KERALA MODEL OF RESPONSE TO COVID-19
This project was supported by the Omidyar Network India as part of their Rapid Response Funding Initiative to address the Covid-19 crisis.
Prepared by Centre for Publ i c Pol i cy Research (CPPR) AUGUST 2020 KKEERRAALLAA MMOODDEELL OOFF RREESSPPOONNSSEE TTOO CCOOVVIIDD--1199
Thi s proj ect was supported by the Omi dyar Network Indi a as part of thei r Rapid Response Funding Initiative to address the Covid-19 crisis.
Prepared by Centre for Publ i c Pol i cy Research (CPPR) SA Road, El amkul am Kochi , Keral a 682020 www. cppr. i n, ccs@cppr. i n Project Team
Authors Nissy Solomon, Senior Research Associate, CPPR (Team Lead) Goutham K A, Project Associate, CPPR Aiswarya Krishnan, Project Associate, CPPR Angela Cicily Joseph, Research Associate, CPPR D Dhanuraj, Chairperson, CPPR
Supported by Ni dhi Chandran (Edi ti ng) Akanksha Borawake (Data and I nformati on Gatheri ng) Ti sa Phi l i p (Data and I nformati on Gatheri ng) Aravi nd Anand Shankar (Formatti ng)
Cover i mage source: Bri ti sh Heral d TABLE OF CONTENTS
ACKNOWLEDGEMENTS i PREFACE ii LI ST OF FI GURES iv LI ST OF TABLES iv ABBREVI ATI ONS v
Chapter 1 I ntroducti on 1 Chapter 2 Contai nment Strategy 8 Chapter 3 Food Securi ty I nterventi ons 25 Chapter 4 Fi nanci al I nterventi on 33 Chapter 5 Awareness and Outreach Programmes 37 Chapter 6 The Resurgence 43 Chapter 7 Eval uati on Framework 48 Chapter 8 Overal l Assessment of Keral a' s Response 58
REFERENCES 64
Annexure 1 Guideline on State Medical Board 68 Annexure 2 Guideline on Virus Surveillance 71 Annexure 3 Health Advisory 74 Annexure 4 Revised Guideline on Testing, Quarantining 78 Annexure 5 Risk Categorisation of Patients 89 Annexure 6 Order on Testing Strategy 90 Annexure 7 List of Items in the Essential Food Kit Provided 100 by GoK Annexure 8 Sannadhasena 101 KERALA MODEL OF RESPONSE TO COVID-19
A C K N O W L E D G E M E N T S
The authors woul d l i ke to thank al l the i nsti tuti ons and the i ndi vi dual s for thei r cooperati on and ti mel y support i n compl eti ng thi s report. We thank the Government of Keral a and thei r vari ous offi ces for thei r assi stance i n provi di ng data, shari ng fi el d management and experi ences, and connecti ng the proj ect team wi th rel evant and i mportant personal i ti es. I t i s to be emphasi zed that the report i s a resul t of persi stent and concerted efforts of many i ndi vi dual s.
We thank Shri V S Suni l Kumar, the Mi ni ster for Agri cul ture, Government of Keral a, for hi s i nsi ghts. We thank Shri Roj i M John MLA for shari ng hi s experi ence. We al so express our grati tude to Dr S S Lal for hi s support i n thi s Study. We grateful l y acknowl edge Dr A Al taaf for hi s val uabl e i nputs that hel ped us i n the wri ti ng of the report.
We extend our speci al grati tude to the members of the Local Sel f Government Department, for gi vi ng us the ground-l evel report of vari ous i nterventi ons. We are thankful to the key i nformants at the Mi ni stry of Heal th (GoK), I ndi an Medi cal Associ ati on, Keral a and, the Worl d Heal th Organi sati on, for gi vi ng us thei r expert opi ni ons on associ ated topi cs.
We woul d l i ke to especi al l y thank Dr Ri j o John, Seni or Fel l ow at CPPR, for hi s stati sti cal proj ecti ons on COVI D-19 devel opments. Our due acknowl edgement to Ms Ti sa Phi l i p for gatheri ng data and i nformati on for the Study undertaken.
