Cooperative Federalism – An Answer to India's COVID Tsunami
by Mohit Saini and Manali Jain
India’s straining health care systems are on the verge of collapse. A year into the pandemic, the devastating second wave of the coronavirus has put millions of livelihoods and lives at risk. The current COVID-19 crisis unveils India’s lack of preparation, the crumbling state of public health infrastructure, and inadequate vaccine preparedness. The supreme court of India called the situation a national emergency.
Prime Minister Modi, however, declared India’s victory over the pandemic back in January this year while addressing the World Economic Forum. Such false claims left many Indians frustrated with their elected state and central governments. It raises many pertinent questions – what was the hurry to declare victory over the virus prematurely? How did they prepare for the inevitable second wave to lessen its impact? What did they do to improve the country’s health infrastructure and the supply of critical care equipment? What domestic and international collaborations were made to deal with much-anticipated vaccine nationalism? How much did they invest in increasing the production of the vaccine, liquid oxygen, and life-saving medicines which are black-marketed and robbed? What are the concrete plans to vaccinate the people? Why are they not transparent in disclosing details of the US$ 1.3 billion PM-CARES fund? And, maybe, the most important one - who is accountable for the irrevocable tragedy millions of Indians are going through?
In March 2020, India imposed one of the world’s most aggressive lockdowns to slow the spread of the coronavirus. Fast forward to May 2021, India has set a global record with more than 500,000 daily infections. These official, undercounted numbers only reflect the number of people who are tested. The unofficial figures which include untested people are significantly higher than this. Further, death by coronavirus is misclassified and underreported by the government. Limited space at crematoriums has resulted in overcharging and cremation on pavements in some places.
The positivity rate of the COVID-19 test is adding to this concern - around 1 in 3 people in Delhi are returning a positive result. The increased infection rate has resulted in testing lags with 3-4 days of wait for RT-PCR tests and the results. Some laboratories are overwhelmed with massive demand for tests. The hospitals, which are already stretched above usual bed capacity, are full now. The situation worsened when some hospitals had an oxygen quota for 4-8 hours only thereby forcing the Delhi government to beg the central government to intervene. The oxygen politics between Delhi and neighboring states exposed the lack of coordination between states. Even the right to die with dignity is under threat.
Social media platforms and news channels are full of stories of horror, disgust, and failure of health systems. In a parallel universe, however, religious gatherings, political campaigning, and sporting events suggest that ‘all is well’ in India. When political leaders themselves downplayed the threat by organizing enormous gatherings, some Indians trusted their immunity and ignored the lethality of novel variants of coronavirus. The situation is so grave that even the hype surrounding India’s COVID–19 contact tracing app, Aarogya Setu, has faded away.
India ranks 145th out of 180 countries on the quality of and access to healthcare. The 2020 Human Development Report rate India among the worst countries globally, with only 8.5 doctors and 5 beds per 10,000 people. As of 2019, there were 1.9 million hospital beds in India with a huge state-level variation. Brookings estimates only 5-8% of the 700,000 government beds to be ICU beds. Assuming 50% of these ICU beds have ventilators, Brookings estimated 17,800 to 25,500 ventilators in government hospitals. To a large extent, this explains the ongoing struggle to find a hospital bed in India.
Until 2020, India spent about 1.3% of GDP on public health, worse than other emerging countries. In March 2021, the government proposed increasing healthcare spending by more than 135% to US$ 30 billion (1.8% of GDP). This proposal also included grants for nutrition, water and sanitation, etc. thereby raising concern over actual allocation to improve public health systems.
While COVID appropriate behavior may limit the spread of the coronavirus, vaccines are the most effective way to prevent it. As of April 21, India administered 130 million vaccine doses in 95 days becoming the fastest nation to do so in the world. This is only 7.65% of the 1.7 billion vaccines needed to vaccinate the majority of its adult population. Further, only 18.5 million people have been fully vaccinated after receiving two doses. Feeling domestic pressure, India stopped shipping vaccines after exporting 66 million doses to 95 countries by March-end. This paused the vaccine diplomacy campaign of the government which in addition to its support to a humanitarian cause was also a rejoinder to China to gain soft power.
The world's largest vaccine manufacturer, Serum Institute of India (SII), was prohibited from producing for India’s private market even though it agreed to sell the doses for US$ 2 to the government. The constrained cash flow made it difficult for the company to scale up vaccine production. It was only last week that the government accepted SII’s request for a US$ 400 million grant to boost its monthly capacity from 70 million currently to more than 100 million doses of AstraZeneca COVID-19 vaccine by the end of May. Finally, the government has also changed rules to fast-track imports of vaccines developed by Moderna, Pfizer, and Johnson and Johnson.
Knowing India cannot afford another national lockdown now, Prime Minister Modi recently asked states to consider lockdowns as the last option. The coronavirus crisis can be dealt with through collaborative decision-making between central, states, and local governments. The size and complexity of India as well as the current health crises reinforce the importance of autonomy of state and local government machinery. The local machinery should be supported to gauge the situation quickly and take preventive actions without waiting for the state and central government approvals.
Hospitals should be provided financial and human resources to create more makeshift beds based on local situations and demand. Health data should be analyzed to create micro-containment zones. and enforce temporary, localized lockdown if needed. Some experts recommend such lockdown in areas with over 10% COVID-19 positivity rate. Local data should be used in assessing risks and avoid lockdown restrictions prematurely.
State governments should improve transparency in disclosing the available healthcare resources. Such resources can be shared on a need basis irrespective of defined borders. The central government should immediately provide financial support to state governments to increase testing facilities, critical care equipment, and beds, etc. Immediate help would be to significantly increase the states’ quota of oxygen procurement from companies. It should work closely with vaccine manufacturers to expand its production capacities and assess its plan to launch the world’s largest vaccination drive. Timely collaboration with state governments, pharmaceutical companies, hospitals, and vaccination centers will be key to distribute the vaccines quickly.
Though late, it is heartening to see global communities stepping up to support India in fighting with coronavirus. The United States agreed to provide raw materials required for vaccine production and medical supplies. The European Union also pledged to pool resources to assist India. Germany is exporting mobile oxygen generation plants and France is providing oxygen respiratory equipment to India.
As of now, India’s topmost priority is to tackle the coronavirus crisis. Once the situation is under control, the Indian government should make an honest attempt to reflect on what went wrong and channel resources to improve the country’s health infrastructure. Hopefully, India can take inspiration from countries like South Korea that learned from Swine Flu in 2009 and developed early warning systems to prepare for a similar crisis. All lessons from the current crisis will be pivotal in improving India’s readiness and proactive response for a future pandemic.
Mohit Saini is an impact investing and innovative finance professional studying Master of International Affairs at The Fletcher School, Tufts University, U.S.A. He is a contributing writer for publishers like The Diplomat, Next Billion, and Down To Earth, etc. Prior to Fletcher, he worked with MSC as an international development consultant in India, Bangladesh, Malawi, and Uganda for six years. Mohit earned his MBA from the Institute of Rural Management Anand (IRMA), India. You can connect with him on LinkedIn.
Pandemic in India is by Gwydion M. Williams and is licensed under CC BY 2.0
