratory testing is an essential component of improved health care for patients. This is especially important as accreditation is emerging as a preferred framework for building a quality medical laboratory system.
- There should be greater development of active medical jurisprudence and consumer redressal forums to address a range of medical, legal, and ethical issues, as well as matters related to human rights.
(Deva Prasad M is faculty at IIM Kozhikode and Suchithra Menon C is faculty at Daksha Fellowship, Sai University Chennai.)
Blog editor: Sunita Bandewar