We often use the diversity of India as an explanatory variable when discussing either operational challenges or shortcomings. However, diverse operational and leadership models might be a great strength to assess the tactical and strategic implementation of the pandemic response against the current challenges. What we need is the convergence of the different models to inspire and encourage shared learning. Although there is no one right model, India is better served by the assorted elements of the diverse and yet unique features that can guide us what to do mostly as we move out of the second wave and avoid the mistakes committed by others. Here is one such assorted set with the acronym MODEL.
Mortality reduction: The best model is one that focuses on preventing the most deaths. Setting up jumbo ICUs during the first wave and not dismantling them after that was instrumental in reducing the mortality during the second wave in Mumbai. Setting up ICUs in district hospitals and piping for oxygenation was done in the states of Karnataka and Tamil Nadu during the first wave. Similarly, oxygenation generation plants were installed in the tribal district of Nandurbar in Maharashtra and also in Kerala with the efforts of the Petroleum and Explosive Safety Organisation (PESO). These are proactive models.
Ownership: States that showed greater ownership often relied on technical advice and critically reviewed the preparedness in ensuring better management of the Covid-19 response. Setting up and relying on the advice of technical advisory committees or state task forces has been implemented successfully in Karnataka, Kerala, Maharashtra, among others. The essence of ownership by the government is to ensure that people and communities are empowered, they are in charge, and they have control over their participation and destiny. This process is bidirectional and requires trust-building through active engagement of the community. So far, such models are seen in Kerala and Andhra Pradesh, wherein community engagement and ownership have been instrumental in Covid-19 response. Involving the panchayati raj institutions has been the hallmark of Karnataka.
Data integrity and transparency: India does not rank well in assuring either the content or the quality of the data collected regarding cases and more so for deaths. Lest we forget, India has been lauded as a world leader for the efforts in the polio eradication (PE) programme, which was built on strong surveillance, transparent data reporting and meaningful response aided by an effective partnership of the technical wing of the ministry with the World Health Organization. All the decisive actions in the PE programme were led by data and data alone. This is a model we need now to assist the leadership.
Equity at the heart: Protecting the interests of vulnerable persons, including minorities, should be at the soul of programme planning. All of India’s vaccination programmes for children have had social mobilisation strategies. It is time the country has a national vaccination policy with a major focus on inoculating vulnerable people. In addition, there are several problems, including stigma and fear, which prevent the vulnerable from seeking testing or treatment when they are affected by Covid-19. Civil society volunteer groups are helping in Karnataka at a crucial time.
Leadership: The objective indicators such as the global health security index do not include leadership, which, according to me, is something critical to the overall pandemic response. This trait has been the single most defining element of every country and state’s success. Nobody imagined that India would go into nationwide lockdown when the country had only 500 cases. Despite unintended negative consequences, the comprehensive and quick response in the form of a nationwide lockdown bought us time to prepare well. It resulted in the least number of deaths compared to anywhere else in the world. Such hard decisions can be taken only by decisive leadership. When cases started surging in the Dharavi slum, most people in the world feared a carnage of sorts. The leadership in Mumbai is an exemplary model of how to steer from the front and the campaign was called “chase the virus”. While the rest of the country was figuring out how to tackle the pandemic, Kerala was far ahead in invoking the Epidemic Diseases Act and setting up protocols to mitigate the spread. Similarly, setting up technology-based apps to quarantine with the help of real-time data and the use of an evidence-based approach to tackle the first wave was the hallmark of Karnataka’s leadership.
To create an enabling environment for shared learning, the Covid-19 response should be institutionalised with equal participation of the states, civil society, researchers and community, among other stakeholders. A test not done is an opportunity not provided to live for the vulnerable anywhere. Hence, a multisectoral, inclusive and equity-promoting approach addressing all social aspects is as necessary as reducing the mortality related to Covid-19. Can we have a diverse model that inspires every state, even other countries, equally with the single objective of the well-being of everyone?
Dr Giridhara R Babu
Professor of epidemiology at the Indian Institute of Public Health-Bengaluru, PHFI
(epigiridhar@gmail.com)