The second wave of the Coronavirus pandemic has surely been aggravated by a casual attitude towards world trends and an absence of preparedness overall. Election rallies and religious gatherings where hundreds of thousands gathered unchecked were allowed. The second wave has been reportedly fueled by two variants- B.1.617 (that was first found in December, 2020 that spread through mass events) and B.1.1.7 (identified first in Britain that reached India through travelers). The former variant has ravaged India, and we are witnessing the worst of it.

India, painting a bleak picture

As of now, the country is facing shortages that are enormously adding to its Covid-19 woes. Shortage of oxygen, medicines, beds, ambulances, crematoria/burial ground space, ventilators, medical staff, food, jobs and lifesaving vaccines. This, with copious amounts of hoarding, black marketing, PR exercises to sustain a global image has proven to be more disastrous than the virus itself.

An Open Data Tracker suggests that over 512 people in India have died due to oxygen shortage in hospitals between April and May 16. It does not include the ones that died waiting for beds and oxygen outside hospitals. The publicly available tracker estimated that the highest number of oxygen related deaths (83 deaths) took place across five medical colleges in Goa. Karnataka reposted 54 such deaths till May 16, including 36 persons at Chamarajanagar Institute of Medical Sciences, 4 patients at KBN Hospital at Kalaburagi, 2 patients at Arka Hospital in Bengaluru, 5 at Shri Bhanji D Khimji Lifeline Hospital in Hubballi, 4 at Kalaburagi government hospital and 3 at Belagavi government hospital.

Moreover, under reporting of deaths across the country has been widely reported in international news media as well. A New York Times report of May 25 states that the official count as of May 24 has been of over 3.07 lakh deaths (at 3,07,231) while in a ‘more likely scenario’ deaths are likely to be over 16 lakhs (1.6 million) and in a worst case scenario, the deaths could be 42 lakhs (4.2 million). The reports states that despite India recording largest daily death toll in third week of May, it is still most likely an undercount. Speaking for world figures, a report by the World Health Organization (WHO) estimated that the global death toll of Covid-19 may be two or three times higher than reported.

(SOURCE: https://www.nytimes.com/interactive/2021/05/25/world/asia/india-covid-death-estimates.html?referringSource=articleShare)

Unsurprisingly, the attention and focus on rural areas have remained acutely absent. To put things into perspective, rural India constitutes a massive portion of India with a whopping 65.53 percent of the total population. This means 89,53,86,226 people. To narrow it down even further, for instance, the Patna High Court recently looked at the district wise breakup of the population living in urban and rural areas in Bihar, which revealed that almost 90 percent of the population resides in rural areas. The pandemic has clearly exposed the reality of the crumbling healthcare infrastructure in urban, so called developed areas. The rural space can be just left to one’s own imagination!

An outbreak like such, goes beyond the framework of public healthcare systems. It involves, and especially in context of a nation this hugely populated, a concrete nexus of Centre-State cooperation, resources, long term strategy planning and instantaneous action. Overall, some states have fared better in managing this crisis, while some States have despairing accounts of tragedy one cannot march on from.

The Prime Minister, while campaigning in Asansol (West Bengal) in April, said that he was elated to see the large crowd that had gathered at his rally, on a day when India recorded 2,00,000 cases and over 1,000 deaths. He forgot to mention how notoriously fragile his Indian state is. The GOI justified the lockdown in March 2020 to ramp up the infrastructure to deal with Covid-19. Whatever little that was done under the garb of one of the strictest lockdowns in the world, has remained calamitously marginal. More so, the government in 2021 is clearly more underprepared than it was in 2020.

The residents of Uttar Pradesh, Gujarat, Bihar, Delhi now explicitly feel abandoned by their respective governments manifested through begging and pleading for basic facilities. The floating images of death in the Ganges shows how India is not counting its dead. These states have had ambulances turned away for lack of space, people dropping dead while gasping for air and Covid patients perishing to hospital fires. Even Delhi had the shocking visuals of dead bodies of near and dear ones being lined up at crematoria and burial grounds.

Here is a closer look of states that have failed to uphold its citizens’ basic right to health with its chronically under resourced healthcare system.

Delhi

All of 1,484-kilometre square of space, and people in the National Capital could not find space to bury their dead. Delhi was forced to build makeshift funeral pyres. The public health expenditure on Delhi between 2020 to 2021 has been Rs. 7,704 crores with approving Rs. 2,578 crores for upgrading and expanding 16 hospitals. In the 2021 budget, Delhi announced the allocation of Rs. 9,934 crores, which amounts to 14 per cent of the total outlay for the health sector.

With a landslide victory in 2015, the Arvind Kejriwal led Aam Aadmi Party (AAP) promised developments in areas like public health care and education. The Delhi Government had proposed a three-tier structure- Mohalla clinics, poly clinics and hospitals. It proposed around 1,000 Mohalla clinics and 125 Poly clinics. But overall, Delhi only has 450 Mohalla clinics and 25 Poly clinics. As this model was widely praised by other states and also got international coverage and praise by former UN Secretary-Generals Kofi Annan and Ban ki-moon. But this too seemed inadequate to tackle Covid crisis.

Further, the government reduced the allocation for the development of Mohalla clinics and polyclinics from Rs. 403 crores in 2018 to 2019 to Rs. 375 crores in 2019 to 2020.  According to ThePrint, AAP’s promise of creating 900 Primary Health Centres (PHCs) and adding 30,000 beds to Delhi hospitals have not been met. According to Government data from September 2020, Delhi only has mere 540 Primary Health Centres.

