What lessons can we learn from Kerala?

The logic is simple and nothing new—morbidity and mortality do not help people earn their livelihoods. So if the intention is to save livelihoods, lifting the lockdown is a self-defeating strategy, since the risk of infection multiplies. But at the same time, continuing the lockdown will mean that the poor are increasingly affected by acute food shortages. The government faces a double-edged sword. And in trying to dodge the strike of this sword, we have seen both a lockdown and then an opening-up. With infections spiralling and the number of deaths steadily rising, it remains to be seen if we are in for a second complete lockdown in the coming days.

The present state of affairs has exposed the weaknesses of the country's health system. The unthinkable has become the new normal. The list of horror stories is long—hospitals refusing to admit patients, unless a non-Covid certificate is shown; people dying because of a dearth of oxygen cylinders; patient being discharged because of testing positive for Covid-19; terminally-ill patients unable to access their treatment regime and many more. The truly heartbreaking stories are those of our frontline workers who died after contracting the virus on the job from the lack of personal protective equipment (PPE).

Without doubt, Bangladesh has made significant strides in the health sector (increased life expectancy, significant reduction in maternal mortality and infant mortality rates, near-universal immunisation of children and more), but the ongoing pandemic has revealed some serious gaps and systemic issues that remain unresolved. We can ill-afford to become complacent with our accomplishments; rather, we have to accelerate our efforts lest we lose ground and reverse the gains made so far. What positive lessons can we draw from how other countries have handled the pandemic?

One success story is that of the South Indian state of Kerala, which has not only contained the spread of Covid-19 effectively, but has also attained a high rate of recovery and low mortality. This success story has been attributed to three factors—the state's strong public health system, its social capital and the active involvement of local governments. What are our chances of emulating Kerala?

In terms of physical health infrastructure, Bangladesh has a strong country-wide network of public health clinics and other institutions. Unfortunately, this advantage cannot be fully utilised for the dearth of human capital. A severe lack of capacity exists at all levels of medical engagement—with doctors, nurses, midwives, medical technologists or even at the management level. The World Bank, in a 2004 study, pointed out the problem of "ghost doctors" in rural medical facilities in Bangladesh—the absentee rate for physicians was 40 percent at the larger clinics and 74 percent at the smaller sub-centres with a single physician. The situation is not much changed, 15 years on. A high concentration of doctors in the metropolises does little to help address the shocking ratio of less than one doctor per 1,000 people in Bangladesh.

Kerala has a long history of sustained planning and effective investments towards its healthcare system. More importantly, the public focus in the state, on not only healthcare but also education, has changed the mindset of the people. We have to understand that it is not enough to just build and equip hospitals. Alongside physical capital, it is critical to build appropriate and adequate human capital. A large hospital operating at gross under-capacity is a sheer waste for resource-crunched Bangladesh.

Since the outbreak of the coronavirus pandemic in Wuhan in December 2019 to the start of our lockdown in late-March, we had about three months of lead-time to prepare ourselves for the unavoidable onslaught. Kerala began systematic preparations in January 2020, which included a host of directives and training modules, starting from simple hand washing to sample collection and transportation; protocol for ambulances; hospital admissions, treatment and discharge; management of biomedical wastes; handling spill of body fluids; management of dead bodies and more. In Bangladesh, the extensive dissemination of "hand washing" and "social distancing" messages have been successful. The positive effect of these messages would have been amplified if other measures were also in place, such as ensuring timely availability of masks for all, easy and safe access to Covid-19 testing services, adequate quarantine facilities, sufficient PPEs for our frontline workers, stringent airport surveillance for incoming passengers, and other protective measures. Meticulous planning and preparation is key to contain the virus.

The declaration of a "general holiday" led many to leave the cities for their home towns. A lockdown to check the proliferation of the virus should have been strictly enforced. Any lenience generates insecurity amongst the citizens, who trust the government for their well-being. We, in Bangladesh, have been taking stop-gap measures rather than well thought-out actions, which has generated confusion among the masses. In dealing with an epidemic or pandemic, alongside a competent health system, we need a trustworthy and aware social system that will react if any anomaly is noticed. This is where we differ from Kerala, which has an adept system of governance, wherein both the authorities and the people facilitate each other. The public is equally responsible for supporting the government and conforming to measures without having the authorities to always police them.

Active involvement of the people through local government is the third of Kerala's strong points. For Bangladesh, such a strategy of empowering local communities for outreach and feedback might have been a more manageable and effective way to check the infection rate. Given our strong local government and NGO networks, the particularly congested areas could have benefitted the most from such an approach, focusing on a responsible neighbourhood and door-to-door engagement. More importantly, this would have immense positive psychosocial impacts for people, knowing help is available when needed. Now, in the absence of clear directives, any person who might happen to fall ill gets socially ostracised. A sense of apprehension prevails of falling sick with even a minor ailment, let alone the virus.

There is no alternative to a strong public health system. During times of crisis, it is the government that comes to the fore, since social welfare is its primary objective. Covid-19 has revealed that many of the developments that have taken place in our health sector have not been deep enough to create lasting improvements. Lack of comprehensive attention to this sector has caused inefficiency, mismanagement, and anomalies to creep in. Efforts have been made to reform the sector but these have not made any meaningful impact. Real developments will happen only when we address the real challenges of lack of capacity and accountability. A corollary to a robust public health system is an accountable private healthcare system. This is much-needed, given that most private hospitals in Bangladesh have become infamous for their lack of ethics. A reformation in the health system will facilitate the public and private sector to work in tandem, supporting each other's work. The status quo of skepticism towards the private sector causes the nation to lose out on potential good work and global recognition.

When an emergency strikes, preparedness is key. We do not have time to build capacity during an emergency and then tackle the emergency. It needs precautionary planning, which is a critical part of good governance. Lack of resources is an oft-cited problem in the health sector but until and unless we address the deeper, more complicated issues, increase in allocations will not help. Rather, greater allocations will allow for greater amounts to be siphoned off.

Firdousi Naher is a professor of economics at the University of Dhaka. Email:naher.firdousi@gmail.com.