(TM
Thomas Isaac and
Rajeev Sadanandan2)
EPW article Vol. 55, Issue No. 21, 23 May, 2020
Introduction
Since
the incidence of AIDS, the first pandemic in the post globalisation era, public
health experts in Kerala have been conscious of the vulnerability of the state
to epidemics in any part of the world. High level of integration with global
economy, large non-resident population living in many parts of the world
andreliance of the state economy on international tourism contribute to the
relatively high vulnerability of the state. Outbreak of Nipah infection in 2018
heightened the threat perception. Since then Kerala has instituted a surveillance
mechanism to actively look for emerging pathogens, including disease X, (WHO’s
term for a hitherto unknown pathogen) that may strike the state.[1] So
when reports emerged from China about an unknown Coronavirus, Kerala went into
alert mode. On January 24th Kerala issued guidelines on managing
what was then called the 2019 Novel Coronavirus (2019-nCoV) and
later came to be called Severe Acute Respiratory Syndrome Coronavirus 2
(SARS-CoV-2).
Since
the epicentre of the disease was known, Kerala focussed on persons who returned
from China (or other hotspots as they emerged). Since data on persons whose
port of origin fell in China (or in other hotspots) was available with the
immigration department, it was possible to identify them and track their
contacts and quarantine them. The first three positive cases were from the
students who had returned from Wuhan. Since all arrivals from Wuhan had been
quarantined, further spread was successfully prevented. All the three recovered
by February 20th and the state remained free of active cases till
March 9th.
The
dynamics of tracing and tracking changed when new epicentres opened in Europe,
Iran and the GCC countries. Many migrant workers living in these countries
returned to Kerala. Kerala continued to track the returnees, now much larger in
number, who remained in quarantine and their contacts. Soon positive cases started emerging from
this cohort and Kerala emerged as the state with the largest number of Corona
Virus Disease (COVID-19) patients in India in India.
Many
simulations about the likely spread of the pandemic predicted a dire situation
for Kerala. An exercise under taken by Protiviti (2020) for Times Network on
April 12, estimated that infections would peak in Kerala on 8th May
with 72,057 cases with 22,281 severe cases needing intensive care. However the
current scenario is that Kerala`s active cases on that day would likely be
around two dozen.
What
helped Kerala was the aggressive strategy of quarantining / placing under
observation everyone arriving from outside hot spots and testing all
symptomatic persons and, if proved positive, tracing their contacts and placing
them under observation. As can be seen from Table 1 the number of new persons
placed in institutional or home quarantine began to sharply increase from 495
cases in the first week of March to 84718 cases in the last week of March. The
peak was reached on April 4th when a total of 171355 persons were
under observation. There after the number steadily declined reflecting the
decline in the new persons put under observation during April.
Since
adequate testing kits were not available the number of persons tested as a
proportion of the persons quarantined remained low till the second week of
April with the numbers going up as Kerala started community surveillance. Important
point to be noted is that almost all the positive cases were from people under
observation. So community spread was effectively prevented, even though the
strategy of testing only symptomatic persons from among the contacts would have
missed asymptomatic contacts who were on observation. Such asymptomatic cases,
even if undetected, would not lead to spread for the simple reason that the
quarantine period would have neutralized the infectious period. That the number
of positive persons remains low, even after the number of tests of persons who
were not contacts was scaled up, is a testimonial to the effective prevention
strategy of the state. Kerala’s strategy of quarantining all travellers from
epicentres cost the state revenue from tourism but has paid off in the number
of potential infections averted.
As
can be seen from Chart 1 the COVID Curve continued to gain momentum through the
month of March. During April the number of new cases testing positive began to
steadily decline and recoveries accelerate. As result the Covid Curve lost
momentum and Kerala managed to flatten the curve of COVID-19 infections till
now. As on May 1st Kerala has the lowest case fatality rate of 0.8
percent and the highest recovery rate at 78.71 percent. The national averages
are 3.23% and 26.52 respectively. Finally by 1st May 2020 Kerala`s
doubling time (30 days) is almost thrice that of the national average (11 days).