When Delhi residents scrambled for beds and oxygen, the High Court had pulled up the government several times for its laxity. Recently, the government was hammered by the High Court for providing inaccurate information on the availability of a 250-bed Covid-19 facility in one Indira Gandhi Hospital in Dwarka, reported LiveLaw. The court was livid as the government assured it that the facility was up and running but in reality, did not admit one single patient even after 72 hours.

Noting that the entire medical infrastructure has been exposed during the pandemic, the Delhi High Court had also opined that the entire system had failed in its duty to provide adequate medical assistance to its residents. The shifting responsibility between the AAP government and the Union government continued in courts with hospitals sending SOS calls for oxygen. On one hand where the state government kept yearning for more oxygen, Centre argued that they are supplying enough but the quantity is not reaching hospitals due to shortage of cryogenic tanks.

The Delhi High Court and the Supreme Court repeatedly pressed and eventually ordered (strictly) that Centre supplies the demanded quantity to Delhi on a regular basis but also pulled up the state government for not taking systematic steps for procuring cryogenic tanks for oxygen and make adequate security arrangements for their movement to various Covid-19 hospitals.

Amidst this conundrum of supply chain management, lives were lost. Twelve Covid patients including the gastroenterology department’s head died in Batra Hospital due to oxygen shortage today on May 1. Jaipur Golden and Sir Ganga Ram Hospitals have lost 25 patients each similarly, in April.

A Right to Information (RTI) activist, Vivek Pandey had filed an RTI seeking information about oxygen plants in Delhi. Despite the Delhi government purchasing 4,500 oxygen cylinders and tanks between July 2020 and April 2021, the capital city did not install enough oxygen plants or engage adequate number of oxygen tankers on time to supply to hospitals. The government, as per the RTI query, also revealed that Delhi did not order or purchase any ventilator between July 2020 and April 2021. 

Currently under lockdown, Delhi seems to have crossed its peak with nearly 7,000 cases in the past 24 hours, but with cases even testing seems to have dropped from 70,000 per day to around 60,000.

Uttar Pradesh

The state has recorded over 16.8 lakh cases and over 19,500 deaths as of May 24. Mathematicians and date management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

According to the latest budget released by the State of Uttar Pradesh, Rs 5,395 crores has been allocated towards National Rural Health Mission and Rs 1,300 crores has been allocated to Ayushman Bharat Yojana. The revised budget towards the Health and Family Welfare department was Rs.20,582 crores in the year 2020 to 2021 and Rs. 32,009 crores in the financial year 2021 to 2022.

A state with the highest percentage of rural population, with approximately over 15 crore people, constituting 18.62 percent of the country’s rural population, has only 2,936 PHCs.  According to PRS Legislative Research, in 2020 to 21, payment towards salaries and pension decreased by 20 percent. The estimated budget was Rs. 1,36,988 crores and the revised amount fell to Rs. 1,09,914 crores.

At the Jhansi Medical College in Uttar Pradesh, the nursing staff had not received their salary for seven months. On 25 March, 2020, with Covid-19, they boycotted work for the day. In an interview to the Caravan, one nurse said that she met a member of the administration who asked them to “cooperate.” She said she told the administration, “We have been cooperating for seven months now. Corona has just appeared on the scene, a month, or a month and a half ago. It hasn’t been around for seven months, right? Then why are you not paying the salaries? Give it to us after two months, but at least give it.”

As per the media, Chief Minister Ajay Bisht alias Yogi Adityanath announced an increase in the salary or honorarium of all healthcare and frontline workers including doctors, paramedical staff, housekeeping staff, sanitation workers, accredited social health activists and Asha, Anganwadi workers. This announcement came a week after Etawah district’s biggest government hospital, BR Ambedkar Hospital, struggled to cope with lack of staff.  

According to an IndiaToday report, the bathrooms in the 100-bed Covid ward were locked after sanitation workers said they would not work in Covid wards. No one from the hospital administration or even medical staff were present in the premises. The families of patients have been forced to open oxygen cylinders.

While addressing the media recently, Yogi Adityanath said within 10 days, active cases have dropped and the situation in the State is ‘under control’, when in actual fact –due to coercion and threat of penal action, more than 1,000 primary and upper primary school teachers on election duty have succumbed to the virus.

The Government’s idea of creating a portal to show availability of Level-2 and Level-3 beds in Covid wards and ICUs in various hospitals within the state failed too, as it displayed incorrect data. The Allahabad High Court criticised the affidavit submitted by the government while noting that albeit the portal showed availability of vacant beds, no hospital could offer any, “This state of affairs that we have come to know about the management of online portal created by the Government today casts shadow upon the Covid Hospital Management,” opined the court.

The vindictive government in UP is asking its citizens to quit complaining. Intimidation, arrests, FIRs for spreading ‘panic’ if raised alarms about oxygen or storage capacity have been the tools adopted for crisis management. On May 11, when the High Court continued to hear the suo motu matter on Covid management and through the government’s affidavit it found that:

-the proper procurement and supply of the life savings drugs/ life support systems like BiPaP machines and High Flow Nasal Cannula Masks have not been made available to the various hospitals

• number of testing has been reduced gradually
• details regarding oxygen production in the State qua 22 hospitals have not been given
• the availability of ambulances with advance life support system is also very less considering the number of districts in the State
• Rs.100 is allocated per patient in Level-1 category hospital despite knowing that Covid patients need highly nutritious food of about 2100 calories in a day
• No details have been given regarding Level-2 and Level-3 hospitals.