At the organi zati on, we are grateful to the seni ors for thei r cri ti cal comments and feedback through vari ous stages of report devel opment and al l the members of CPPR for thei r support i n compl eti ng the report.
i KERALA MODEL OF RESPONSE TO COVID-19
P R E F A C E
D Dhanuraj, PhD Chairperson, CPPR
COVI D- 19 has di srupted the gl obal order i n an unprecedented manner. The vi rus has chal l enged every one i rrespecti ve of thei r gender, nati onal i ty, sex, and age. The response and reacti on to the pandemi c was a mi xed bag; to begi n wi th, some di scounted the threat of the vi rus, some others opted for the l ockdowns whi l e others wai ted ti l l a cl ear trend emerged. A l arge number of deaths i n I tal y i n the earl y months of the pandemi c was a warni ng to others on what i s comi ng. Many countri es tri ed to curb the spread of the vi rus by announci ng the restri cti on of the movements of the general publ i c. A vacci ne i s sti l l a few months away. Unti l then, i t i s the i nsti tuti onal capaci ty and i ts outreach to fi ght back COVI D-19 that becomes cri ti cal factors i n control l i ng the vi rus i n the earl y months.
Keral a i s gl obal l y recogni sed for i ts advanced Human Devel opment I ndi cators. Pri mary Heal th and Educati on provi si ons i n Keral a are abl y managed and wel l pl aced i n compari son wi th the devel oped countri es. Synonymous wi th i ts mi grant workers across the gl obe, Keral a was the fi rst State to hi t wi th the COVI D-19 vi rus i n I ndi a. Whi l e the other states i n I ndi a were taken aback by the very nature of the vi rus spread, whi ch was growi ng so exponenti al l y, Keral a coul d fl atten the graph i n a few weeks’ ti me. Thi s has l ed to the attri bute and ‘ Keral a model ’ of contai ni ng COVI D-19.
As I wri te thi s preface, the si tuati on i s dynami c i n I ndi a. I ndi a has become the epi centre of COVI D-19 spread. Wi th the current thi rd wave hi tti ng Keral a, the model has al so been cri ti ci sed. Even though i t i s too earl y to come to a concl usi on on the model based on the current wave (there are many reasons for the current wave i n Keral a, that shoul d al so be consi dered), i t i s academi cal l y essenti al to document and anal yse the response of the Keral a Government (‘ Keral a Model ’ ) duri ng the fi rst two waves. Such a study wi l l hel p set up many i mproved protocol s and i nsti tuti onal mechani sms prepari ng for si mi l ar events i n
i i KERALA MODEL OF RESPONSE TO COVID-19 the future. Wi th the support of Omi dyar Network, the Centre for Publ i c Pol i cy Research (CPPR), Kochi has attempted to record the COVI D-19 response by the State of Keral a. The study has l ooked i nto government orders and ci rcul ars; hel d i ntervi ews wi th stakehol ders, and anal ysed the data avai l abl e i n the publ i c domai n. Si nce the movements and one-on-one meeti ngs were restri cted, al l assessment tool s were appl i ed usi ng onl i ne pl atforms onl y.
I hope thi s academi c endeavour wi l l hel p i n generati ng more di scussi ons, debates and di al ogues i n the soci ety about the Keral a model . Such conversati ons coul d onl y add to the ri ch academi c l i terature emanati ng from vari ous parts of the worl d about COVI D-19 response dai l y. Let' s hope thi s smal l attempt by CPPR hel ps the heal th researchers and soci al workers i n thei r war to contai n the COVI D-19 vi rus.
i i i KERALA MODEL OF RESPONSE TO COVID-19
L I S T O F F I G U R E S
F i g u r e 1 State Profile at a Glance
F i g u r e 2 Timeline of Kerala’s Immediate Response till May 1, 2020
F i g u r e 3 COVID-19 Progression of Kerala vs India as on May 4, 2020
F i g u r e 4 Progression of COVID-19 Cases in States with 100+ Confirmed Cases as on May 10, 2020
F i g u r e 5 Indian States with 100+ Confirmed COVID-19 Cases as on June 2, 2020
F i g u r e 6 District-wise Distribution of Registered Volunteers in Kerala
F i g u r e 7 COVID-19 Statistics of Kerala as on August 11, 2020
L I S T O F T A B L E S
T a b l e 1 PDS system in Kerala:
T a b l e 2 Evaluation Framework
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A B B R E V I A T I O N S
A P L Above Poverty Line A S H A Accredited Social Health Activist A T M Automated Teller Machine A Y U S H Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy B P L Below Poverty Line C C T V Closed-Circuit Television C H C Community Health Centre C M D R F Chief Minister's Distress Relief Fund C M S Church Missionary Society C O V I D Coronavirus Disease C R E D A I Confederation of Real Estate Developers Association of India
C S R Corporate Social Responsibility D I S H A Direct Intervention System for Health Awareness D M O District Medical Officer G I S Geographic Information Systems G o K Government of Kerala G S D P Gross State Domestic Product I C M R Indian Council of Medical Research I H M E Institute for Health Metrics and Evaluation I M A Indian Medical Association I M C Indian Medical Council