Table
1
Number
of persons on home quarantine, hospital isolation, tested, positive and
discharged in Kerala [30/01/2020 – 02/05/2020]
|
|
Number of persons
|
|
Period
|
Placed in
home quarantine
|
Under
Isolation in hospitals
|
Tested
|
Positive
and put on treatment
|
Discharged
after being cured
|
|
30/01 to
15/02
|
3430
|
207
|
415
|
3
|
0
|
|
15/02 to
29/02
|
289
|
30
|
70
|
0
|
3
|
|
01/03
to 07/03
|
433
|
62
|
197
|
0
|
0
|
|
08/03 to
14/03
|
6863
|
549
|
1215
|
19
|
0
|
|
15/03 to
21/03
|
46301
|
452
|
1819
|
30
|
0
|
|
22/03 to
28/03
|
83792
|
926
|
2351
|
130
|
13
|
|
29/03 to 04/04
|
52218
|
1007
|
3677
|
124
|
34
|
|
05/04 to
11/04
|
10160
|
1090
|
4419
|
67
|
93
|
|
12/04 to
18/04
|
534
|
725
|
4611
|
26
|
114
|
|
19/04 to
25/04
|
2260
|
755
|
3586
|
58
|
81
|
|
26/04 to 02/05
|
4424
|
719
|
8823
|
42
|
62
|
(Source:
Kerala Health Department)
The
first major wave has been effectively controlled. There is a high probability
that the epidemic could rebound, as has happened in many other countries that
achieved similar success early in the epidemic. The large scale return
migration expected from latter half of May will pose a major challenge to
keeping the epidemic under control. However the factors that helped Kerala
control the first wave and defy dooms day predictions has useful lessons for
management of health emergencies in low resource settings.
Chart
1
The
trends in COVID cases of Confirmed, Active, Recovered and Dead
Source:
https://dashboard.kerala.gov.in/
This
paper will explore the factors that contributed to Kerala’s successful response
to COVID-19. We argue that, in addition to a robust health system and demand
for health care, social capital of the state, the trust based social contract
between the state and people and the active involvement of the community
through local governments have played a significant role in Kerala’s success.
We also look at a plausible exit strategy for the state from the current
situation.
Health
Care System in Kerala: Demand and Supply
The
core element of Kerala’s response to COVID-19 is the strong health system of
the state. Good health indicators
achieved by Kerala have been attributed to both supply side interventions by
successive governments and other agencies and demand side interventions by
social movements. Spread of
education, particularly among women, also had a salutary impact on consumption
of health services. (Jeffrey, 1992)
The
establishment of the first public dispensary in 1819 by the Maharaja of
Thiruvithamkoor (the princely kingdom in the southern region - the main
constituent of the present Kerala state) was the first major intervention in
the creation of modern public health system. By 1860 Thiruvithamkoor had seven
government medical institutions. Being converts to the western system of
medicine themselves, the royal family lent their prestige to promoting health
services (Nagam Aiya, 1906). This roused interest in western medicine, while
the practice of Ayurveda continued to be popular. Education and medical
institutions were a part of the evangelical mission of the Christian
Missionaries. (Ramankutty, 2000, Baru, 1999)
While
underlining the importance of the pioneering efforts of royalty and
missionaries in Travancore, it must be also understood that there were similar
initiatives from the government and the missionaries in British India. Never
the less we find that by 1940 while British India had 6.8 institutions per square
kilometre and 21.27 beds per lakh population (Government of India, 1948) Thiruvithamkoor
had 22.56 institutions and 46.81 beds respectively (Government of Travancore, 1941).