UP seems to be at a juncture of systemic failure at each level.

Gujarat

As per reported data, the state has had 7.9 lakh cases and over 9,000 deaths as of May 24. Mathematicians and data management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

Gujarat is among the states which has been notorious for under reporting deaths. On April 27, 2021 Gujarat’s local newspaper Sandesh set aside five pages for obituaries in the Rajkot edition alone, while the state’s Covid-19 dashboard recorded only 14 deaths in the previous 24 hours. Thus, making obituaries better indicators of death count in the area, rather than official data. On the same day, the newspaper stated that 87 bodies were cremated following Covid protocol over the last two days while the government only recorded two Covid deaths. 

City-wise, the highest disparity during this time was in Gandhinagar that reported three official Covid deaths even though 80 bodies were cremated as per Covid protocol. Similarly, Jamnagar cremated 208 bodies as per Covid protocol but the official data only acknowledges 23 Covid deaths. In Rajkot, 124 bodies followed the protocol but only 27 Covid deaths were reported. There have been reports of people waiting in queues outside crematoria to cremate their loved ones as well as outside burial grounds. On April 13, multiple publications including The Times of India, The Telegraph, Hindustan Times and a few others carried a report by the Press Trust of India (PTI) about how frames of furnaces at two Surat crematoria had begun to melt under pressure as bodies were being cremated round the clock. However, official data constantly defied such reality on ground, gaslighting the media and the public at large.

A report stated that Gujarat issued about 1,23,000 death certificates between March 1 and May 10, however during this period only 4,218 Covid deaths have been recorded. Further, a fairly recent report in The Hindu, of May 16 suggests that official data of number of deaths emerging from rural and remote districts were about 20 times lower in some districts.

The High Court took stock of the situation in the state while noting at the outset that the state seems to be in an “health emergency”. As of May 18, Gujarat has recorded over 7,60,000 cases and 9,200 fatalities. In this year’s budget for the financial year 2021 to 2022, the government allotted Rs. 11,323 crores towards the health sector. Comparing this budget estimate to the previous year’s revised estimate, the Gujarat government’s expenditure on the health sector has actually dropped to 5 percent from 5.2 percent.

Based on the National Health Policy report (2017), that aims at informing, clarifying, strengthening and prioritising the role of the Government in shaping health system, stated that the current financing to the health sector needs a push. It suggested “Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5 % by 2025” and also increase the state sector health spending to more than 8 percent of their budget “by 2020”. Despite this recommendation, the percentage remains consistently low at a 5 percent.

Gujarat has hardly seen an increase beyond six percent in the health sector. Perusing the past expenditure on healthcare, the percentage of total budget Gujarat has spent on health has been abysmally low. As projected by a Times of India report, the state data shows:

Despite having faced major challenges in the health sector because of the pandemic, Gujarat is lagging behind. The state’s budget to the nutrition and social welfare has also plummeted to a minus 23 percent. The revised estimate in the financial year 2020-2021 was Rs. 9,293 crores and the budget estimate for 2021-2022 stands at Rs. 7,160 crores.

India’s so called ‘model state’ had ambulances turned away from hospitals for lack of beds. It suffered from massive under reporting of Covid-deaths. Bhaskar reported on how from March 1 to May 10, within a span of 71 days, around 1,23,000 death certificates were issued but the government concealed this number and recorded only 4,218 deaths. The non-transparency was so apparent that the high court had to intervene to order the government to be honest about Covid-19 data.

Bihar

The state has had about over 6.96 lakh cases and over 4,700 deaths as of May 24 Mathematicians and data management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

Bihar’s Covid stories hit even harder after apocalyptic images of saffron pyres on the river banks and bloated bodies in Ganga emerged. The projected population of Bihar is 13.12 crores. For 13.12 crore people, Bihar managed to construct only 1,994 PHCs, out of the allotted budget of Rs. 5,766 lakhs between 2019 to 2020, as per government data.

Further, as per the recent budget for the period 2021 to 2022, the Bihar government set aside Rs. 360 crores towards incentives to ASHA workers. But according to a NewsClick report from May, ASHA workers have been persistent in their demand for Rs. 10,000 as honorarium and state employee status to ASHA facilitators over the past few years, but none have paid heed to it. Despite several protests at PHCs across Bihar, the government has turned a deaf ear to their demands.

Even though ASHA workers have remained prompt from day one of the pandemic, regular honorariums and expecting Covid incentives is a distant dream with some workers not having had received 16 months of payment in the State. As per reports, health sector has been devoted about Rs.13,264 crore this year.

The NITI Aayog Health Index report (2019) illustrates the deterioration of Bihar’s overall performance between 2015-16 and 2017-18, with a fall in many sectors such as sex ratio at birth, fertility rate, low birth weight, staff nurse vacancies and fully functional PHCs (mere 1,994). Bihar saw the highest decline of 6.35 points from 2015-16 to 2017-18 in the health index amongst larger Indian states.