I P C Indian Penal Code K E A M Kerala Engineering Architecture Medical K F C Kerala Financial Corporation K I N F R A Kerala Industrial Infrastructure Development Corporation K M S C L Kerala Medical Service Corporation Limited K S I D C Kerala State Industrial Development Corporation
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L S G Local Self Government L S G D Local Self-Governing Department M E A Ministry of External Affairs M E R S Middle East Respiratory Syndrome M G N R E G A Mahatma Gandhi National Rural Employment Guarantee Act M H A Ministry of Home Affairs M o H F W Ministry of Health and Family Welfare M S M E Micro Small and Medium Enterprises N C C National Cadet Corps N C D Non-communicable Disease N H G Neighbourhood Group N H M National Health Mission N R I Non-Resident Indian N R K Non-Resident Keralite N S S National Service Scheme O R C Officers' Reserve Corps P D S Public Distribution System P H C Primary Healthcare Centre P H F I Public Health Foundation of India P P E Personal Protective Equipment R R T Rapid Response Team R T - P C R Reverse Transcription Polymerase Chain Reaction S A R S Severe Acute Respiratory Syndrome S D M A State Disaster Management Authority S D R F State Disaster Response Fund S L B C State Level Bankers Committee S S L C Secondary School Leaving Certificate T P R Test Positivity Rate W C P Women Component Plan W H O World Health Organization
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CHAPTER 1 INTRODUCTION
I mage source: PTI
The novel coronavi rus di sease (COVI D), whi ch was fi rst reported i n Hubei provi nce of Chi na i n December 2019, has taken the worl d by storm wi th i ts astoundi ng speed of contagi on. The vi rus has transcended boundari es i nfecti ng 20, 290, 216 peopl e gl obal l y, wi th an overal l death tol l of 7, 39, 980 as of August 11, 2020. I ndi a has been grappl i ng wi th the si tuati on for more than three months and has responded wi th vari ant versi ons of l ockdown to l i mi t the transmi ssi on. Nati onal l y, the vi rus has i nfected a total of 2, 294, 438 peopl e and cl ai med 45, 597 l i ves as on August 11, 2020. Each State of the country i s tackl i ng a uni que set of chal l enges posed by the cri si s, but one State has emerged as a harbi nger of hope for the rest.
Keral a, the fi rst State i n I ndi a to regi ster a COVI D-19 case, was under the l i mel i ght for i ts handl i ng of the pandemi c, offeri ng an exempl ary model on what can be an effecti ve and wel l -organi sed outbreak-response mechani sm. The State averted the surge i n the number of cases and successful l y fl attened the curve i n the second wave of i nfecti on. Wi th the i nter-state movements and return of expatri ates, Keral a i s currentl y geari ng up for another cruci al battl e agai nst COVI D-19. One of the di sti ncti ve features of Keral a' s devel opment story has been i ts conti nued focus on soci al sectors l i ke heal th and educati on (Ramankutty 2000). The foundati on for an affordabl e medi cal care system was l ai d even before the formati on of the
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State. Wi th the i ncepti on of the returnees from Chi na, ri gorous State i n 1956, heal th conti nued to contact traci ng and testi ng, be a pri ori ty sector that formed a uni versal food securi ty, si gni fi cant share of the rehabi l i tati on of mi grant l abourers, government’ s expendi ture. The the establ i shment of communi ty conti nual pri macy gi ven to the heal th ki tchens, etc popul arl y came to be sector bui l t a strong publ i c heal th known as the “Keral a Model of system i n the State. COVI D-19 Response”. The Ni pah Vi rus outbreak of 2018 The fol l owi ng research i ntends to was one of the chal l engi ng heal th shed l i ght on the State’ s response cri ses the Heal thcare department of to COVI D-19 and i denti fy l essons of Keral a was confronted wi th. The pol i cy and practi ce for other States experi ence gai ned from handl i ng the to respond and prepare for any outbreak fami l i ari sed Keral a wi th future heal th cri si s. The study contai nment measures undertaken expl ores the i nterventi ons duri ng epi demi c breakouts. The two undertaken by both government and consecuti ve fl oods i n the year 2018 non-government actors that and 2019 al so establ i shed a strong faci l i tated the State to effecti vel y i nsti tuti onal memory i n frami ng contai n the spread of the vi rus effecti ve response mechani sms to duri ng the fi rst two waves of the si tuati on i nduced by the COVI D- i nfecti on. The research al so 19 pandemi c. suggests a framework whi ch can be Wi th the onset of COVI D-19, Keral a adopted by other States by undertook a seri es of contai nment remodel l i ng i t as per thei r contextual measures. The earl y steps taken by requi rement. the State such as the survei l l ance of
1. 1 Methodol ogy
The study adopted qual i tati ve methods of assessment. The response of the State towards the pandemi c as a whol e i s di vi ded i nto three waves for the conveni ence of the study.
