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Men wearing protective masks walk inside the premises of a hospital on March 17, 2020. | Photo Credit: Reuters
How well India fights the novel coronavirus will be shaped not only by specific measures to tackle it, but also by the overall capacity of its public health and management systems. How capable is India’s public management system of tackling COVID-19? Some indications are available in a case study that I conducted in 2017-18 of a district.
If the virus were to spread in the district studied, its elected representatives would be aware and vocal about it. The local media too would report it. There would be considerable pressure on the district administration to act. In case of laxity, we can expect adverse media reports, and complaints to the State government. However, this pressure would build up only after a visible occurrence of the virus.
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Prevention, early detection and medical assistance to the affected would be more difficult. The first stumbling block would be the paucity of health facilities. For a population of over 12 lakh, the district had 26 government health centres with doctors, including the district hospital, community health centres (CHC) and primary health centres (PHCs), which is one per 35 villages and 0.5 towns. These had 820 beds (one for more than 1,500 people and less than one per village). There were 173 sub-health centres (SHCs), one per 5.4 villages. SHCs did not have doctors, but had auxiliary nurse midwives (ANMs) who were not medically qualified, but trained by the Public Health Department. Further, the health centres had an overall staff vacancy rate of more than 30%, and over 55% among class 1 and 2 posts, mainly doctors. One sample rural PHC had no full-time doctor. A doctor from a neighbouring PHC visited once or twice a month. The lab technician and pharmacist were shared with another PHC. There was a staff nurse who managed the PHC. When she handled a delivery at night, she had to attend to the PHC the next day. In another sample CHC, there were only three doctors against the sanctioned strength of six, one ward boy when four were needed, no dresser, and the doctors complained that there was no one to get patients in stretchers from the door.
In the sample SHCs, while basic equipment (instruments to measure blood pressure and glucose levels, vaccines, etc.) were available, the buildings were in poor condition. The ANMs did numerous surveys in their area of five to seven villages, and those interviewed reported difficulty in carrying instruments, vaccines, etc. They had asked for transportation, but to no avail. It can be imagined that with this manpower and infrastructure, stretched even at ordinary times, it would be difficult to follow additional protocols for the novel coronavirus.
However, there could be solutions. The District Collector could take charge at an early stage. In the short term, a capable District Collector could mobilise personnel from other departments, volunteers, and private medical practitioners and create temporary medical facilities. The capacity of the health system would thus increase manifold.
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However, there are three riders to the above solution. One, all District Collectors may not be capable because frequently, officials are posted on the basis of political patronage, not ability. In the district, in the previous 10 years, there had been eight District Collectors and 15 Chief Medical Officers. Thus, the leaders of the battle against the virus would most likely be new to the district. Two, the study showed rampant rent-seeking. As in the case of calamities, officials could pilfer government funds, and weaken the initiative. Finally, cracks will appear in these solutions if the crisis continues over time, even where officials are capable and honest. It will not be possible to rope in personnel of other departments or volunteers indefinitely. If there is a law and order crisis, the District Collector’s attention will shift.
The bare-bones health system will then have to cope. Not only will this be inadequate, but new problems could emerge. In the district, because of deficient public health facilities, people accessed private services often. The well-off went to private doctors in nearby towns, while the poor frequently went to traditional healers and ‘Bengali doctors’ — individuals without medical qualifications who ‘treated’ the villagers at a modest fee. It is not hard to imagine that many more such doctors would appear with rising anxiety and desperation and leading to further impoverishment and possibly harm to ordinary people.
How the public management system will deal with the COVID-19 threat will be shaped by these characteristics of the system. There could be good crisis management in the short term, but in the long term, inadequate health facilities will not match up. Along with the immediate response to the virus, there is need to think about creating long-term, sustained capacity in state institutions.
Rashmi Sharma is Senior Visiting Fellow, Indian Council for Research on International Economic Relations and a former IAS officer
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