Does Robust Health Infrastructure Alone Mitigate a Pandemic? Comparison of Health Systems and the Pandemic Mitigation in 2020 in Three Indian States

Madhya Pradesh

In the past, Madhya Pradesh was repeatedly flagged in the World Health Organization (WHO) and reports of other expert health organisations for failing to improve health indicators. The State has had one of the worst performances among the other States of India. For example, in 2008, Madhya Pradesh, Bihar and Uttar Pradesh accounted for 15% of the world’s total new-born deaths (WHO, 2009). It records the highest Infant Mortality Rate (IMR) among the Indian States and has one of the highest Maternal Mortality Ratio (MMR). The State has a population of 72,626,809 and a decadal growth rate of 20.3%, according to the Census 2011. The population density is 236 per sq. km (Central Bureau of Health Intelligence, 2019). A population of 5,688,993 lives in slums, distributed across 303 towns, constituting 7.8% of the total population.

The state is also one of the poorest in India. The per capita Gross State Domestic Product (GSDP) is only ₹72,599 compared to an average of ₹122,376 across India (at current prices and base year of 2011–2012). The correlation of poor IMR and high poverty levels and vice versa has been acknowledged by development planners (Government of Madhya Pradesh, 2007). Due to the lower-than-average State income, the State has been doing poorly in government expenditure on the health sector.

After the Independence of India when Madhya Pradesh State was first constituted, it followed on the course of nationally adopted socialist goals to expand public health services, especially in the rural areas. However, towards the 1990s, per capita, state expenditure on health in the State began to decrease, although Central government funding for health was broadly consistent. The expansion of rural primary healthcare centres was subverted by the adoption of a goal for targeting specific listed diseases and implementing family planning programmes (UNDP, 2013). In 2020, there were 1,171 Primary Health Centres (PHCs) and 309 Community Health Centres (CHCs) in the State. There were 465 total government hospitals with a total of 31,106 beds (Central Bureau of Health Intelligence, 2019).

Kerala

Per capita total health expenditure in Kerala is almost three times more of Madhya Pradesh, although in real terms, in 2020, it was only ₹5,000 crores greater than the total health expenditure in Madhya Pradesh. Per capita government health expenditure in Kerala was recorded as more than double that of per capita government health expenditure in Madhya Pradesh. However, in ratio terms, it was just 1 percent of the GSDP, the same as that in Madhya Pradesh. Per capita out-of-pocket expenditure in Kerala worked out at ₹5,111, more than 2.5 times the out-of-pocket expenditure in Madhya Pradesh. The total out-of-pocket expenditure in the State formed 2.7percent of GSDP (Central Bureau of Health Intelligence, 2019).

Population in Kerala is 33,406,061, half the size of Madhya Pradesh, but the population density is much higher at 860 persons per sq. km, more than double the national average and almost four times that of Madhya Pradesh. In Kerala, 50 percent of the population lives in urban areas in 520 towns and cities. Only 202,048 persons across fifty-nine towns live in slums which constitute 0.6 percent of the State population (Census of India, 2011). Only 7.1percent of the population, or 2 million people, live below the poverty line so that Kerala has the lowest Below Poverty Line (BPL) ratios among the major States. It made rapid progress in income levels in the last 2 decades to scale 1.5 times the national average income in 2015.

In health indicators, the State has the lowest IMR of 10 among the major states in India and an equally relatively lower MMR of 66. The State public health infrastructure has a total of 38,804 hospital beds in 1,280 hospitals, thus, constituting hospital beds to population ratio of 1.16 beds per 1,000 persons (Central Bureau of Health Intelligence, 2019).

Experts attribute the higher socio-economic development performance in Kerala to the trajectory of consistent development investment in the State. The colonial regime neglected to invest in developing a modern healthcare model, but the southern princely States in the Kerala region improved public healthcare by making substantive State contributions. After the Independence of India, the relatively higher investing remained undisrupted. Dissemination of knowledge of political process and rights of access to public services made popular mobilisations in the State demand improvements in public health and education (Ratcliffe, 1978, pp. 123–144). The government health services expanded rapidly until the 1980s but began to slow after 1985. After that, the thrust for the development of health and medical infrastructure was taken up more rapidly by the private sector than by the public sector. The number of private hospital beds increased from 49,000 to 67,500 between 1986 and 1996, amounting to a growth of 40 percent in the private sector beds capacity. The number of beds in the government sector grew only 5 percent in the same period (Kutty, 2000, pp. 103–109).