1. First wave—the period ranging from January to February. It covers the State’s response in detecting the early cases of infection. 2. Second wave—the period ranging from early March to May. It includes the State’s containment measures adopted after the detection of Pathanamthitta Cluster. 3. Third-wave—the period ranging from the first week of May to present day as of August 11, 2020 is considered the third wave. It includes the measures that are undertaken by the State with the arrival of expatriates and residents of other States.
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The study emphasises on the first two matrix will be assessed based on the waves of infection from the period degree and prevalence of each starting from late January to early component and such a tabulation will May. The ongoing developments help us to determine the dominating observed in the third wave are factors and also the replicability of the presented in the document with the model. Each of the interventions is available information at the time of classified as long-term, medium-term writing. The effectiveness of the and short-term subject to the time it government's response to COVID-19 is takes to set up the responses assessed in terms of the effectively among the target administrative, socio-economical and population. This is done to explore the non-governmental factors. possibilities of implementing these
The study aims at grading the measures in other Indian States either interventions and management in the by replicating them or modifying them form of a matrix which is designed in in accordance with their socio- such a way that it incorporates all the economic conditions. It should be interventions / measures adopted by noted that some of the elements of the State in response to the pandemic. the Kerala model of crisis management The measures are mapped against the are intrinsic to the Kerala society and corresponding departments / are very much dependent on the institutions / organisations to various social, cultural, economic and understand the extent of the political developments over centuries stakeholders’ engagement in planning which are not easily replicable. and implementing interventions. The
1.1.1 Data Collection Methods
The data collection employed in the Government (LSG) representatives, study uses both components of Ministers in charge, Medical primary and secondary data collection. Professionals, etc. A semi-structured Primary data was undertaken through format was adopted to interview the key stakeholder interviews to stakeholders as it gives the flexibility understand the ground level- to accommodate different operations of the governance system perspectives, thereby allowing space and to substantiate the findings of the to explore other associated aspects in study. The key informants of the study the study. The sources for secondary included officials engaged in the data include Government notifications, operations of COVID-19; ranging from Amendments, and articles from Kudumbashree workers, Local Self international and national newspapers.
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1. 2 State Profi l e
Keral a i s a State on the southwestern Figure 1: State Profile at a Glance Mal abar Coast of I ndi a. The State covers an area of 38, 863 square ki l ometres. I t i s bordered by Karnataka to the North and northeast, Tami l Nadu to the east and south and Lakshadweep Sea to the west. Keral a i s the 13th most popul ous State wi th a popul ati on densi ty of 860 per sq km.
The Economy of Keral a i s the 10th Administrative units Districts : 14 l argest i n I ndi a wi th ₹7. 82 tri l l i on i n Gross State Domesti c Product (GDSP) Taluks :63 Towns : 520 and a per capi ta GSDP of ₹204, 000. Non-Resi dent Keral i tes (NRKs) have a Villages : 1018 si gni fi cant rol e to pl ay i n the progress of the State. As per the 2018 survey Land Area Population Density on Keral a Mi grati on conducted by the 38,863 sq km 859 per sq km Centre for Devel opment Studi es, the Population : 33,387,687 number of emi grants i s esti mated to be 21 l akh. The l argest concentrati on of expatri ates i s i n the UAE, fol l owed 52% 47.9% by the USA. Rural Literacy rate : 94% Keral a i s a uni que State i n I ndi a that Literacy : 92.98% Population i s known for i ts hi gh performance i n Percentage : 52% the Human Devel opment I ndex, 0. 78 i n 92.07% 96.11%
2018. I t has l ow mortal i ty rates, hi gh Urban l i teracy and l i fe expectancy rates Literacy : 95.11% Population across the country, al ong wi th a Percentage: 47.70% posi ti ve sex rati o. The State’ s Households Household size endeavours and agendas have come to 78,53,754 4.3 be hai l ed as a “devel opment model ” for other States to l earn and draw i nspi rati on from. Fi gure 1 summari es the profi l e of the State. Source: Census
