Coronavirus | Opeds and editorials

Adopting a public systems approach to COVID-19

The progress of COVID-19 in India varies across States. The virus is now spreading more rapidly in southern India including States which had earlier received worldwide attention for ‘flattening the curve’. The surge in Kerala has not yet led to an appreciable increase in the mortality rate though. At the other end of the spectrum, Maharashtra and Delhi have slowed the rate of growth of cases but have registered higher mortality rates than most States. Gujarat is no longer the national epicentre but has registered the highest mortality rate of all. Maharashtra, Delhi and Gujarat are among the wealthiest regions of the country. It would seem from this that for a society, wealth is not necessarily health, leading us to surmise that the relation between them is mediated by something else, possibly the availability of public goods.

Characteristics and provision

A public good has the characteristic that it is accessible to all. Clean and sanitised public spaces, made possible by deploying a society’s public health infrastructure, are a perfect example of a public good. The isolation and quarantining of infected persons implemented by a public agency would be another. In both these cases, members of a society benefit from the existence of a public good, which secures their health without having to pay for it, at least not directly. However, this characteristic has implications for public-goods provision. The feature that it does not exclude makes it unlikely that the private sector, motivated as it is by profit, will supply the necessary health infrastructure in sufficient quantity and at prices affordable to all. So, public goods would have to be publicly provided.

Comment | Predictions, pandemics and public health

Two States of India where the existence of a relatively better public health infrastructure has diluted the impact of COVID-19 are Goa and Kerala. Goa has one of the lowest mortality rates in the country outside northeast India. Kerala has recorded a slightly higher death rate but also had faced greater challenges early on with travellers returning from the hotspots of the world, namely Wuhan (China), Italy and the United Arab Emirates. Subsequently, the trickling in of emigrants turned into a rush. The number of cases rose in the State but, as said, the death rate did not rise significantly. It may be mentioned that the public health infrastructure is to be understood as comprising hospitals and medical personnel. In a crisis, the role of the latter is perhaps more important. And, ‘personnel’ are more than just doctors. It includes nurses, health assistants, laboratory technicians and sanitation workers.

Infrastructure and outcome

Health outcomes are the result of an interaction of forces ranging from the level of expertise of health personnel to the civic sense of a population. The latter is manifested mainly in the willingness of the public to cooperate with the drive against the disease by using masks and adopting social distancing in public. However, we have reason to believe that the existence of a well-functioning public health infrastructure is central. This can be seen from its distribution across various States. As the measure of infection is directly related to the extent of testing, it is safer to rely on the mortality rate as the indicator of resistance to COVID-19. Now, outside the northeast, where many States have remained relatively unscathed, Maharashtra and Gujarat have recorded among the highest mortality rates and Goa and Kerala among the lowest. As of June 25, Ministry of Health data show Maharashtra and Gujarat with mortality rates that are six and eight times, respectively,that of Kerala’s.

We can see a relationship between basic indicators of the level of public health infrastructure and mortality in these two sets of States. Take the per person availability of allopathic doctors, hospitals and beds in the public sector. In each of these categories, Maharashtra and Gujarat do much worse than Goa and Kerala. Goa does better than Kerala on all indicators other than hospitals per person, registering a lower mortality rate.

Comment | How public health boosts an economy

Even though much more research is needed to establish the role of the public health infrastructure, the observed association between it and a population’s resilience in the face of COVID-19 is striking. It is important to understand that there is nothing inevitable about the sparseness of the public health infrastructure in Maharashtra and Gujarat. It is just that they chose to devote a far lower share of their national income to public health, despite their higher aggregate and per capita incomes compared to some other States.

So, States of India harbouring greater wealth than most have registered a higher mortality rate from COVID-19 even as some with far less have succeeded in containing them. In a way, the former face challenges that the latter mostly do not — mainly crowded urban spaces where social distancing is not possible. However, it is likely that their weaker public health infrastructure left them less resilient to the epidemic, resulting in higher mortality. Clearly wealth is not always health; when an epidemic strikes public capital in the form of a strong health infrastructure is.

Poor utilisation

We would however be advised to go beyond a focus on physical assets, such as hospitals and ventilators alone if we are to understand what determines a society’s resilience to an epidemic. It has long been recognised that ‘how you use it’ may matter more than ‘how much you have’ when it comes to any asset, particularly public capital. We may have only of late started worrying about our public health infrastructure but we have for long been aware that much of India’s publicly created infrastructure is poorly utilised. In particular the vast sums spent on irrigation have not resulted in a commensurate expansion of the area irrigated, at least in a truly functional sense. That this is a valid concern is evident when we note that Goa spends no greater a share of its domestic product on health than Gujarat does but turns in a much lower mortality rate. It suggests that the same amount of government expenditure can go much further with better stewardship.