Even
within Kerala we find a sharp and growing divergence in health and education
facilities between Thiruvithamkoor and Kochi in the South and Centre and
Malabar region directly under the British rule in the North. The latter was
relatively backward in social indicators when compared to the former and the gap
widened during the colonial period. The divergent experience in social
development between North and South Kerala has been attributed to the
difference in the agrarian structures, the former being dominated by Zamindar
like land lords and the latter characterized by their relative absence. It
facilitated the emergence of a rich farmer class and, later, the development of
agro processing industries in the South and emergence of modern classes. This
was the back ground of powerful social reform movements in the different castes
and communities in the South generating demand for education and health care
which were perceived as ladders in upward social mobility (Tharakan, 1984, 2008).
Such social intermediation was relatively weak in the North (Kabir and
Krishnan, 1992).
Malabar
region began to close the gap with rest of Kerala after the unification and
formation of Kerala. The first Communist government in 1957 initiated
substantial investment in health and education facilities in the North. The
popular demand for health and education gained momentum with the movement for land
reforms and its implementation. The vital contribution of the demand from below
for public health has been dramatically revealed in Mencher`s comparison of the
primary health care centre (PHC) in Palakkad in North Kerala and that in
Thanjavoor in Tamil Nadu. The demand for health care and awareness of entitlements
in Kerala were so high that any denial of services in Kerala would be met with
protests. (Mencher, 1980)
Owing
to popular pressures from below, successive governments in Kerala have invested
substantially more in healthcare and education when compared to the rest of
India. The share of health expenditure in total government expenditure for all
Indian states in the period 1960 to 1970 was 8.13% while it was 10.43% for
Kerala. However the fiscal crisis of the
state government from the 1970s forced cutting back the social expenditure
raising questions regarding limits to Kerala Model. (George, 1993) The health expenditure ratio declined over
time shrinking to 7.69% in 1985-86, 6.81% in 1995-96, 5.5% in 1999-00 and 4.5%
in 2004-05[2]. When
government cut back investments in health, the private sector stepped in to
meet the demand supply gap. (Sadanandan, 2001)
From
the low in 2004-05 the importance of health in Kerala’s budget began to creep
up during 2006 – 2011 period touching 5.1% in 2010-11 which was maintained till
2015-16. The government that came to power in 2016 launched the Aardram mission
with objective of transforming primary health care and increasing the
percentage of population using government hospitals. Under the mission more
than 5289 posts of hospital workers were added. In addition to doubling plan investment from Rs 629 crores in 2014-15
to Rs 1419 Crores in 2018-19[3] through
budgetary resources, Rs 2266 Crore raised through a special purpose vehicle (Kerala
Infrastructure Investment Fund Board) was committed to improving hospital
infrastructure and equipment (Government of Kerala, 2020). Results have already
become evident: the percentage of persons using government facilities went up from
34% in the 71st round of NSSO [2014] to 48% in the 75th
round (2017-18). (NSSO, 2015, 2019)
Response of the Health Department to COVID-19.
South East Asian countries, like Taiwan, which had
very close links to China and were expected to have an epidemic similar to the
Chinese one, benefited from their experience of having managed the SARS
epidemic which had a similar route of spread as COVID-19[4].
The experience of managing two episodes of Nipah gave Kerala a comparable
advantage. Health workers were trained to trace, track and transport persons
with symptoms safely, isolation beds and protocols for providing supportive
care were in place and people were familiar with the importance of observing
house quarantine. Above all people had lived through the terror of an unknown
pathogen and never underestimated the threat of the new virus. Kerala had the
experience of having managed a comparable threat and had the confidence that
they could handle this too.
From January 2020 Kerala started preparing
systematically to handle a possible outbreak. The standard operating procedures
issued by the state covered such areas as infection prevention and control for
ambulances, management of bio medical waste, handling spill of body fluids,
disinfection and sterilisation, hand washing, management of dead bodies, use of
Personal Protection Equipment (PPE) and sample collection and transportation. A
set of consolidated guidelines covering testing, quarantine, hospital
admissions, treatment and discharge was also issued and revised often to
accommodate changed perceptions and strategies. The guidelines were accompanied
by training modules.
