Looking back at the Containment Plan
Looking back at India’s Containment Plan of the Government of India in April 2021 it is striking that it did not build for scenarios as the current second wave. The keywords in the plan are policy decisions and technical inputs. In retrospect, that plan looks woefully inadequate. It did not take stock of hospitalization, infrastructure status, hospital beds, medical supplies, medicines etc. It was a plan for containing people in a geographical unit. At that time though, I thought it was a decent plan that brought coherence in the early wave of the pandemic.
The schematic is instructive in understanding how to build and plan for healthcare crisis such as this second wave of Covid – 19. It builds on a militaristic command and control with clear lines of communication and reporting.
Centralized decision making and tight control on essential resources as well as key decisions by the Central government has come under severe criticism as this second wave of Covid-19 burns through the country. With more than 400,000 cases per day and more than 4000 lives lost, the situation often seems out of control.
While the containment plan set in place a clear mechanism for flow of information and decisions across the admin system, it lacked a reality check. Since it did not project for a situation as the current one, the assumption of containment was rather simplistic. It was not built for a situation where every village gets infected and there is tremendous demand for medical help across swathes of the population.
Technical inputs, reviews and coordination elements of the plan have completely broken down.
On a podcast, Dr Bang and Nachiket Mor discussed India’s healthcare and pandemic response. Decentralized public healthcare could have made for a better containment and response, Dr Bang argues. It was wrong to have all important decisions taken in Delhi and imposed on the whole country. He is concerned about the involvement of communities, village councils and their agency. The root cause of sub-optimal Indian healthcare is a paternalistic attitude of the Indian state. It takes the position of ‘providing’ for every citizen. Dr Bang seems to suggest that this has led to much harm and will not work. Communities must be involved in making decisions that affect them. Whereas, he observes, that in the districts things reduce to ‘Collector and SP raj’. The phrase points to complete take over of district affairs by the District Collector and the Superintendent of Police in an autocratic fashion.
I have mixed feelings about this framing by Dr Bang, but I value his insights more because of the deep rooted and long experience he has working in Gadchiroli, Maharashtra. He reasons –
So what we learned is that COVID-19 management in India as a whole—there are 700 districts and there are nearly 700,000 villages—each district and each village is different. So a monolithic arrangement, and administration from taking decisions about every detail about every human being, was absolutely inappropriate. And few medical experts, though they may be very intelligent, very competent, cannot be as intelligent and competent as to govern 140 crore people.
Looking at the containment plan, it can be seen how Dr Bang’s suggestion could have improved its effectiveness.
On limits of decentralisation, Nachiket Mor’s diagnosis is compelling too-
“Now, this balance has to be struck well, if we go the other extreme, and let the community figure this out, I would submit to you, you will get the kind of variation in response that you saw on COVID-19. The challenge for us in India is that partly, perhaps it is, you know, all of the broader issues that were raised earlier. But it’s also that we have not built the comprehensive primary care system that is necessary. So while we are anxious that perhaps an excessively centralised direction is being given, the reality on the ground is that communities are being left to their own devices. There isn’t really that much care available to them today, so they don’t actually see that centralisation play out, except when it’s a national decision, like a national lockdown, where people are forced to migrate. And in fact, it is communities operating on their own, trying to do the best they can, unfortunately.
We see elements of both playing out in the country at the moment. The containment plans, response mechanisms, coordination committees, task forces… all of these above all needed an acknowledgement that the pandemic’s threat is real. That it can mean serious harm, which it has.
Poverty of a nation is not just about per capita income. That is less important. In case of India it is impoverishment of its governance, administration and leadership. It is also true that its 1.3 billion holds other possibilities too.