Also read | We must continue with core public health and physical distancing measures: WHO Regional Director

A public systems approach is needed to first understand and then to address situations such the one we are now facing as the epidemic swirls about us. It takes into account both the physical resources available in the public domain and the practices adopted in governing their use. Every day we are reminded of the lapses in these practices. And death is not the only impact of COVID-19. There is also the distress it unleashes upon the living and the trauma that results from it. We read of bodies left beside patients in a prominent public hospital in Mumbai, of a man trying to revive his mother by himself in an isolation ward of a government hospital in Agra, of a woman giving birth in an autorickshaw as she was refused admission to several hospitals, including a government one, in Bengaluru (out of the unverified fear that she may be a spreader of COVID-19), and of a stalling crematorium at Delhi’s Nigambodh Ghat. Not all of this necessarily reflects the niggardliness of the public health infrastructure in the richest parts of the country. It is also a case of a lack of accountability in the public health sector. Right now, India’s public health infrastructure and its responsiveness should be the principal concern of the government. Adopting a public systems approach to the problem is the key.

Pulapre Balakrishnan is professor of Ashoka University, Sonipat. With inputs from Sreenath Namboodhiry, academic associate of IIM Kozhikode

Related Topics
This article is closed for comments.
Please Email the Editor

Printable version | Apr 15, 2021 8:42:03 AM |

In This Package
Examination priorities: On annual exams amid the pandemic
The secrecy around deaths after vaccination
Indian universities need immediate vaccination
Lessons from COVID-19
The second wave: On why new COVID-19 vaccines should be cleared
Weighing in on the saga of a vaccine
Rising poverty: On pandemic-induced disparities
A booster shot for India’s vaccination plan
Allaying concerns: On public trust and vaccination programmes
A moral test: On the vaccine divide
Efficacious too: On Covaxin
Sustaining the drive: On COVID-19 vaccination phase 2
Vaccine inequities: On need to vaccinate all above 45
Addressing vaccine reluctance and policy hesitancy
Redefining the exit plan for COVID-19
Boosting confidence: On need for efficient use of COVID-19 vaccine stocks
Opening up the vaccine market
Origin and spread: On the source of SARS-CoV-2
New questions: On COVID-19 infecting one-fifth of Indian population
A year on, mind the gaps in the pandemic response
Should Board exams be conducted in one go this year?
No to vaccine nationalism, yes to global cooperation
Tempered optimism: On India’s sliding COVID-19 graph
The best shot against COVID-19
More vaccines than takers
Managing the rollout: On addressing vaccine hesitancy
Injecting confidence: On India’s COVID-19 vaccination drive
Vaccine optimism and the scientific uncertainty link
Building trust in vaccines
The debilitating side-effect of a flawed vaccine trial
Gearing up: On vaccines and public trust
A hurried gamble: On vaccines and transparency
The second dose: On COVID-19 vaccine
A constant vigil: On the new coronavirus strain in India
Unmasked, reflections on the pandemic and life
Caution pays: On Centre’s COVID-19 surveillance guidelines
Towards an effective vaccination distribution policy
Essential dry run: On COVID-19 vaccination drive
COVID-19 and limits of political accountability
The purpose of a vaccine
Clear the fog, draw up a clear vaccination policy
Rein in the vaccine nationalism, the profiteering
In vaccine race last lap, the key steps for India
The storage tale of two vaccines
T-cell immunity and COVID-19
COVID-19, climate and carbon neutrality
Signs of easing: On India’s COVID-19 fight
Has India passed the COVID-19 peak?
Sooner, better: On indigenously developed COVID-19 test kits
The battered Puja economy
Outline of a pandemic fight, by and for citizens
Pandemics and the collective consciousness
Vaccines with a global common good guarantee
Saving lives under the long shadow of the pandemic
Until vaccine: On Unlock 5
The challenge of changing health behaviour
Weighing the costs: On COVID-19 vaccine
The slow and frustrating journey of recovering from COVID-19
Health worker safety deserves a second look
Unlocking campuses: On UGC’s revised academic calendar
Recovery from COVID-19 can be a struggle
Uniting to combat COVID-19
Coronavirus fears and preconception advice
An agriculture-led revival as flawed claim
A necessary pause: On the COVID-19 vaccine race
The uncertainties over COVID-19 numbers
The challenges in counting the dead
COVID-19 deaths may be higher than reported
The many challenges in estimating deaths
Alone at the top: On India’s COVID-19 numbers