The
additional investments in the health sector and the preparedness contributed to
high morale of the health workers which is indeed a sharp contrast to the sense
of helplessness and unrest among health workers in many of even the elite
medical centres in the country. From the beginning health minister of Kerala,
who had led the Nipah response from the front, provided strong and visible
leadership to the health department. The level of confidence health system
displayed in dealing with the epidemic and the trust the people of Kerala had
in the government health system rose from their competence demonstrated in
handling the Nipah crisis and the aftermath of two floods.
Social
Foundation of the COVID-19 Response
While
the health system remains the most significant contributor to Kerala’s health
status, demand side factors such as female literacy, empowerment of dalits and
other socially disadvantaged groups other than tribals, high levels of
political mobilisation, active involvement of panchayats and municipalities,
emergence of civil society groups, high salience of health issues in political
discourse and an active media have been important ingredients in ensuring that
health remained important to the people and government of the state. It has
also ensured that epidemic prevention efforts are supported by other actors in
Kerala society.
The
state government also tries to actively tap the synergies springing from coordinated
action with the above social actors and tap the abundant social capital in the
state. The high density of associational relations like non-government
organisations, religious groups, trade unions, libraries, clubs, and professional
associations who get involved in social issues have been identified as the
source of social capital (Heller, 1996). It has also been linked to reduction
of poverty in the state (Morris, 1998). Every political party has to
demonstrate their involvement of working with the people to remain relevant and
their units involve in activities related to rural poverty, women empowerment
and palliative care. These initiatives exist independent of government and
complement government’s efforts. They were on the scene during the Nipah crisis
and floods and now have mobilised themselves to support the COVID response too.
Transparency
and Trust in Government
Management
of health emergencies require active collaboration by the population, who may
be required to make unpleasant sacrifices. To achieve such collaboration people
must have trust in their government (Scot et al, 2016). Traditionally trust in government has been
high in Kerala. This was augmented by the success in managing many crises in
recent years. So messaging on social distancing and self-quarantine were viewed
seriously by the people who also exercised peer pressure on errant persons.
During
times of crisis people value reliable information even if it is bad.
Willingness of government to share information with the people constantly
increases transparency and generates trust. The Chief Minister of Kerala, after
reviewing the data and discussing policy decisions, share the important
information with the people every day through a live press conference which has
been the most watched event in recent days in Kerala. Constant information, not
all of them good, is shared through the mainstream and social media. Government
has borne the entire cost of testing and treating COVID-19 in the state.
These
actions have earned for government the trust of the people, which creates the
environment for people to co-operate with government even if the task is
difficult. They believe that their government is transparent sharing truthful
information, will take care of them should they fall sick and support them if
they need it. In return they are prepared to subject themselves to restrictions
government has imposed to control the epidemic. It is generally felt that the government
has been successful so far. The real test of this trust will come if and when
the situation becomes serious and the state’s capacities are in danger of being
overwhelmed.
Decentralised
Participatory Planning
The
leadership provided at the ground level by local government institutions, who
have been empowered with funds, functions and functionaries, played a major
role in coordinating activities in other sectors with health interventions and
also supporting health initiatives at the level. The year 2020 marks the 25th
anniversary of the People’s Plan Campaign for democratic decentralisation that
has placed Kerala as the fore runner in decentralisation (Thomas Isaac and
Franke, 2000). In addition to investing their own resources in augmenting human
resources, drugs and equipment and launching into areas that were ignored by
the formal health system such as palliative care and rehabilitation, local
governments have been active on prevention and control of infectious diseases
and disaster management. Having managed the periodic vector and water borne diseases
every year and health consequences of floods in two successive years had
prepared them to manage the current health emergency.
Disaster
Management has been and will continue to be a centralised hierarchical process.