Bihar’s low nutrition levels have made the impact of the pandemic worse. According to National Family Health Survey (2015-2016), 48 percent of children under the age of five are stunted, whereas, 21 percent are wasted and 44 percent are underweight. More than two-fifths of women (42%) and 38 percent of men are either too thin or overweight or obese. More men and women are thin than overweight or obese.

Despite repeated directions to the state on medicines, testing, other infrastructural issues, most of them have remained on paper. For instance, during a hearing on 4 May, the court pointed out that on April 23, the government had assured it that 60 oxygen beds at ESIC Hospital, Bihta were being enhanced to 500 beds. However, on May 3 the court was informed that the State Government has not been able to ensure proper utilisation of even 60 oxygen beds, let alone enhancing the number of beds.

Bihar was also in a complete state of mayhem with allowing unregistered hospitals to run as Covid designated hospitals. The Patna High Court has also pulled up the government for providing contradictory information about oxygen supply, beds and other Covid related facilities and directed it to come clean. In the beginning of the second wave, ambulances carrying patients were asked to return from hospitals for lack of amenities.

As early as April 18, reports came in that Bihar hospitals were suffering oxygen shortage for a week. The Bihar chapter of Indian medical Association (IMA) had lodged a protest over the government’s mismanagement of Covid treatment in hospitals. Ten days later, reports came in that on April 25 four people died of oxygen shortage while one died due to lack of medical attention; there were also reports of hospitals asking patients’ families to arrange for oxygen cylinders themselves. As of April 28, as many as 16 private hospitals had only a day’s stock of oxygen left and in both private and government hospitals there a total of 900 ventilators throughout the state.

Further, Bihar also tops number of deaths of doctors as per the Indian medical Association, followed by UP and Delhi. 90 out of 280 doctors who have died across India are from Bihar.

There has also largely been misreporting in number of deaths. Between 1 April and 13 May, 2,579 last rites of Covid-19 victims were held at the four crematoriums and one Muslim burial ground within the limits of the Patna Municipal Corporation (PMC). However, the overall Covid-19 deaths during the same period stood at just 2,092, which is 487 less than the figures shared by the four crematoriums and one burial ground in Patna alone.

All such data points expose not only the mismanagement and lack of governance but also the clandestine attempts made by the state to hide its faults and paint a rosier picture reflecting poorly on the performance of the government and its handling of a pandemic.

Conclusion

With Prime Minister Modi’s victorious declaration at Davos for having “saved humanity from a big disaster by containing corona effectively”, India’s stark reversal on ground has shaken two things- people’s trust and Modi’s own image. As a federal set up, Indian States are mandated to cooperate with the Centre on response and action but they too are to be blamed for this shortcut to public health.

Related:

Right to Health: The forgotten Constitutional mandate
Anger simmers as bodies pile up outside crematoria in Gujarat
Are obituaries in Gujarat newspapers a better indicator of real Covid-deaths?

The post Covid-19: Which Indian states failed miserably in tackling the pandemic? appeared first on SabrangIndia.

The pandemic while bringing on a sea of tragedies for Indians, has exposed the unpreparedness of callous governments which left people to the mercy of an over-burdened and a structurally weak health system.

While the enormity of the second wave of Covid in India caught the central as well as state governments off guard, the myopic, even authoritarian attitude of the Central government in 2020, taking decisions unilaterally without consulting state governments has made matters worse.

Under the Constitution, health is a state subject and it is for states to build their own capacities and health care systems as they deem fit. However, at times of crises, in the true spirit of federalism, under the National Disaster Management Act (NDMA), 2005, consultation and coordination are key. This has been woefully lacking.

A healthy cooperative spirit honouring the Federal principles of the Indian Constitution would have been in order; setting up an Inter-State Coordination mechanism that was consultative and inclusive. Instead, we had a series of diktats and flip-flops from the Centre. This combined with weakened state health infrastructures left populations reeling.

Some states fared better: How and Why?

• Nos of persons/ Primary Health Centres
• Nos of Govt Doctors/Persons, Population

While putting the onus entirely upon the states in terms of handling the Covid-19 Pandemic is not entirely correct legally speaking, it remains crucial to examine the role played by state governments and how some states have fared better in managing the Covid-19 fallout better than some other states. There are certainly many factors involved here including building of a robust public health care system over the years, building capacity, augmenting and retaining human resources especially medical professionals, maintaining optimum levels of bed to population and doctor to population ratio as also real time management of crisis by administration under the leadership of an able government. More than anything else, making good, efficient and affordable healthcare accessible to the maximum number of Indians, in the most remote areas, is fundamental to democratising the right to health.

Role of state governments

The International Monetary Fund in its latest World Economic Outlook October 2020 has advocated all major economies to allocate adequate resources for healthcare as the near-term policy priority. While availability of hospital beds and health care workers is essential, elaborate and sustained administrative support and additional healthcare expenditure has gained importance in managing a crisis like Covid. Therefore, a simplistic analysis of public health expenditure will not reflect upon a state’s performance in handling Covid.

The second wave/surge of Covid in 2021 caught the Centre as well as States completely not just unawares but showed up Indian authorities for an absence of scientific and rational understanding of a worldwide Pandemic. Worldwide countries and societies experienced a second wave while India carelessly gloated on coming out of the Pandemic. This attitude showed up the unpreparedness of governments and the callous complacency that set in due to a brief dip in cases which was not in tandem with increasing administration of vaccination doses to the maximum population.