The participants we need in Phase 3 trials
Differential impact of COVID-19 and the lockdown
More than a vaccine, it is about vaccination
COVID-19 and a country club India must leave
A quest for order amid cyber insecurity
You are reading
Adopting a public systems approach to COVID-19
Milestone of a million: On India’s COVID-19 numbers
Testing times: On university exams
Predictions, pandemics and public health
It’s time to flatten the pandemic stereotyping
Viral outrage only spikes the data
Sending the right message
Needed: Clear testing data
The social contract needs to be rewritten
The pandemic is about eyes shut
Joblessness and opportunity in Tamil Nadu
Green-lighting ecological decimation amidst a pandemic
COVID-19 has no religion
A case for extension: On rural jobs scheme
Surely, even if slowly: On a COVID-19 vaccine
Bend it like Italy: On flattening the COVID-19 curve
Promise and delivery: On India’s first COVID-19 vaccine
States hold the key: On Unlock 2.0
PCR testing is a double-edged sword
Science vs nonsense: On Patanjali’s COVID-19 claim
Shut and open: On tennis during the pandemic
The perils of follow the leader syndrome
The many questions about Favipiravir
In new lockdown, a second chance for Tamil Nadu
United front in Delhi: On Kejriwal government-Centre camaraderie
A prescription of equitable and effective care
Multilateralism post COVID-19
Making public transport safe during COVID-19
A better rate: On COVID-19 recovery
Look back in relief: On the migrant labour crisis
Needed, a transfusion for public health care
Wrong priorities: On keeping religious places open during a pandemic
Crossing the line: On Delhi’s decision to limit health services
Profit, not profiteering: On regulation of COVID-19 testing charges
In Persian Gulf littoral, cooperative security is key
Paging the private sector in the COVID fight
Curves and recoveries: On India’s coronavirus numbers
India’s Parliament is missing in action
Axing the economy’s trunk
Scripting a new narrative for COVID control
Open with caution: On Unlock 1
It’s time for a universal basic income programme in India
The waning of subaltern solidarity for Hindutva
Export blocks: On India’s trade amid the pandemic
A moment to trust the teacher
The echo of migrant footfalls and the silence on policy
Enjoying the fruits of their labour
Helping supply chains recover
The heavy burden of social suffering
An effective lockdown
The lockdown has highlighted stark inequalities
Will sport be the same in empty stadia?
Cinema after COVID-19
The eternal longing for the distant home
Working safely: On workplaces during the pandemic
A hole in the whole: On health sector woes
China, better prepared for the post-COVID world
How public health boosts an economy
Keep it retrospective
Backing the ‘angels in white coats’
Standstill: On opening of stadia for training
Flawed stimulus is justice denied
We need social physicians
A callous response
Peaking: On India’s coronavirus tally
Farm gate in focus: On amending Essential Commodities Act
A question of quarantine: On migrant workers and other travellers
TASMAC tribulations: On Tamil Nadu liquor sale
The pandemic and the challenge of behaviour change
One for the poor: On Centre’s corona package
Lockdown syndrome: On virus-induced economic crisis
Are India’s labour laws too restrictive?
Stop the return to laissez-faire
States cannot be left to the Centre’s mercy
Local motif: On Modi’s call for self-reliance
Liquidity lifeline: On Nirmala’s MSME package
A plan to revive a broken economy
Provide income support, restore jobs
Perilous state: On State finances
COVID-19 and the path ahead
Reaffirm cooperative federalism
Riding roughshod over State governments
Tragedy on the tracks: On the killing of 16 migrant workers
Coming to terms: On India refusing to admit community transmission
The trends shaping the post-COVID-19 world
The epidemic and ensuring safety in courts
Responding to COVID-19 at the grassroots
The face of exploitation
Contempt for labour: On dilution of labour laws
Slower growth and a tighter fiscal
Back home: On return of Indian expatriates
Blame game: On Donald Trump’s anti-China rhetoric over COVID-19
Resuscitating multilateralism with India’s help
A war-like state and a bond to the rescue
Fear and loathing in the land of the free
Everyone wants a good stimulus
Rent control amidst pandemic
Slow release: On lockdown 3.0
No comfort in numbers: On Bengal’s coronavirus cases
Pandemics without borders, South Asia’s evolution
India’s disease surveillance system needs a reboot
No relief for the nowhere people
BRICS against COVID-19
Recovering early: On India’s COVID-19 patients
It’s about food, nutrition and livelihood security
Taiwan’s coronavirus protocol shows how it is done
Needed: a pandemic patent pool
Getty Images/iStockphoto
Plasma therapy is no silver bullet
