Kerala was the first Indian state to be affected by Covid-19 with the highest number of cases at one point in time, but today it has a flat infection curve and one of the highest recovery rates in India. In this post, S.M. Vijayanand, Chief Secretary (Retd.) of the Government of Kerala, analyses Kerala’s experience in managing the Covid-19 crisis in the state and highlights critical takeaways for other states.

Kerala was the first state affected by Covid-19 in India. Till early March, the cases kept on moving up, and the state soon had the highest number of active cases in India. Then the effects of Kerala’s strategy to fight Covid started paying off and as on date the results are quite encouraging, if not substantial. As of today, it has the highest recovery rate, the least death rate and slowest progression in the country. This has drawn applause from the medical profession, social activists, academics, and people at large. Hence, it will be useful to analyse Kerala’s experience.

What Kerala did? Pathbreaking planning and action

Kerala took advance action in preparing for a serious Covid attack even before the first case was detected. Learning lessons from the Nipah attacks that fortunately were geographically more confined, and which it was able to counter, the Health Department got its act together quickly this time and alerted the officials from top to bottom. As soon as the first case was detected, elaborate contact tracing was done and put in the form of a map. In a short period of time, the Health Department acquired the skills for contact tracing, often in partnership with different agencies and individuals. Once the cases started increasing, the intensity of contact tracing could also be scaled up through the process of learning on the job. This anticipatory preparedness laid the foundation of the state’s effective response.

Another area of good performance has been the surveillance system. Right from early February, health staff were deployed in the four airports to screen patients coming from abroad. This process became systematically elaborate and active. On the ground the Health Department-led surveillance system took on a community-based character with the involvement of elected representatives of local governments, particularly village panchayats, members of the self-help group (SHG) system called ‘Kudumbashree’ in Kerala, and the citizens themselves. Since Kerala is a tourist state and has many people working outside the country (nearly 2.5 million), it had to be doubly careful. Also attention has to be perforce spread across the whole state including interior rural areas, in view of the tourist resorts in the hills and scattered nature of the non-resident Keralite population. The Police department actively got involved in this process. The level of coordination seen in this exercise is very difficult to achieve in a governmental set-up and that too in the face of real personal risk.

From the outset, the state resorted to dynamic planning anticipating an extreme scenario. Support of the private hospitals was sought and obtained. Large spaces that could safely quarantine people, including both public and private hospitals, and as a last resort, even empty houses which are aplenty in Kerala were mapped. Now the state has identified around 100,000 hospital beds, with potential for ramping it upto 200,000 in the event of an emergency. In the first fortnight of March itself, masks and hand sanitisers, which had disappeared from the market or became too costly, were produced locally especially by Kudumbashree teams. At the same time, local R&D (research and development) efforts were made to develop vaccines, improve testing systems and facilities, and even attempt advanced technological interventions such as plasma therapy.

It is to be noted in particular that almost the entire treatment burden of the nearly 450 affected people fell on the governmental health system. Analyses often fail to note the success of treatment that even saw a 93-year-old man and two persons above the age of 80 come out hale and healthy. This is one area which needs a professional study post Covid-19. With the rise in the number of cases, Kerala, which had only one testing facility – the National Institute of Virology in Alappuzha – increased it to 14 such facilities within a short period of a month. It could also set up Covid wards and hospitals fully equipped at short notice.

Managing the spread

The state was the first one to come up with a separate law to handle the Covid-19 problem. The state also resorted to a lockdown to minimise the spread. Instructions for reaching out to the public were regularly issued and the police was sensitised to make it as humane as possible.

Social security

In early March itself, the state came up with a Rs. 200 billion relief package. In order to put cash into the hands of the poor, social security pensions were distributed, assistance from the welfare funds was released and interest free loans to the members of the SHGs were provided. The public distribution system (PDS) was activated and free rice provided to every card holder irrespective of the type. In addition, kits having essential condiments are also being provided through the PDS outlets.