Money spent by the state government on health infrastructure, mainly public health care system, may give the government a solid foundation to work on but it is not a sure shot way of handling the crisis. Having a robust public health care system includes infrastructure, a strong referral system as well as adequate human resources, adequate coverage proportionate to the population and so on.

One of the most important strategies to reduce the out-of-pocket expenditure is to strengthen the primary health care system in the state. Health care systems build on a strong comprehensive primary care service acts as a platform which can reduce the health expenditure considerably.

Public Health Activist, Ravi Duggal, wrote in June 2020 in The Hindu Businessline that states that spend more on health care were less affected by the Covid impact.[1] Larger states like Bihar, Uttar Pradesh, Jharkhand, Madhya Pradesh, Odisha, West Bengal, Karnataka, Gujarat, Maharashtra and Punjab turned out to have the weakest primary healthcare system owing to low spending on health care. Says Duggal, two indicators of availability of public health services is the number of government doctors per lakh population and number of persons per Primary Health Centre (PHC). Again, states like Bihar, Uttar Pradesh, Maharashtra, Karnataka, and West Bengal have more than 30,000 persons per PHC and less than the national average of nine government doctors per lakh population. It is not a coincidence that Maharashtra, Karnataka and UP have also allowed privatisation of the health infrastructure.

The data derived from Health Ministry’s National Health Profile, 2019 showed that Kerala had 15 government doctors per lakh population and 42,403 persons per PHC. On another scale, where WHO recommends a doctor patient ratio of 10:10,000 in Kerala it is 16.5 doctors per 10,000.

The data on public health expenditures across states is reflected in a table as below:

Privatisation of public health care

The NITI Aayog has recommended  handing over of district hospitals to the private sector under PPP arrangements as a solution for improving health care system. However, data increasingly suggests that states which have reasonably robust primary healthcare have been able to deal with the Covid first wave, better than the states that did not have a good public health system. Naturally, the same is analogous to higher spending of states on health care out of its GDP and its annual budget. The 2017 National Health Policy recommends 2.5 per cent of GDP or ₹3,800 per capita (at 2017 prices) as the appropriate spending for delivering reasonably good health care predominantly through public health facilities. This translates into ₹5 lakh crore public health spending for the country or 2.5 per cent of GDP or 8.3 per cent of total government budgets.

Privatisation of public health care will only increase out of pocket expenses for people, making health care more and more expensive in the country and out of reach of millions. The example is playing out in reality as governments and courts are having a hard time capping rates charged by private hospitals for Covid treatment. Even in times of such a national health emergency, the private sector sticks to it primary objective – making money. On the other hand, a public health care system has been over burdened and taking on patients unable to afford the sky rocketing private hospital charges.

Almost  62.4% of expenditure on health is borne by households and rest by government. It is well-known that such a high share of out-of-pocket expenses imposes a financial hardship on household budgets and more than often pushes vulnerable households into debt and poverty.

Kerala tops the charts

Kerala has seen the third highest cases in the country following Maharashtra and Karnataka with more than 24.2 lakh cases and over 7,000 deaths – –as per the official count– as of May 24. Mathematicians and data management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

Primary Healthcare Performance Initiative analysed Kerala’s health care reform over the years whereby the state gave local governments control of 35 to 40% of the state budget for improving care and access, regardless of income level, caste, tribe, or gender, reflecting a goal of not just effective but also equitable coverage. The current Public Health Centre (PHC) system consists of sub-centers, primary health centers that support five to six sub-centers and serve a village, and community health centers. Overall, Kerala has maintained low infant and maternal mortality rates, and higher literacy rates, when compared to the national average.[2]

Kerala’s Expert Committee for health submitted a report in 2014 whereby it identified Kerala to have one of the highest ‘out of pocket’ expenditures on health in the country. As per National Health Accounts (2004-05) Kerala had the highest per capita public expenditure as well as highest private expenditure in the country. In its 2020-21 budget, Kerala has allocated 5.5% of its total expenditure on health.

An article in the Huffington Post stated that for over 60 years, Kerala’s health indicators—infant and child mortality rates, birth rates, life expectancy, sex ratio and maternal mortality ratios—have consistently topped the country, despite its middling economic achievements and high unemployment rates.

On May 10, Kerala government fixed a cap on prices that may be charged by private hospitals for Covid treatments. General wards would now cost Rs. 2,645 per day including registration charges, bed charges, nursing and boarding charges, surgeons, anaesthetists, medical practitioner, consultant charges, blood transfusions, oxygen, medicines, pathology and radiology tests and others.With the same facilities, an ICU bed will cost Rs. 7,800 and an ICU bed with a ventilator is capped at Rs.13,800. This move was lauded by the Kerala High Court as well.

Kerala is often described as a state without the urban-rural divide, with civic infrastructure in rural areas being comparable to those in cities. It is also a state with the highest elderly population in the country, with about a fifth of its population over 60.