But the experience in Kerala demonstrates the importance of local level
planning, mobilisation and intervention within the larger macro framework,
which ensures equity and access in mitigation efforts. A formal recognition of
this new responsibility came with the government order empowering the local
governments as the agency to prepare local level disaster management plan. The panchayat/municipal
level disaster management reports analyse recent natural disasters particularly
floods, and then propose medium term mitigation projects which would be taken
up by the local governments or proposed to the higher tiers of government. They
would also include an immediate action for response in case such a disaster
recurs. The state government has also been organising a volunteer force, with
at least one volunteer for 100 people, to be coordinated by the local
governments during disasters. Management of COVID-19 fitted in this framework
for disaster management of panchayats and municipalities.
Local
Governments and Health
People`s
Planning was launched with a declaration to transfer 30-35 % of state plan
funds as untied funds to local governments. Health has been a major beneficiary
of this financial devolution. Indeed, an important rationale of the large transfer
was to improve the quality of government services in education and health. It
was expected that the local level plans would reflect people’s priorities more
effectively, which in Kerala would definitely benefit the health sector. During
the initial years results were mixed. The overall investment in state and local
plans for health doubled from 2.2 to 4.5 per cent (Thomas Isaac and Franke,
2000).
The
efforts were stymied by the reluctance of the major power holders in the health
sector, doctors, to engage with local governments. They were also reluctant to
shoulder additional duties involved in implementing local health projects,
particularly, construction activities. Over time this attitude changed and
medical personnel began to be actively involved in the local planning process.
They realised that it was much easier to get their priorities accepted by the
local elected representatives than the bureaucratic hierarchy. There has been a
large body of literature that have attempted to evaluate the impact of decentralization
on health care. Though there is always scope for improvement the studies, by
and large, support the thesis of positive impact (Elamon et
al2004, Chathukulam 2016, Azeez 2015, John and Jacob 2016, Chandran and Pankaj
2014, Abdul Azeez 2015).
The
involvement of the local governments in health care at the primary level has witnessed
the dramatic improvement after the launch of Aadram Mission. Local governments
contribute to improvement and maintenance of the buildings of primary health
centres and sub centres, purchase of drugs and medical equipment, employ
doctors, nurses and paramedical staff on contract and supplement the honorarium
of ASHA (Accredited Social Health Activist) workers. They also provide the
bridge between health department and civil society organisations such as
palliative organisations, voluntary food programs and kudumbasree health
volunteers. They have an important role in geriatric care, support for
differently abled and finance the special schools for children with cognitive disabilities.
They are in charge of prevention of vector and waterborne infectious diseases. Given the high
level of involvement of local governments in health and related sectors it was
only natural that they play an important role in the fight against COVID-19.
Local
Governments and the Pandemic
On
20th March 2020 the involvement of local government was formalised
through a government order. It listed generation of awareness about COVID-19
and Break the Chain movement, sanitation, support for persons in isolation,
ensuring availability of essential items and documentation of prevention
efforts including inventorying medical and other resources and number of
persons who needed additional support as responsibility of local governments.
It also listed the functions of different levels and office bearers.
Beyond
the above formal assignments, what brought out the strength of the local bodies,
were the community kitchens to provide food to whoever needed it, which sprung
up in less than three days across the state. They were set up wherever they
could be: closed down hotels, school kitchens, marriage halls. Most of the provisions
needed- rice, pulses, condiments, vegetables and even meat and fish - were
mobilised through donations. Apart from one or two cooks every kitchen was run
by a large number of volunteers as kitchen helpers, parcel makers and
distributers. At its height the community kitchens were serving more than five
lakh meals per day. For persons who could not come to the kitchens food was
delivered at home.
It
was possible to scale up the operation so effectively in such a short time
because of Kudumbasree, a network of women’s neighbourhood groups (Kannan et
al, 2017). They have a strong tradition of involvement in poverty alleviation programmes.
They were already operating 946 catering units and 1479 cafรฉ units. There were
also palliative care groups that provided food free to the doorstep of
destitute bed ridden persons. The local governments drew on their experience
for setting up their community kitchens. As the economy exits from the lock
down, the community kitchens will also withdraw but most of them would be
taken forward as budget hotels by Kudumbasree women providing meals at Rs. 20
and even free to the needy.