Delhi

Delhi was a Union Territory directly administered by the Central government until 1991, when it was restructured to give more self-governance powers to Delhi, and it was renamed the National Capital Territory of Delhi. The population composition of the State is unique because only 2.5 percent reside in census rural areas. The total population as per the Census 2011 is 16,753,235, half the population size of Kerala (Census of India, 2011). The population density of 11,320 persons per sq. km is the highest among the three compared States. Around 11 percent of the State’s urban population lives in slums (Ministry of Housing and Urban Poverty Alleviation, 2010). The large size of the slum population intensifies the human development problems in the State. Lower-income levels and lack of access to infrastructure and services in the slum pockets aggravate the health system challenges in the state (Ali, 2003).

The IMR last recorded in the State was 16, higher than in Kerala but lower than Madhya Pradesh. The improvement of health indicators is supported by the growth of State expenditure on healthcare. It was only 6.7% of government spending in 2004–2005, but this increased to 11.5% of total State expenditure and 0.75% of total GSDP in 2015–2016. Per capita State health expenditure has also risen to ₹1,992 from ₹560 in 2004–2005 (Central Bureau of Health Intelligence, 2019).

The penetration of PHC is lower than in Madhya Pradesh and Kerala. There are only 5 PHCs and 12 sub-centres. However, the number of total hospital beds grew by 20% in the decade between 2005 and 2015 (Central Bureau of Health Intelligence, 2005). The number of medical institutions grew 30% from 865 to 1,125 in the previous decade (Department of Planning, 2000). Delhi stands out among the three comparison states for the consistent higher allocation to public health expenditure in the total State expenditure.

Despite the comparatively higher public investments in health in Delhi, the health system has been characterised by the co-existence of poor health outcomes with the high economic productivity of the population. The PHCs are unable to meet the healthcare needs of the poor. The gap in healthcare service providers has been filled by the private sector, which constitutes expensive institutions such as the Max Super Specialty Hospital on one end and inexpensive but unscrupulous private clinics on the other end (Gusmano et al., 2017, pp. 23–29). Delhi was at the centre of the expansion of the private healthcare sector in India between the 1970s and the 1980s. The Second National Family Health Survey (1998–1999) recorded that 29% of the households in Delhi were receiving healthcare services from the public health sector while 70% preferred the private sector (International Institute of Population Sciences [IIPS], 2000).

Madhya Pradesh

The three-tier federal healthcare system, operating at the rural curative, the State and the National level, implements services for universal preventive and centres health for citizens (Chokshi et al., 2016, pp. 9–12). The Madhya Pradesh public health system implements some state-level patient assistance schemes, such as providing free treatment to children of BPL families suffering from heart illnesses, making medical grants to BPL families for major surgeries, and free distribution of generic medicines. A State-level experiment of making local communities responsible for the administration of public hospitals by setting up Hospital Management Committees called Rogi Kalyan Samiti or RKS [patient welfare committees] proved successful and was celebrated for its health outcomes. This experiment was later replicated in other States.

The decentralised health system in Madhya Pradesh has undergone the experience of managing disease epidemics since the early 1990s. The first RKS set up in Indore town in 1994, for example, prevented in the town a plague outbreak spreading from the neighbouring state of Gujarat (Sadanandan & Kumar, 2006, pp. 86–224). The RKS supervised an emergency clean-up drive at a major referral hospital in Indore. It was successful in preventing a major outbreak of the disease in the Indore region. After this, the State government endorsed the setting up of RKS across the State and, due to its success in the State, it also became part of the National Health Improvement Programme from the year 1996.

Madhya Pradesh was also one of the first State governments to implement other schemes for decentralising health planning. In 2002, it inaugurated a scheme for providing basic healthcare to mothers and children by assigning a health worker and a midwife to each village. This initiative helped institutionalise village-level health planning as the health workers received important feedback useful for deciding local-level health priorities. The local health monitoring committees audited the provision of essential local health services such as safe drinking water, sanitation and immunisation, but it also established health communication links with the population important for controlling any pandemic crisis (Sharma, 2001, p. 219). The communication of health workers and the population and the information of local-level health requirements were relayed to the district administration.