For the beneficiaries of Anganwadis (childcare centres), their quota of food is provided at their doorstep once a week, covering adolescent girls, pregnant women, lactating mothers, infants up to three years of age, and children from three to five years of age.

Since Kerala has a large number of in-migrants estimated at around 2.5 million, special arrangements were made to provide them with cooked food or food materials, as per their choice. Nearly 20,000 such camps are functioning – the largest number anywhere in the country. Also the camps that are quite cramped are constantly monitored to ensure sanitation and avoid health incidents.

Free cooked food is being provided by local governments to all those who need it, with the support of Kudumbashree members. Further, help lines are available to elderly people who can access their medicine or food materials through volunteers. Thus, the policy of ‘no one left behind’ has been operationalised.

How Kerala did it

Kerala followed a community-based approach under the leadership of local governments, especially village panchayats, municipalities, and municipal corporations. The local governments mobilised the support of Kudumbashree. Further, volunteers currently numbering more than 330,000 have been registered. Under the leadership of the elected ward member, squads were formed for outreach and feedback. The psychological impact of this has been very positive. People have realised that help is close at hand, is assured, and even lone voices for help would be heard and responded to. This has succeeded to a large extent in reducing the anxiety, particularly of those quarantined and citizens confined to their homes. Government hospitals at all levels, from the primary health centres to the medical colleges, were given clear responsibilities. The field-level staff including ASHA (Accredited Social Health Activists) workers functioned as teams with clear protocols and regular instructions.

For the elected representatives and the Kudumbashree members, capacity-building was ensured through simple manuals and electronic classes. Coordination at the middle level has been largely done by the District Collectors working very closely with the District Medical Officers and the district-level heads of the police. These teams provided a vital link between the government and the field formations, and undertook the task of troubleshooting.

At the top level, a war room functions with key officials. The Chief Minister (CM) himself took the lead particularly from mid-March. The most visible and applauded initiative of the government has been the CM’s daily communication with the people followed by a press conference. The communication focuses on facts, hides nothing, states all problems, stresses the dangerous situation, and comforts the people with specific assurances. Every major issue that arose during the day is highlighted in these communications, along with the measures the government has taken or intends to take. Good deeds are published and bad behaviour is mildly rebuked. This has complimented the grassroots initiatives perfectly.

How could Kerala do it? The Kerala model of development

Kerala has a long history of public action that was visible even during the incredibly casteist era, which made Swami Vivekananda describe Kerala as a “lunatic asylum”. From mid-19th century, even during the days of monarchs, primacy was given to health and education. The social reform movements, particularly in the early part of the 20^th century, enabled the backward classes and the dalits to benefit from these government initiatives. It is interesting to note that while fighting the most aggressive caste system in the country, all the social reform movements sought liberation by way of human development, that is, health and education.

The nature of the State also was quite different. It was the least repressive in the pre-independent India and often tried to meet public demands in an accommodating fashion.

Post-independence, and more so after the formation of the state of Kerala in 1956, the governments became socially and developmentally progressive. Land reforms, and effective public distribution system (critical in a state that produces only around a third of its food needs) were pushed aggressively. A wide social-security network – now reaching out to 4.74 million individuals – was developed. At the same time, the emphasis on human development became even more striking, while conscious and successful efforts were made to reduce intra-state regional and social inequalities. All these came to be known as the ‘Kerala model of development’.

In the 1970s, Kerala innovated the with creation of institutions of excellence in various spheres of development, most of which have acquired national and international stature, the best known of which is the Centre for Development Studies. Two other such institutions are the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum and Rajiv Gandhi Centre for Biotechnology, Trivandrum (started in the 1990s). These have suo motto taken up high quality rapid research for dealing with Covid-19.

A high watermark of Kerala’s development was the literacy movement that saw a new dimension of public action in the beginning of the 1990s, along with constructive and voluntary public service. The tempo generated by this grassroots-level initiatives culminated in the “big bang” decentralisation of the mid-1990s, and the launch of the now famous ‘Peoples’ Plan’. Power and authority for local development was transferred to the local governments, which received approximately one-third of the Plan funds, out of which one-fourth was given practically in an untied form with plenty of freedom for local-level decision-making according to local needs.