Yet
another responsibility of the local government has been monitoring the camps of
migrant workers and ensuring their food and medical treatment. Kerala accounted
for 65 percent of the 23567 camps and 47 percent of the 6.5 lakhs migrant
workers sheltered in them in India[5]. The
local government representatives and officials visit the camps, check sanitation,
provide food kits in some locations and, in some cases, even made available
free mobile chargers and games like chess and caroms to keep them engaged. An
interesting good practice is that of Uralunkal Labour Contract Cooperative
Society, the largest construction cooperative in India with nearly 3000
workers, majority of whom are migrant workers. The migrant workers are
encouraged to take membership in the society so that they get full benefit of a
member (Thomas Isaac and Williams, 2017). When the crisis came, those workers
who wanted to return home were sent back at the expense of the Cooperative
itself in special buses. While the situation of the migrant workers is far from
satisfactory the local governments tried to make them as bearable as possible.
In
addition to health and local self-government departments, similar guidelines
were also issued by other departments such as police, disaster management, education
and a few other departments on how to support COVID-19 prevention efforts. Such
guidelines would not produce the desired results if their implementation was
not coordinated and monitored. Performance monitoring and coordination of the
functioning of different departments are meticulously reviewed by the Chief
Minister every day and results of the analysis shared with the people of
Kerala.
Exit
Strategy
Kerala
is now preparing an exit strategy from complete lock down. An important
challenge would be to track and test and where needed quarantine or treat the
expected 5 lakh migrant Malayalees who would be returning from gulf and other
foreign countries and also from other states in India. Local governments have
been involved in identifying all the potential return migrants in their area
and are collaborating with Public Works Department to find hotels, hostels,
unoccupied flats and large houses to quarantine them. Already accommodation has
been identified for 2.5 lakh persons. All the returnees have to be quarantined
and tested and those found positive would be isolated and
treated. There would be also option for the return migrants to use hotel
accommodation for quarantine on payment.
The
second component of the exit strategy is reverse quarantine. All persons above 65
and those suffering from chronic diseases, who are at higher risk of adverse
consequences if infected, will have to stay indoors and, if necessary, in the
isolation rooms in the houses. For Kerala this will be a daunting task with 13.5
percent of population above the age of 65 and high incidence of diabetics and hypertension.
Quarantining more than 40 lakh people in the house would require big data analytics
to draw up regional strategies. Equally important are the local level planning
to provide medicine, counselling and if necessary, free food to those who are
quarantined. Personal hygiene, habits of hand washing and use of masks will
have to be strengthened. Some of the local governments like Aryad Block
Panchayat and constituent Gram Panchayats are already experimenting with reverse
quarantining. Using digitised health data of all the citizens, telemedicine,
free food, medicine and counselling to the needy, their effort is to ensure
that the aged and other vulnerable sections stay home safe.
Third
component of the exit strategy would be carefully opening up livelihood
activities. The first to open up was agriculture and allied sectors and cottage
and small scale industry. These sectors are largely with in the domain of the
local governments. Cultivation of paddy and mixed crops in the coconut
homesteads in the state have been declining. Perhaps COVID-19 crisis may provide
an opportunity to reverse the trend. Even during the lock down period vegetable
cultivation was being promoted and is going to be taken up on a campaign mode.
Peoples’ Plan Campaign had succeeded in establishing large number of
aggregation models of participatory small scale vegetable cultivation. The
Agriculture Department is in the process of drawing up a comprehensive package
for agrarian revival in collaboration with the local governments. The reopening
the traditional industries will be paralleled with program for promoting new
enterprises. The budget for 2020-21 had
provided for generating five new jobs in non-agriculture sector for every 1000
persons in every local government area.
The
MGNREGS activities constitute an important component of the exit strategy. They
would be front loaded to the maximum extent to provide employment and income to
the poor. It has been decided that the focus of the program will be on
de-silting and reconstructing about half the 80000 km canal network in Kerala,
which would help to mitigate the possible flood during monsoon and help
irrigation in summer. The gram panchayaths are the sole agency for the
implementation of the MGNREGS works in Kerala and a convergence approach with
the local plan is being adopted.