The State implemented a communicable disease control programme in the rural areas from the 2000s (Singh et al., 2009). In 2018, the State disease surveillance system was put to a test when an outbreak of the Zika virus occurred. More than 100 people were affected, but the disease control system was able to contain the outbreak through getting health advisories issued throughout the districts, isolating the larvae identification zones, and exterminating identified aedes aegypti mosquitoes.

The village-level health planning initiative helped shift the burden of health planning responsibility from the State and district administration to the village governance bodies. It ensured the requirement of financial resources for health management was decided at the appropriate levels of planning. At the same time, the district administration retained the authority to act on the local-level health management plans and utilise State finances appropriate for the local plans.

Kerala

Kerala has a relatively high per capita total government health expenditure, but the share of the primary healthcare budget to the total government health budget is lower than that of Madhya Pradesh. Madhya Pradesh has spent more out of its budget on improving primary healthcare than Kerala in the same time period. Madhya Pradesh has been expanding the network of PHC under the national healthcare expansion programme, the National Health Mission, which aims to provide ‘accessible, equitable, and affordable healthcare to everyone. On the other hand, the reason for lower expenditure on primary care in Kerala is that the health system is more developed than in Madhya Pradesh. This has required higher allotment to human resources spending and non-primary healthcare services’ (Berman et al., 2017).

Nevertheless, the need for strengthening the primary health sector has also been acknowledged in Kerala for the role local health policy performs in the early detection of diseases and prevention of epidemics. The state health centres have envisaged the development of a public-funded free universal and comprehensive health system. The state government runs a scheme called the Aardram Mission for improving public hospital infrastructure and enhancing popular trust in the State public health system. A health volunteer community called the Arogyasena was started for public health interventions based on the specific epidemiological needs of Kerala residents. State government schemes have local-level components which seek to create interventions through community participation. Parallel State health missions, government agencies, non-government organisations and other civil bodies have been involved in the implementation of the state schemes at the local levels. Elected representatives supervise these community health schemes at the ward, panchayat and district levels (State Planning Board, Kerala, 2019).

The disease surveillance mechanism of the State’s health system was able to recognise and contain the outbreak of the Nipah virus in the State in 2018. The outbreak affected two districts, Kozhikode and Malappuram. During the outbreak, people who came in contact with confirmed or probable cases of the virus attack were listed. They were monitored daily for their health Status, and the samples were tested until they came out of the maximum incubation time period of the virus. The control of the Nipah virus outbreak has acclaimed success in 2018, and credit for it was given to the resilience of the health system, administrative effectiveness, political commitment, leadership and active community participation (State Planning Board, Kerala, 2019).

In the past, the Kerala government has taken note of the general increase in a load of communicable diseases and therefore activated a disease surveillance programme called the Aarogya Jagratha. The Jagratha got public health centres at multiple system levels to control the transmission of communicable diseases. Micro-level action plans in the wards and district-level plans were made. The programme made autonomous private societies such as resident welfare associations, non-governmental welfare bodies, voluntary organisations and State-operated organisations such as the Haritha Keralam, Kudumbashree, and Suchitwa Mission part of the implementation framework.

Delhi

The health system in Delhi comprises the medical institutions of the Central government, State government, the Municipal Corporations of Delhi, the New Delhi Municipal Committee (NDMC), and private sector hospitals. In 2010, the State government institutions had only 20% of the total hospital beds in Delhi; the Central government had close to 30% share, the municipal corporations 12%, and about 40% were with the private sector. The State and the municipal corporation health services in Delhi control the programmes for the preventive healthcare and health promotion (National Rural Health Mission [NRHM], 2012).

The high urban population, population density and concentration of slum areas in Delhi have required the state health system to have a high degree of coordination between the different levels of government to keep convergence between varying administrative and financial norms, roles and responsibilities, accountability structures, and capacities of the health services.

A further complexity weighing on the system is the socio-economic composition of Delhi’s population, of which migrants constitute 40%. It poses a challenge to the provisioning of uninterrupted healthcare services and disease surveillance. Apart from these factors, due to the high urban population and the socio-economic disparities in the population, the health system has a double burden of managing a heavy load of both communicable and non-communicable diseases in the population (NRHM, 2012).