Take care of yourself too, fellow journalists
Strategic shift: On home isolation of mild coronavirus cases
Coping with today, planning for tomorrow
No end in sight: On India’s coronavirus strategy
Vividly imagining the life of migrant workers
A task for South Asia
Privacy concerns during a pandemic
Unlocking justice in the lockdown
Safe return: On migrant worker distress
The outline of another pandemic combat strategy
Pandemic and panic: On Tamil Nadu’s five-city lockdown
Protecting the poor from becoming poorer
Did SARS-CoV-2 begin from a lab?
Protection for protectors: On safety of healthcare workers
Rapid failures: On antibody testing kits
The COVID-19 paradox in South Asia
Fishing in troubled waters during a pandemic
How will India emerge out of the lockdown?
Making doctors wash hands
Locked out of cities, homes and livelihoods
Script of unity: On coronavirus and social prejudices
Exploiting a pandemic: On Trump’s immigration policy
The village is still relevant
A time for planetary solidarity
There may be no going back
No transparency in West Bengal
Focus on the curve: On India’s COVID-19 numbers
Economy in lockdown: On India’s worst case scenario
A shot of hope with a game changing vaccine
Caught in the heightened arc of communal polemics
Singing the corona tune
Helping a lending hand: On RBI’s second lockdown stimulus
A season of change: On IMD forecast system
A virus, social democracy, and dividends for Kerala
Across the gulf: On stranded Indian workers
Virtual reality: On telemedicine
A blueprint to revive the economy
A case to use JEE-Main instead of JEE-Advanced this year
Will the aviation industry recover from the pandemic?
Data-driven reporting during COVID-19
Stress test: On revised lockdown guidelines
Disastrous decision: On Trump halting funds to WHO
Cease the distractions, seize the moment
Getting the containment strategy in India right
In India’s response, a communications failure
Harmonising with nature
End the harassment of farmers now
A narrowing window: On extension of lockdown
Corona bond: On Eurozone COVID-19 rescue package
Halting the march of rumours
Polls during a pandemic
The pandemic and the contours of a health response
Economic liberalisation and its faults
Invasive, alien, most fearsome
Trade in tatters: On the global slump
Wanted, a collective national endeavour
Disingenuous and no antidote
COVID-19 and the crumbling world order
Women’s safety during lockdown
Lives and livelihoods: On economy after lockdown
Stage fright: On denying community transmission
Team India and winning the pandemic battle
In time of need: On hydroxychloroquine export
Will COVID-19 affect the course of globalisation?
Finding a scapegoat in WHO
Curating news for children during pandemic
A time for extraordinary action
For better use: On MPLADS funds
Needed, greater decentralisation of power
A key arsenal in rural India’s pandemic fight
Preparing for exit: On lifting the lockdown
Sanctions and pandemic: On America’s Iran policy
‘A script of action, responsibility and compassion’: Chief Minister Ashok Gehlot writes on Rajasthan’s fight against COVID-19
Taking a long view of the pandemic fight
Ten questions posed by the virus
A different economic approach
Why healthcare workers above 60 should be ‘benched’
Enemy at the gates: On Kerala-Karnataka border row
Reducing farm distress during a pandemic
Why everyone should wear masks
The criticality of community engagement
A niggardliness that is economically unwarranted
The spectre of a post-COVID-19 world
Light and sound: On Narendra Modi’s 9-minute light ceremony
A million and counting: On global coronavirus spread
Safe forests, safe people: On diseases of animal origin
Quarantine and the law
Making the private sector care for public health
Looking east to contain COVID-19
Limits to rugged individualism
Uncritical endorsement: On exodus of migrant workers and the Supreme Court
Beyond the blame game: On the Tablighi Jamaat episode
A long road: On India’s 21-day coronavirus lockdown
The missing notes: On politics and the fight against COVID-19
China’s zero: On China’s lead in containing coronavirus
Unprecedented step: On Wuhan lockdown
The return of the expert
Lessons from Hubei
A pandemic in an unequal India
Faith can’t override public health
Devising a people-centric response to COVID-19
Karnataka CM writes on how the State is fighting the pandemic
Tamil Nadu CM writes on how the State is stopping the pandemic in its tracks
The hunt for a cure begins with telling the truth
COVID-19 and a city’s anatomy
Long live the nation-state
The COVID cycle
Coronavirus | The worst of times, the best of times
It’s also a fight against punitive measures
The age of the neoliberal virus
The deep void in global leadership
Thinking national, acting local
Every man is a part of the main
Beyond social distancing to fight COVID-19
Next Story