Unlocking
the economy is a much larger exercise than local agriculture and industry
programmes. It would require concerted action from the Central and State
Governments. The state has already drawn up certain priority sectors such as
pharmaceuticals and medical devices industries, bio technology and information
technology sectors, value adding agro processing industries and tourism. The
new brand image the state has gained as safe and resilient region would be
utilized to attract investment to these sectors. With the expected heavy return
migration, special efforts would also have to be made for the rehabilitation
and reintegration of migrants. Large scale infrastructure investment from
resources mobilized through special purpose vehicles like Kerala Infrastructure
Investment Fund Board (KIIFB) will also be playing a major role in the exit
strategy.
Fiscal
Crisis
The
State Government has already appointed two committees, one by Planning Board
and the other by Gulati Institute of Finance and Taxation to study the impact
of COVID pandemic on the economy and state finances respectively. It is not our
intention to discuss these ongoing exercises. Special packages have to be
prepared for each of the industrial sectors. For the MSME sector as well as the
farm sector, the moratorium period should be extended to one year with an
interest waiver and the existing loans restructured to provide additional
working capital. While the Central Government has been generous with the tax
concessions for the corporates it has been extremely miserly towards the MSME
sector. The conditions imposed for accessing central governments support for PF
and ESI concessions are too unrealistic for most industrial units in Kerala to
take advantage of.
The
biggest handicap of the state government has been the unprecedented fiscal
crisis that the state government is facing. The states own revenue have shrunk to
one tenth of the normal and overall revenues including the central devolution
is insufficient to even pay the monthly salary. This situation has not deterred
the state government from rolling out a 20,000 crore Covid package, half of
which is essentially direct income transfer to the people under lockdown
conditions. This has been largely financed by front loading the borrowings, the
co-operatives and kudumbasree micro finance.
At
present we have a strange situation in the country when the central government
is following a moderately expansionary fiscal stance while it is forcing states
to cut expenditure in times of the pandemic crisis. What one does is
neutralised by the other. It is very important that the state governments are
also taken into confidence and provided with additional fiscal space by raising
the fiscal deficit ceiling to five percent, full payment of the GST
Compensation and a special COVID pandemic grant to neutralise the decline in
central devolution.
Conclusion
The
STEPP framework, developed by the United Nations to deal with the Ebola
outbreak[6], -
Stop the outbreak, Treat the infected, Ensure essential services, Preserve
stability and Prevent further outbreaks - has become a standard reference norm
for health emergencies. Being a health emergency, health systems will be the
centre of the response. In STEPP only treatment is the exclusive domain of
health department. A comprehensive response will need to go beyond health
systems and mobilise the entire society. A large-scale, coordinated
humanitarian, social, public health, and medical response will be needed
(Farrar and Piot, 2014). Kerala’s COVID-19 response has passed this test. While
the exemplary leadership at state level in addressing the crisis has been
widely noted our discussion also highlighted the importance of the social
capital and the active involvement of the people through local governments that
played a significant role in Kerala’s success.
The
challenge is not over yet. We do not know the prevalence of the virus in the
community which may lead to new clusters developing silently. The large number
of expatriates and from other places in India who are set to come back is yet
another major challenge Kerala is gearing up to meet and may adversely impact the
disease situation. Till a proper vaccine is discovered or herd immunity
develops people will have to learn to live with the Virus. However Kerala has demonstrated the resilience
to handle all but the worst case scenario and perhaps avoid such an eventuality.
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[2] Reserve Bank
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within the
stipulated period of five years. He added that“….in case the amount in the
GST Compensation Fund fell short of the compensation payable in any bimonthly
period, the GST Council shall decide the mode of raising additional resources
including borrowing from the market which could be paid by collection of cess in the sixth ear
or further subsequent years". States were assured that compensation will
not be restricted to the compensation Cess collected. Section 10(i) of the
compensation Act reflects this position.