A report in Al Jazeera from May 11 states that in Kerala and Tamil Nadu, medical oxygen production was augmented and hospital capacities were increased expecting cyclical spikes and troughs of Covid-19 infections. Until late March, Kerala’s case fatality rate (CFR), which is the percentage of deaths to positive coronavirus cases, hovered at 0.32 percent, while in Tamil Nadu, it was 0.52.[3]

However, the state Assembly elections became the hindrance in the continued efforts of the administration to keep Covid spread in check and compelled the newly elected government to enforce a lockdown. Yet, Kerala is one of the few states, which has not faced oxygen shortage until now. In the past year, Petroleum and Explosive Safety Organisation has made concerted efforts to set up oxygen plants and maintain the existing ASU (Air Separation Unit) plants and manufacturing plants both in public and private sectors.[4]

Tamil Nadu

Tamil Nadu has seen 19.4 lakh cases with over 21,000 deaths –as per the official count– as of May 24. Mathematicians and date management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

The State has separate Directorate of Public Health with its own budget. It is staffed by a professional cadre of trained public health managers who are promoted to the Directorate after long years of experience of planning and oversight of public health services in both rural and urban areas.

A study by Swaniti Initiative on Tamil Nadu Public Health System states that apart from having a separate budget for public health in Tamil Nadu, the size of the public health budget is large relative to spending on secondary/tertiary medical care and medical education. The Directorate of Public Health has consistently had larger budgets than the two other Directorates in the Health Department. The state (a) separates the medical officers into the public health and medical tracks, (b) requires those in the public health track to obtain a public health qualification in addition to their medical degree, and (c) orients their work towards managing population-wide health services and primary health care ─ while those in the medical track obtain additional clinical qualifications and are oriented towards providing hospital care.[5]

Tamil Nadu has a Public Health Act, which specifies the legal and administrative structures under which a public health system functions, assigns responsibilities and power to different levels of government and agencies.

A research conducted in 2019 indicated that OOPE per episode of hospitalization in public health centers was lowest in Tamil Nadu (₹2395) and highest in Punjab (₹10540).[6]The Chief Minister Comprehensive Health Insurance Schemes (CMCHIS)cover costs up to ₹5 lacs including quality medical and surgical treatment in public and private health centers. Studies also suggest that good public health care infrastructure, distribution of free medicines, and health insurance for formal sector employees may be the other reasons for low OOPE in Tamil Nadu.[7] While WHO recommends a doctor patient ratio of 10:10,000 in Tamil Nadu it is 19.1 doctors per 10,000.

Tamil Nadu implemented free medicine distribution scheme for all who are utilising public health facilities for treatment since 1995

In its 2020-21 budget, the state has allocated 5.7% of its total expenditure on health. A report in Al Jazeera from May 11 states that in Kerala and Tamil Nadu, medical oxygen production was augmented and hospital capacities were increased expecting cyclical spikes and troughs of Covid-19 infections. Until late March, Kerala’s case fatality rate (CFR), which is the percentage of deaths to positive coronavirus cases, hovered at 0.32 percent, while in Tamil Nadu, it was 0.52.[8]

However, the state Assembly Elections became the hindrance in the continued efforts of the administration to keep Covid spread in check and compelled the newly elected government to enforce a lockdown. Worse, mass election rallies, negative and irresponsible messaging by leaders (giving speeches without wearing masks) caused a rapid spread of the virus. Until April 23, there was sufficient oxygen supply in the state but merely 2 weeks later, the state was facing a shortage of 50 MT of oxygen and the Sterlite plant which was set to open in a week was the faint hope for the state. Chennai has been operating an oxygen war room which functions 24×7 since May 6 with the aim to create a smooth access chain for oxygen for hospitals treating Covid patients in the state.

Odisha

The state has had 7.1 lakh cases as of May 24 and has had about 2,500 deaths – as per the official count—so far. Mathematicians and date management experts worldwide have projected that India’s deaths could well be three-five times higher than officially admitted figures.

Odisha is the second most poor state in India (estimated poverty rate of 32.6%[9]) in the country with a population of over 42 million and a large concentration of scheduled caste and schedule tribe population. Despite high levels of poverty in the state, there have been notable improvements in health outcomes. The state has combated issues like child mortality, maternal mortality over the years.

Political stability in the state has been attributed to political attention towards socio economic development. The per capita spending on health by Odisha government has increased over the years. In 2018 it was Rs.1,143 which increased to Rs.1,413 in 2019 and marginally increased to Rs.1,557 in 2020. It’s not among the highest per capita spends compared to other states where you have north eastern states with way higher expenditure like Arunachal Pradesh (Rs.10,869), Sikkim (Rs.5,971), Mizoram (Rs.5,145) to name a few but it’s definitely more than a few larger states like Maharashtra (Rs.1,266), Uttar Pradesh (Rs.1,032) and Karnataka (Rs.1,505).

Owing to its high poverty levels, the state’s health policy was more focused on an equity based health policy. The Health Equity Strategy (2009–12) aimed to improve the health of the most disadvantaged people in the State, and recognizes the particularly poor health status of Scheduled Tribes and Scheduled Castes and the comparatively poorer districts. The Nutrition Operational Plan (2009–15) aimed to achieve maximum nutritional health of all children below six years of age, especially for the poorest and the most disadvantaged, through effective inter-sectoral coordination.

In Odisha a strong focus of the Health Equity Strategy and the Nutrition Operational Plan was closing the health and nutrition gap between state level outcomes and those of Scheduled Tribes and Scheduled Castes and the underserved KBK+ districts.[10]The Southern belt of 11 districts in the state is known as KBK+ and is made up of the districts of Bolangir, Boudh, Gajapati, Kalahandi, Khandamal, Koraput, Malkangiri, Nabarangpur, Nuapada, Rayagada, and Sonepur.