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1.2.1 Health Infrastructure
The NI TI Aayog Heal th I ndex 2019 foundati on i n the heal th sector. posi ts Keral a as the top-performi ng A uni que aspect of the heal thcare State, by recordi ng a stel l ar servi ces provi ded i s the recogni ti on performance on several i ndi cators and i nsti tuti onal i sati on of meeti ng the targets set under Al l opathi c, Ayurvedi c and Sustai nabl e Devel opment Goal s. One Homeopathi c medi cal systems by the of the factors underl yi ng Keral a’ s State government. The al l opathi c performance i n heal th i ndi ces has system i s accessi bl e to both rural been the State’ s focus on bui l di ng a and urban areas. Rural areas are strong network of publ i c heal thcare mai nl y served by heal th centres— systems over many years. mul ti purpose uni ts renderi ng Tradi ti onal l y, Keral a has had a l ong preventi ve and curati ve faci l i ti es hi story of organi sed heal thcare. (the concept of rural heal th servi ce Before the advent of Europeans, del i very through PHCs 1 was i n l i ne there exi sted i ndi genous wi th the recommendati ons of the systems l i ke Ayurveda and other Bhore commi ttee i n 1946 and of the tradi ti onal practi ces of medi ci nes on Nati onal Pl anni ng Commi ttee' s whi ch peopl e rel i ed to address thei r subcommi ttee on nati onal heal th). heal th concerns. The peri od from State formati on to The rul ers, mi ssi onari es and soci al earl y 1980s, the State wi tnessed a reformers had a consi derabl e rapi d expansi on of government i nfl uence on the State i n adopti ng heal th servi ces. The total number of progressi ve reforms i n the soci o- beds i n government hospi tal s i n the economi c envi ronment of the State. Al l opathi c medi cal system i ncreased The Church Mi ssi onary Soci ety (CMS) 20, 000 i n 1970–71 from around popul ari sed the use of modern 13, 000 i n 1960–61. By 1986, the systems of medi ci ne i n 1816 when total was 36, 000, whi ch grew to peopl e fol l owed i ndi genous systems 38, 000 by 1996. The government of medi ci ne (John, 2018). The rul ers pl ayed a pi votal rol e i n devel opi ng of the erstwhi l e pri ncel y States of the foundati on set for an Travancore and Cochi n promoted unequi vocal heal th system i n the i ni ti ati ves to make the modern State i n the earl y years but fai l ed to medi cal system avai l abl e to thei r make further devel opments due to subj ects, thereby l ayi ng a strong the fi scal cri si s from the 1980s
1. Primary Health Centres (PHCs) are State-owned rural healthcare facilities in India that form the most basic units of the healthcare system. They are single-physician clinics with facilities of minor surgeries.
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(Ramankutty 2000). Thi s gap was As per the 2017–18 report on bri dged by pri vate pl ayers as the pri vate medi cal i nsti tuti ons i n Keral a sector burgeoned i n great numbers by the Department of Economi cs and duri ng the 1980s and 90s, cateri ng Stati sti cs, there are 13, 008 to the heal thcare needs of the regi stered pri vate medi cal peopl e i n Keral a. I n the peri od from i nsti tuti ons of whi ch 6920 1986 to 1996, beds i n pri vate i nsti tuti ons are under al l opathy i nsti tuti ons grew from 49, 000 to system of medi ci ne, whi l e the rest 67, 500. Pri vate hospi tal s now 6088 are under AYUSH. The surpass government faci l i ti es both cumul ati ve bed strength of these i n terms of beds and empl oyment pri vate medi cal i nsti tuti ons as of of personnel . 2017–18 i s 1, 05, 373.
The number of government The doctor to pati ent rati o of Keral a, hospi tal si n Keral a i s 1280. As per whi ch stands at 1: 400 i s hi gher than the Nati onal Heal th Profi l e 2019, the the WHO prescri bed rati o of 1: 1000. l atest fi gures on bed counts i n The total number of doctors i n Keral a government hospi tal s stand at possessi ng recogni sed medi cal 38, 004 beds (rural 16, 865 and urban qual i fi cati ons (Under the I MC Act) 21, 139). Keral a al so has a strong regi stered wi th State Medi cal Ayurvedi c Tradi ti on whi ch conti nues Counci l s/Medi cal Counci l of I ndi a (up to be a mai nstream source of to 2018) i s 59, 353 as per NHP. I n treatment i n Keral a. As per NHP, the State, the number of al l opathi c Keral a government has 126 hospi tal s doctors i n government hospi tal s i s and 806 di spensari es i n Ayurveda. 5239. I n rural Keral a, the number Under the umbrel l a of AYUSH of al l opathi c doctors at PHCs i s (Ayurveda, Yoga & Naturopathy, 1169, speci al i sts at Communi ty Unani , Si dda and Homoeopathy), i t Heal th Centres (CHC) i s 40, whi l e has a total of 162 Hospi tal s and heal th assi stants and heal th workers 1473 Di spensari es. The number of are 2210 and 11, 351, respecti vel y. AYUSH regi stered doctors i n the State i s 41, 606.