A mobile health scheme operating in Delhi since 1989 has been providing dispensary services and primary healthcare outreach to slums and unauthorised housing Societies in Delhi. Mobile van dispensaries of the Delhi government move to designated places in slum areas, also called the jhuggi jhopri clusters, two times a week to provide the essential health services. The policy for frontline health workers has undergone some changes in recent decades with the rapid increase of population in the slum areas. Only outreach services are now performed by visiting health workers, while the basic health services are provided at the health centres. A new scheme called Mohalla Clinics or neighbourhood clinics was started in 2015 to expand the network of primary health centres in Delhi and enable the urban poor to access public health services.

The State unit of the national epidemics control system called the Integrated Disease Surveillance Programme (IDSP) has successfully controlled outbreaks of the H1N1 pandemic, avian flu, cholera, hepatitis, dengue and typhoid in Delhi in the past. Due to the complex governance structure of Delhi’s health system, effective control of pandemics requires smooth information exchange and coordination between the district and local reporting units and the State government and public health laboratories. The changes in the administrative structures of the Delhi government since the 1990s, and the dual control of the Central and the State governments in aspects of the administration, created a unique situation for Delhi during the Covid-19 pandemic when it was forced to take quick lessons and devolve authority to the district-level administration.

Madhya Pradesh

As described in the previous section, the State disease surveillance system in Madhya Pradesh had some experience in reporting and handling epidemics. However, the global lack of knowledge of the aetiology and epidemiology of the Covid-19 virus disrupted the functioning of the usual disease surveillance system in India. The Central and State governments were neither prepared to mitigate the effects of the rapidly transmitting virus nor could they mobilise extensive laboratory testing resources to isolate and stop the virus transmissions. In Madhya Pradesh, the first set of Covid-19 cases was detected early, that is, in the fourth week of March 2020 in four international travellers returning from Germany to Jabalpur town. District officials quickly followed the protocols that had been developed by then for tracing transmissions by contacting the cases and tracing their social contacts with other people, but it was suspected the virus might have already been transmitted to unknown persons. At the time, there were only two testing centres in the State.

Madhya Pradesh did not adopt a different State-centric strategy initially. It went along with the national lockdown ordered by the Central government on 25 March 2020 for containing the local transmissions and disrupting the spread. Since epidemiological knowledge of the virus was still at a nascent stage, strategies for containment were derived from the experience of transmissions of the H1N1 influenza in 2009 when it had been observed that the disease was reported in large numbers in big cities with large population movements. However, it did not disperse much in the rural areas. ¹ The State government was quick in implementing the centralised containment guidelines by invoking executive powers under rules called the ‘Madhya Pradesh Epidemic Diseases, Covid-19 Regulations, 2020’ to empower the district-level officers and IDSP units.

At the time of the beginning of the lockdown in Madhya Pradesh, there were only twenty-three active cases in the State. However, 30 days later, Madhya Pradesh had the third-highest number of case fatalities at 103 and 2,090 total cases. In this one month, the government received stranded residents of Madhya Pradesh working in other States and sent workers of other States to their home States. Although the lockdown gave the State some time to prepare for the oncoming increase in case burdens, the arrival and dispersal of migrants after that exposed it to severe strain. A total of 1.4 million migrants returned to the SJtate by the end of May 2020. Due to the movement of people, the number of active cases increased to 7,024 in the same period. The State government relied on super-active disease surveillance and community-driven monitoring in the mohallas [neighbourhoods] to contain the disease outbreak.

District officials realised the infrastructural limitations of the State in handling and treating active Covid-19 cases beyond the State’s capacity. The impact of the pandemic was mainly mitigated through effective coordination between health organisations and institutions of the State. Existing medical facilities were quickly turned into quarantine centres and some district hospitals were converted into dedicated Covid hospitals for treatment. The lack of equipment and facilities was met by support from private hospitals and private doctors (Dixit et al., 2021).