In Odisha, the underserved and poorer districts in KBK+ have been given special attention including mobile health units which have become the major source of health care in the remote and inaccessible villages. The other efforts include control of malaria related deaths, increasing access of women to health care, posting newly appointed doctors in KBK+ areas and paying them more, increasing institutional deliveries, carrying out surveys to identity out of pocket expenses and so on. This has resulted in reduced gap in ST women and children and others in utilising health care, increased institutional deliveries, progress in reducing number of underweight and stunted children, reducing nutrition disparities in ST children and other social groups and so on.[11]

Odisha was the first state that took proactive steps to ramp up its health care system particularly having a Covid-19 hospital with intensive care units (ICUs) on public–private partnership mode and was among few states to have created a Covid-19 hospital at each district in record time. It also took measures like and setting up a taskforce to oversee the Covid-19 response daily press briefings. These proactive efforts suffered a slight blow when migrants started returning to the various districts across the state in May 2020. Overall, though, it has managed to keep its fatality rate to very low i.e., 0.4%. At present, Odisha has 50 Covid hospitals with maximum number of seven such hospitals in the most affected Ganjam district. Besides, it has built-up 178 Covid care centres and 17,647 temporary medical centres (TMCs). Bulk of these facilities was created as early as May 2020 when number of Covid cases was not so high and by end of May, 2020 it had dedicated Covid health centres in all districts. The government used panchayats and community-based organisations like well-entrenched self-help groups for managing the movement of migrant workers, arranging shelter and running quarantine centres to providing other critical support.

While many states were found struggling in the initial phase of pandemic, Odisha’s long experience of running relief operations during natural disasters has come critical in terms of swiftly organising shelters for migrants and stranded persons during the lockdown. in April, the state empowered sarpanches to ensure quarantine of returnees and their families and all Gram Panchayats (GPs) were allowed to exercise their jurisdictions at the ground level to aid monitoring efforts of the facilities. [12] Odisha has allocated 5.5% of its expenditure for health in 2020-21.

Low public spending = poverty

While public spending on health is an indicator of good human development index, it is also an indicator of poverty. It is largely observed that people get pushed into poverty due to higher out of pocket expenses (OOPE) on health, since that expense is unavoidable and with a weak public health system, people are compelled to shell out money from their pockets for untoward or unforeseen medical emergencies which pushes them further towards poverty.

Evidence shows that medical poverty owing to high OOPE increased from 32.5 million in 1999–2000 to 50.6 million in 2011–12.[13] A research conducted in 2019 examined whether poor people in poorer states end up spending more on health expenses. As per 2014 figures, Assam had the highest percentage of people using public health centre (87%) followed by Odisha (80%), West Bengal (70%), Rajasthan (64%). It showed that states that were economically better-off used more of the private health centers, while poorer states used more of the public health centers. Further it also found that the poor in State with higher poverty level used public health services for hospitalisation.

Oxygen shortage

The current stage of the Covid crisis in the country is where people are dying of lack of beds and shortage in oxygen supply. Thus, it is important to look at these parameters before declaring any that any state has performed better than others. Until May 12, Kerala, Tamil Nadu had not raised an SOS for oxygen but on May 13, these states, in addition to Andhra Pradesh raised an alarm to the Centre demanding more oxygen. Kerala which had been sending surplus medical oxygen to neighbouring state Tamil Nadu and Andhra Pradesh, has now halted the supply citing demand in its own state. Officials in Kerala said they had to stop supply to ensure the state is able to meet its own demand, with its Covid caseload expected to rise to 6 lakh by 15 May.[14]

In Conclusion

While these states have fared relatively better than the rest of the states in managing the crisis, it is certainly too soon to laud their efforts. With experts predicting a third wave of Covid to be on its way in India, it is necessary that all states remain on their toes and are consistently keeping up the work they have been doing until and also take lessons from the better performing states such as Kerala, Tamil Nadu and West Bengal so that concerted efforts conclude in a successful stint at combating Covid.

*Feature image by Javed Anees (District Hospital, Tirur) via Wikimedia Commons.

Also read:

Right to Health: The forgotten Constitutional Mandate

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Monsoon fury has gripped central and southern Indian States. The floods have crippled life in vast areas, affecting millions. The death toll from floods in the Indian states of Karnataka, Kerala Madhya Pradesh, Maharashtra and Tamil Nadu rose to at least 150 on Sunday, as rescue teams raced to evacuate people and waters submerged parts of a world heritage site.

Exactly a year ago, devastating floods left 400 dead in the southern state of Kerala.

Media reports from India said:

The monsoon rains triggered floods have claimed 72 lives in Kerala so far.

According to government data, 58 people are missing and more than 250,000 people have been shifted to 1,639 relief camps.

At least 2,966 houses have been damaged completely in Kerala.

Hundreds of people are still stranded at Attapadi in Palakkad District.

On Sunday, Vadakara in Kozhikode district recorded 21 cm of rainfall, the highest in the state as of 8.30 AM Sunday, followed by Kodungallur in Thrissur (19.9) and Perinthalmanna in Malappuram (13.8),

The state government has said that water level in major dams was not a cause of worry as of now. Idukki Dam, one of the biggest in the state, now had only 36.61% capacity.

Incessant rainfall causes landslide at Kavalappara

Incessant rainfall in Malappuram caused landslide at Kavalappara. National Disaster Response Force, Fire and Rescue Department and Forest Department officials engaged in search and rescue operation in the area.