As part of decentralisation, the public institutions of human development, namely, anganwadis, and schools and hospitals upto the secondary level, were brought under the control of local governments. Around this time, the Kudumbashree movement was started. While SHGs in the rest of the country focused on thrift, credit, and livelihoods, Kerala gave emphasis to gender empowerment and accessing development in addition to its conventional roles. This was seen as the next step in democratic decentralisation, creating social capital, particularly among the poorest sections of the society. This explains the unique strength of Kudumbashree network.

A conscious policy decision was taken right from the beginning that SHGs and local governments would work together in an equal relationship between the two autonomous entities, one representing social democracy and the other representing political democracy. In a sense, this helped realise Ambedkar’s idea of inseparability of social and political democracy, to a considerable degree.

With local governments working closely with the community-based women’s organisations, a lot of developmental experimentats have been initiated. For example, 10% of the funds devolved to the local governments has to be spent on gender plans, and another 10% for vulnerable groups like the elderly, children, and the differentially abled. This started a new phase of the Kerala model, focusing on care and compassion, and merged with the caring state in the 21^st century the welfare State that Kerala proudly claims it is. The best and most successful example of the caring state that Kerala is in practice is that of the palliative care movement led by local governments, harnessing professionals and the civil society in a collective act of grace and compassion, beyond the normal political calculus of votes or money. This model developed over the last 12 years has achieved international recognition.

Although the local governments initially seemed to focus too much on infrastructure and made several mistakes in running institutions of public service delivery, things have changed significantly over the last 10 to 15 years. It has been estimated that in the last five years, over 500,000 students have returned to government schools, a kind of positive ‘voting with the feet’. Of late, the primary health system has regained its role through effective outreach to combat the non-communicable diseases, which are the bane of Kerala, and the new communicable diseases of which Covid-19 is the most macabre.

An important feature of the Kerala model is migration. From ancient times, Kerala has had a flourishing interaction with the Middle East and Southern Europe, and since the middle of the 20^th century, Keralites have easily migrated to different countries and including the Gulf region since mid-1970s to seek better jobs. It is estimated that more than 2.5 million Keralites work outside the country, and an equal number of migrants from other part of India work in Kerala. The harsh conditions of migrant life are known to most of the Keralites, and hence, there is also a healthy respect for the in-migrants. So much so, they are called guest (‘atithi’) workers.

Of course, it also needs to be mentioned that there are lot of concerns that call for immediate action. These include conspicuous consumption, substance abuse particularly of alcohol, crimes against women and children, and so on. It is rather shameful that the tribals and the traditional fisher-folk continue to be treated as outcasts. Also, the ecological concerns remain largely unaddressed.

Conclusion

All the aspects of Kerala’s strategy to manage Covid-19 could be adapted in an emergency situation by any state of India. For such actions to be internalised and made sustainable, the nature of the State needs to change with focus on care and welfare. The biggest learning that needs to be nationally replicated on an emergency mode is the strengthening of the primary healthcare system within a short span of time. There cannot be any substitute for this through private interventions or market-based products like health insurance. Another critical takeaway from the Kerala experience is the importance of strong local democracy, institutionalised in the form of local governments, and strengthened by partnership with the SHGs. This can easily be adopted as India has 250,000 village panchayats with more than 3 million elected representatives of which more than 40% are women, and over 6 million women’s SHGs. Funds are there through MNREGA (Mahatma Gandhi National Rural Employment Guarantee Act)[1] and Union Finance Commission grants. All that is required is to provide the spark, which can only be political. This needs serious reflection and caution. It is worth recalling that 24 April marked the 27th anniversary of the 73rd and 74th amendments to the Indian Constitution to introduce local self-governance in rural and urban India, being passed unanimously in the Parliament and given the President’s assent – to be operationalised within a year.

Note

1. MNREGA guarantees 100 days of wage-employment in a year to a rural household whose adult members are willing to do unskilled manual work at state-level statutory minimum wages.