Delhi

Although Delhi has relatively Improved health infrastructures and disease surveillance and reporting system, the WHO already alerted densely populated cities like Delhi of the disproportionate impact of the disease outbreak in such overcrowded habitations (WHO, 2020). The disease surveillance system was put on alert relatively early, that is, by the first week of March 2020, and the chief minister of Delhi was already reviewing responses of the government agencies. District bureaucrats also responded quickly to the developing emergency and got District Task Forces of the State health system ready for the crisis. Implementing by the Union Minister of Health and Family Welfare, the travel advisory, developed, international travellers arriving from Covid-19 affected countries were screened at Delhi airports.

As in Madhya Pradesh, the Delhi government also promptly notified special regulations for control of the pandemic. It started surveillance of the disease in all the hospitals through setting up flu screening corners. However, despite the proactive working of the disease surveillance system in Delhi, because of the large numbers of passengers arriving and transiting through Delhi, there were already forty cases by the last week of March 2020. This increased to almost 3,000 cases and fifty-four deaths 30 days later, despite the strict enforcement of the lockdown.

In June 2020, the number of cases in Delhi was the second highest among all the Indian States. The number of cases was growing at twice the rate of the national average. It was realised that the State surveillance system was failing to catch up with the rate of disease transmission (Chatterji & Chauhan, 2020). The government bolstered the efforts of the disease surveillance mechanism in Delhi by making the district officers and district epidemiologists have a more significant role in the management of the outbreak. The rate of disease testing in the community was increased to arrest the transmissions. The devolution of authority to district administrative officers and district medical officers had the essential role of enabling quick decision-making at the local levels. This step of the Delhi government ensured that the district’s health system could rapidly respond to a developing emergency pandemic-related situation.

The rapid increase in the number of cases was alarming as the health infrastructure and beds availability were relatively better than other SJtates, but it was not limitless. The government responded to mathematical models of health experts predicting the future hospitalisation numbers by converting public halls, stadiums and schools to Covid treatment centres. The density of disease testing was increased to maximum. The government also sent pulse oximeters to some home isolation patients to decrease the load on institutional treatment centres. The Central government was made aware of the development of the crisis in Delhi. The Central home department and the Delhi State government enhanced its communication. Because of the unique federal political system in Delhi, the urgency of coordinated and strategic deployment of resources by the Centre and the State government was realised as an utmost pressing concern.

Kerala

In 2020, it was reported that Kerala managed to control the Covid-19 outbreak relatively better than the two other States in terms of the rate of cases growth and the disease fatalities. In the initial period, Kerala was able to manage the disease better without significantly expanding the rates of disease testing. Due to having the experience of arresting the 2018 Nipah virus outbreak, as Kerala residents returned from foreign virus-affected countries, the State’s health system responded effectively, if not quickly, in identifying the Covid positive cases. In the first week of March 2020, one particular family of five who had just returned to Kerala, all reported Covid-positive, broke the home isolation rules and were suspected to have infected several relatives and people in public places at once. When district authorities became alerted of the risks posed by them, it made health surveillance workers trace their contacts. The health workers received the necessary the private sector support from the community to successfully trace and isolate persons who had come into contact.

The early efforts of the disease surveillance mechanism were supported by the State political leaders and local level elected representatives. The surveillance mechanism engaged with the community by sensitising multiple agencies, local governments, non-government organisations and made the local units the partners in the thrust for containing the disease outbreak (Isaac & Sadanandan, 2020). Greater health literacy of the population helped health workers and district officers raise consciousness in the community of the dangers posed by the pandemic.

Although the national lockdown was ordered in the fourth week of March 2020, Kerala already had a semi-lockdown in the State from the first week. The movement of migrants in the State between April and May 2020 was less dense than it was in Madhya Pradesh and Delhi. In the 2 months between April and June 2020, 72,000 expat workers, original residents of Kerala, returned to the State from the Gulf countries and other Indian States, and about 300,000 workers left Kerala for their home States in the North and East India.

The Kerala strategy did not make viral testing the mainstay of its approach. It depended on proactive tracing of primary and secondary contacts of the Covid-19 positive cases and depicting on route maps and flow charts of the movements of the positive cases, disseminating crucial information quickly among the community, and activating the community surveillance network to get the social contacts to identify vulnerabilities and get tested for the disease. The active cooperation received from the public apart from the advanced coordinated joint response forwarded by the State organisations helped the State government gradually Slow the outbreak’s momentum in the state.