In one of the major flood-related calamities to hit Kerala this year, as many as 30 families are feared trapped underneath a landslide in Kavalappara at Bhoothanam, Malappuram and 10 people have reportedly died.

According to locals, as many as 50 people are missing, who have not been located either in the relatives’ houses or in relief camps.

Incessant rainfall in Malappuram causes landslide at Kavalappara

“Puthumala village is no more”

Nearly 100 acres of tea estate land, along with a temple, mosque, post office and the plantation company’s canteen, were washed away on Thursday evening in Puthumala, 11 km from the scenic hill town of Meppadi in Wayanad. “Puthumala village is no more,” said a villager, who survived the landslide. While six bodies were recovered from the debris on Friday, villagers fear another 15-20 people may be buried underneath.

Bengaluru-Mangaluru National Highway remains closed

In the wake of series of landslides, the national highway connecting Bengaluru and Mangaluru remains closed at least until Monday.
Officials said that there was slight reduction in the water level in the Netravati river in Dakshina Kannada district.

The water level near Bantwal has also reduced from 11 meters above the danger level to 9.1 meters above the danger level.

Flight operations resume at Kochi international airport

Flight operations from the international airport at Kochi resumed on Sunday afternoon, two days after it was shut due to inundation of the runway area following heavy rains. The Abu Dhabi-Kochi Indigo flight touched down at around 12.15 pm, marking resumption of the operations.
Chief Minister of Kerala Pinarayi Vijayan has expressed anguish at the manner in which some sections are spreading rumors about contributions to the Chief Minister’s Distress Relief Fund. He said that the fund would be used only for the needs of the affected and not for anything else. He said that it was unfortunate that some negative campaigns are currently on.

Vijayan said that the state government has not yet asked for funds from the Centre. He added that the Centre was providing all support for the ongoing relief and rescue work.

Vijayan on Sunday held multiple review meetings with senior officials and later told reporters that though the rains had subsided in the state, people should remain vigilant.

More rains in Kerala, predicts Met department
In a big relief to those engaged in rescue efforts, the rains on Sunday appear to have come down. However, the Met department has predicted more rains are predicted in the coming days across Kerala. The government has asked everyone to remain alert and be receptive to warnings.

Karnataka floods: 26 dead so far
The Indian state of Karnataka saw no let-up in rains, with 26 people losing their lives so far in rain related incidents.

As many as 235,000 people have been moved to safety.

Most rivers are in spate and Karnataka Chief Minister B S Yediyurappa has termed the natural calamity the biggest in 45 years.

Rescue and relief works are on in full swing in flood-ravaged districts of Karnataka, with a let up in the rains and water receding in most of the affected areas.

A PTI report said that situation was improving and search is on for those who have gone missing and efforts are being made to reach out to those who need to be evacuated. Eighty taluks, a local government tier, of 17 districts in Karnataka have been affected due to floods and rains. The number of affected villages in the state is 2028.

In Karnataka, nearly 600,000 people have been evacuated. At present, 1,168 relief camps operational across the state. More than 300,000 people are living in the relief camps.

Maharashtra floods: Sangli boat capsize toll rises to 17
With the recovery of five more bodies, the death toll in the boat capsize tragedy in Sangli in the Indian state of Maharashtra district has gone up to 17.

Over 30 people have been killed in rain-related incidents in five districts of western Maharashtra in the last one week, including 17 who drowned when a boat capsized near Brahmanal village in Sangli on Thursday.

More than 400,000 people have so far been evacuated from flood-affected parts of Maharashtra.

The Met department has predicted heavy rains on Monday at isolated places in Pune, Kolhapur and Satara districts of Maharashtra, which are affected by severe floods.

According to IMD, intensity of showers will reduce further on Tuesday, which will help in carrying out rescue operations. Similar forecast is also issued for coastal Ratnagiri and Sindhudurg districts, which have been receiving excess showers for the last seven days.
 
Tamil Nadu to seek relief from Centre
The Tamil Nadu government will seek flood relief fund from the Centre after total assessment of the loss due to the rains in Nilgiris district, state Animal Husbandry Minister Udumalai K Radhakrishnan said Sunday.

Amit Shah surveyed flood-hit area
Union Home Minister Amit Shah conducted an aerial survey of flood-hit areas of Belagavi district in Karnataka. The state’s Chief Minister BS Yeddyurappa was also present.

Heart breaking, says Rahul Gandhi
Congress leader Rahul Gandhi on Sunday termed as heart breaking, the suffering of people due to floods and landslides in his constituency Wayanad and urged the state and Central governments to provide immediate aid to those hit by the natural calamity in Kerala.

“It is heart-breaking to see what all the people of Wayanad have lost. We will do everything in our power to help them get back on their feet,” he tweeted.

Rahul promised to do everything possible to get them back on their feet.

Andhra Pradesh: 2 major reservoirs almost full
The two major reservoirs on river Krishna, Srisailam and Nagarjuna Sagar in the Indian state of Andhra Pradesh have almost been filled to capacity after virtually being dry for several months in Andhra Pradesh. Rains are still continuing in the upper riparian states of Maharashtra and Karnataka, bountiful water is flowing in the river, filling up all major reservoirs along its course. Heavy discharges from rivers Tungabhadra and Bhima are also adding to the flood surge in Krishna.

Courtesy: Counter Current

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