1. 3 Chronol ogy of Keral a’ s Response to COVID-19
When the news of COVI D-19 the ti mel i ne of i mmedi ate outbreak emerged gl obal l y, the State i nterventi ons executed by the government put together an Government of Keral a (GoK). extensi ve system of checks to avoi d Consi deri ng the dynami ci ty of the grave eventual i ti es. Fi gure 2 shows study, the ti mel i ne consi dered here
0 6 KERALA MODEL OF RESPONSE TO COVID-19 i s unti l May 1, 2020, when Keral a i nfecti on, whi ch the State i s reported Zero cases. The currentl y fi ghti ng. The resurgence of repatri ati on of workers from abroad the new cases i s di scussed i n has ushered the thi rd wave of Chapter 6.
Figure 2: Timeline of Kerala's Immediate Response till May 1, 2020
JAN 20 JAN 23 JAN 24 JAN 30 Comprehensive Guidelines Screening of Special control room First Wave: sent to all districts by the passengers from China set up in the 1 Case Department of Health and Directorate of Health Recorded Family Welfare Services
FEB 02 FEB 03 MAR 08 MAR 11
Established Declaration of Second wave: Surveillance Testing COVID as State Pathanamthitta Strengthened at Airport, Laboratories Disaster Cluster Seaport, and Railway Detected Station, Borders
MAR 12 MAR 15 MAR 20 MAR 27 Revised Guideline Break the chain Announced Rs 20,000 Proposed Kerala on Quarantine, Campaign Cr Social Protection Epidemic Disease testing and Programme Ordinance admission
APRIL 04 APR 10 APR 11 MAY 01 Sentinel Developed Rapid Issued Advisory on Surveillance to test Antibody Testing to the use of anti- Day-zero samples of Check Community body kits vulnerable Segment Transmission
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CHAPTER 2 CONTAINMENT STRATEGY
The multi-pronged containment strategy, backed by Section the existing decentralised governance and health Snippets systems, made it possible for the State to flatten the curve in the Second wave.
Early Response Contact Tracing
A State level control room Risk-based criteria was adopted was set up immediately after for test, trace, quarantine and the news of COVID emerged treat in China ASHA workers and Kudumbasree Maintained a record of returnees members were engaged in from COVID-19 affected response measures countries and quarantined them and their contacts Route maps of the patients were Restricted Public gathering and published through various print, closed down educational visual and social media channels institutions Strategic Testing Sentinel Surveillance
Adopted judicious testing by maintaining the test positivity rate to stay below 2 percent The charge of implementation was on district collectors Rigourous testing were undertaken during the The tests to detect community initial periods to trace all possible suspected transmission were done on priority groups cases Separate team for each priority group was Sentinel Surveillance was initiated to detect alloted community spread
Quarantine Facilities and Home Quarantine Strategies Local Self Government Organisations were given the responsibility to ensure the availability of essentials Rigorous contact tracing followed by strict quarantining mechanism was undertaken A media surveillance team was functioning from the district centres who observed print, visual and Strict enforcement of home quarantine mechanism social media to know the needs of the people under qurantine. Besides, it kept a tab on pneumonia Quarantining protocol was deaths and debunked fake news based on risk-based categorisation LSG bodies were entrusted with general monitoring Ward-level Rapid Response Teams were deployed to of those who are under observation check whether the suspects are adhering to the quarantine protocols
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The containment strategy adopted by the State garnered a lot of media attention within and outside the country. It was a multifaceted approach and consisted of several governmental and non- governmental actors. The earlier experience with the Nipah virus outbreak familiarised Kerala with contact tracing and effective infection control mechanism. The virus detected in mid-May in 2018 claimed 17 lives in Kerala, a case fatality rate of 88.9 per cent. Quoting a medical professional from Indian Medical Association (IMA), Kerala, contacted for this study Source: The New Indian Express
Although Kerala contained Nipah effectively by the timely intervention of the government machinery, the measures undertaken were not very sophisticated. The high case-fatality rate coupled with the fact that subsequent infection cases emerged from the public health systems exposed the State’s lack of infection control mechanisms. This event, however, gave a good lesson on effective contact tracing, setting up of isolation units and building infection control mechanisms.
The episode alerted the health system measures and its institutional of Kerala of its systemic flaws, and memory enabled Kerala in designing a the knowledge gained thereupon came rapid response to COVID-19. The handy in controlling the present ensuing sections give details on the crisis. The combination of proactive measures undertaken by Kerala.
