The only certainty in the coronavirus-induced global chaos is that the idea of the nation-state as the all-powerful, enforcer of social order is back. After decades of globalisation, neo-liberalisation and privatisation, in this moment of crisis, people across the globe are looking to their national governments and willingly giving up their civil liberties in favour of absolute State control. From Europe and the United States (US) to India, citizens are encouraging, in fact, demanding, that their governments improve surveillance and build capacities to police everyday life. Social distancing, social isolation, lockdowns are the new normal. The State commands it and people are willing to comply.
Ironically, this demand for excessive State control is in part a consequence of State failure in managing public health systems and developing robust mitigation strategies. Many countries in Europe and the US failed to test and contain the virus in its early days. South Korea and Singapore that seem, for the moment, to have avoided large-scale lockdowns focused on deploying State capacity toward mitigation through aggressive testing and contact tracing. But the trade-off is greater State capacity for surveillance.
These strategies are perhaps necessary but with their invocation, the nature of State-society relationships and the dynamics of State capacity in shaping State behaviour are likely to undergo a fundamental transition, globally.
As India readies itself for greater restrictions, it is important to examine the State capacity failures that led us to a place where lockdowns seem inevitable, and ask what needs to be done to redeploy State capacities in ways that protect citizens, while keeping State power in check.
In India, the coronavirus pandemic is unfolding in the context of a broken health system. India’s health failures are well known — our health infrastructure is weak and under-resourced, health facilities are poor, and quality of care is abysmal. In this context, it is perhaps easier to focus on containment through lockdowns rather than invest our faith in a broken health system. This is why the government’s appeal to move in the direction of a slow but inevitable lockdown in our cities has been well received and widely supported. But social distancing, despite lockdowns, in a poor country with high population density is near impossible. And with cases mounting every day, without a war like effort to strengthen our health system, this may do little to contain the deadly virus.
The Indian State, for all its failures, has a remarkable ability to shine when it goes in to mission mode — the State can conduct elections even as we routinely fail in basic administrative functions such as health and education. Given this, a well-coordinated mission-mode response is not unfeasible. But to do this, our policymakers have to first start believing in our public health system and begin investing in its capacities, rather than focusing on coordinating and managing shutdowns.
At a minimum, three critical things need to be done. First, aggressive testing. The relative success of countries that adopted this strategy is well-known. The Indian Council of Medical Research is slowly changing protocols and bringing in the private sector to expand testing. This is good news, but more needs to be done urgently.
Second, service readiness. India will not be able to pull off a Chinese miracle and build hospitals in 10 days. But it certainly can prioritise hospital readiness by upgrading facilities — add beds and procure equipment. This will require the administration to reduce red tape and speed up expenditure. Utilisation levels of government health budgets in India are extremely low. In 2018-19, only 59% of the total National Health Mission budget for the year was spent. At the hospital level, spending is even lower — only 38% of the funds made available for hospital upgradation were spent. Moving money at this stage is critical. Once the system starts moving, more resources can be added. In addition, funds need to be provided to prepare primary health centres and wellness centres built under Ayushman Bharat to triage and treat mild cases so that hospitals do not get overwhelmed.
Third, human resource management. India doesn’t have enough doctors, but, in many parts of India, government MBBS doctors are under-utilised. As economist Jishnu Das’ work has shown, doctors in rural primary health centres see barely eight to 10 patients a day. These doctors can easily be redeployed to service clusters where outbreaks take place. At the same time, community health workers (the one resource India has invested in over the last decade) can be trained with clear protocols and guidance to raise awareness, help patients navigate the health system, and seek appropriate care. In the event of an outbreak, we need to ensure that only critical patients reach hospitals. Some states are doing this, it needs to be scaled rapidly.
But to do this, we need to set up robust Centre-state coordination mechanisms. State governments such as Kerala are ahead of the curve, while others, especially in northern India, will struggle. The Centre needs to play a crucial coordination role, sharing strategy, expertise and human resources. In the short-term, investing in the existing public health system will help us deal with the crisis better. In the long-term, they can serve as the foundation for an agile and functional public health system.
The coronavirus pandemic has sharpened the focus on the role of the State and its relationship with citizens. The future of the State, particularly in India, will depend on the choices we make today. This could be our opportunity to strengthen our health systems and rebuild faith in public systems. Or we could invest in building capacities for enforcement and policing, which may have unwelcome consequences in the long-term.