2.1 First Wave
The State government began response mechanisms. District establishing control centres to control centres were also set up to coordinate actions and timely support manage the local affairs. following the news of COVID-19 Given the high number of expatriates contagion in China. An addendum to and foreign tourists travelling to Testing, Quarantining, Hospital Kerala, the State took proactive admission and Discharge criteria for measures. It was on high alert and COVID-19 was issued on January 5, continued to enforce surveillance in 2020. It introduced the hospital all international airports even before protocols to follow in case a person is the World Health Organization (WHO) a coronavirus suspect. On January 24, declared a human-to-human 2020, a State control centre was transmission. formed to coordinate different
0 9 KERALA MODEL OF RESPONSE TO COVID-19
On January 23, 2020, a medical mandatory quarantine for all student returnee from Wuhan landed passengers arriving from China or in Cochin International Airport. With any country notified to be affected— the onset of symptoms on January 27, this implementation was weeks the district surveillance officer was before the Union Government’s contacted and she was admitted to an decision to do the same. The initial isolation ward in the District General measures were to identify and Hospital of Thrissur. On January 30, conduct risk-based categorisation of she tested positive for the Virus. With all travellers from China and their that, India recorded the first case of contacts. Such passengers, as well COVID-19 in the Thrissur district of as their close contacts, were to be Kerala. Health authorities later isolated for 28 days. Approximately shifted the medical student to an 1924 people were kept under house isolation ward of the Medical College surveillance and 75 under hospital Hospital, Thrissur for better surveillance. Two more positive observation and care. As recounted by cases were identified, one each from a Kudumbashree official, with the Kasargod and Alappuzha Districts of reporting of the first case, Ministers, Kerala. Subsequently, on February 3, District Collector and health officials the State government declared a arrived at the Medical College and health emergency which enabled the called for meetings to implement State to utilise the State Disaster plans to tackle the pandemic. The plan Response Fund (SDRF),2 constituted was based on the State's experience under Section 48(1) of the Disaster in tackling the Nipah outbreak. Management Act, 2005, where a
To discuss and decide on patient State government can use up to 10 management in medical institutions, per cent of the funds available in the State constituted Medical Boards SDRF for providing immediate relief (Annexure 1) on February 2 in all to the victims of natural disasters Medical Colleges, District Hospitals that are considered to be disasters and General Hospitals. The Medical within the local context in the State. boards consisted of the This also gives authority to the Superintendent of the hospital, HoD Police force to arrest individuals General Medicine, HoD Respiratory who ignore the State government Medicine, HoD Anesthesiology, HoD directives and take action against Infectious Disease, HoD Microbiology perpetrators of fake news. and HoD Community Medicine. A health advisory (Annexure 3) was
The government on February 2 issued issued in due course to track, in its guidelines (Annexure 2), identify and test peopl e (student
2. The State Disaster Response Fund (SDRF), constituted under Section 48 (1) (a) of the Disaster Management Act, 2005, is the primary fund available with the State Governments for responses to notified disasters. 1 0 KERALA MODEL OF RESPONSE TO COVID-19 returnees as well) with a travel Wards. WhatsApp groups were history to Wuhan since January 15, al ready establ i shed and functi oni ng 2020. Such travellers and their close si nce the response to the 2018 contacts were kept in isolation for 28 fl oods. The I MA offi ci al sai d the days. The advisory also directed all deci si ons were communi cated to the lodging businesses to maintain a grassroots l evel s wi th a great l evel register of travellers with travel of transparency i n the system. “The histories to COVID-19 affected pri mary measures were screeni ng, countries. Daily district-level review quaranti ni ng, contract traci ng and meetings were held to analyse the i sol ati ng the posi ti ve cases”. Swi ft situation with the respective acti ons on these l i nes gave Keral a Ministers, District Collector, DMO, the advantage to strategi cal l y Police personnel and LSG contai n the spread. On February 12, representatives among others in each wi th no further cases bei ng district where COVID-19 cases were confi rmed, the State deci ded to reported. The Kudumbashree official wi thdraw the heal th emergency. The explained the functioning of the fi rst wave ended wi th the recovery communication network, where of al l three cases reported. directives from the Chief Minister’s Thereafter, a hi gh state of response Office were sent to district-level and survei l l ance conti nued to be committees who disseminated the appl i ed. directives to the Panchayats and
2. 2 Second Wave of Infecti on
With the inflow of natives and onl y ensures the easi ng of pressure foreigners from the European and Gulf on the hospi tal and State systems. countries, the State began to see the However, Keral a’ s strategy second wave in the month of March. attempted to contai n the vi rus from Speaking of the overall operations of the very source i tsel f by the State, the IMA medical aggressi vel y traci ng the pri mary and professional mentioned, “Kerala secondary contacts and treati ng adopted the Source-Reduction Strategy, also called Crushing the them. Thi s crushi ng of the curve i s Curve. This is different from the refl ected i n the data trends starti ng strategy of flattening the curve. The from March to May 8 (see Fi gure 4). flattening strategy is formulated for On May 1, Keral a had 16 acti ve cases countries where the number of cases but reported no new confi rmed shoots beyond the capacity of the cases, marki ng a Day Zero. system to contain the spread”. It
1 1 KERALA MODEL OF RESPONSE TO COVID-19
Although measures taken in this setti ng; that i s, the l ockdown from period were swift and praiseworthy, it the Centre decl ared on March 24, is to be noted that there were few 2020 l i mi ted the movement of external factors that Kerala peopl e to the State. Thi s, i n addi ti on capitalised on; foremost factor being to i ts earl y measures undertaken that Kerala (as with all the States) hel ped the State i n contai ni ng the functioned in a largely controlled spread.
Figure 3: COVID-19 Progression of Kerala vs India as on May 4, 2020
After making its presence in Kerala testi ng, i sol ati on, hospi tal admi ssi on first, many Indian States started and di scharge. I n that, a cl i ni cal reporting positive cases by March. categori sati on for COVI D-19 Thereupon, the cases surged in many management was i ntroduced, States in India. By early March, Kerala wherei n those wi th mi l d symptoms saw an upshot of COVID-19 cases, (Category A) are advi sed to undergo becoming the State with the highest stri ct home i sol ati on wi thout havi ng number of cases among all Indian to do a testi ng or hospi tal States (see Figure 4). treatment. Peopl e devel opi ng mi l d
The government implemented multi- symptoms have to i nform DI SHA pronged measures to combat the hel pl i ne and Doctors from nearby second wave of infections hitting PHC wi l l tel ephoni cal l y moni tor the Kerala. Revised guidelines (Annexure progress of pati ents. Pati ents wi th 4) were issued for the management of hi gh-grade fever or comorbi di ti es COVID-19 patients concerning their (Category B and C) wi l l be summoned
1 2 KERALA MODEL OF RESPONSE TO COVID-19
Figure 4: Progression of COVID-19 Cases in States with 100+ Confirmed Cases as on May 10, 2020
to the designated COVID-19 COVI D-19 as a noti fi ed di saster. As treatment centres for clinical per the Centre’ s noti fi cati on, 25 per assessment. cent of the al l ocated funds can be March 4 onwards, universal screening, spent on measures for quaranti ni ng, airport safety protocols and orders to testi ng and screeni ng and up to 10 screen travellers at all international per cent SDRF al l ocati on for airports and seaports were procurement of essenti al announced. The government issued equi pment/l ab for COVI D-19. COVI D- protocols to track travellers from 19 cel l s were consti tuted i n al l COVID-19 affected countries who governmental departments for entered the State three weeks before better coordi nati on i n State the commencement of universal response. I nsti tuti ons wi thi n the LSG screening as well. Asymptomatic ran awareness i ni ti ati ves (expl ai ned foreign arrivals were also to be kept in i n Chapter 5) l i ke the ‘ Break the isolation until their test reports were Chai n’ campai gn, conducted available. As the cases gradually sani tati on dri ves, ensured increased, social distancing measures avai l abi l i ty of essenti al s, etc. On were enforced by the State. March 23, a State-wi de l ockdown ti l l Educational institutions and public March 31 was announced. The next spaces were closed and religious day, the Uni on Government institutions were asked to reduce the announced a 21-day nati onwi de number of devotees. Further l ockdown to fi ght the spread of the guidelines and precautions on various vi rus. hygiene norms were also issued. To further strengthen the measures The Union Government announced to l i mi t the contagi on, the Governor
1 3 KERALA MODEL OF RESPONSE TO COVID-19 of the State promulgated Kerala individuals with no contact or travel Epidemic Disease Ordinance on March history. Besides the testing of 26, 2020. With the Ordinance in place, people in the community, the the State government can notify any sentinel surveillance would be disease as an epidemic disease if it responsible for analysing collected thinks that the State or any part of data to track the rise and fall of the State is under the threat of an COVID-19 cases. This system would epidemic disease outbreak. Under the assess the risk and also identify the provisions of this Ordinance, the clusters or hotspots with COVID-19 State government is empowered to infection. By the first week of April, prohibit any activities that it over 13, 000 tests were conducted in considers to be sufficient to transmit the State, higher than any other diseases from person to person. States in India. Along with the rapid Realising the need for more testing, testing, protocols were set up to the State ramped up its testing implement the tests. Additionally, infrastructure in this period. During wi th 800 medical student the first wave of the pandemic, the volunteers, the IMA of the State samples were tested only at the announced setting up of surveillance National Institute of Virology, Pune as systems in each district, with a team mentioned in the government visiting one area every day. guideline dated February 1, 2020. By For the maximisation of resources, the month of March, with the increase the Health Minister of Kerala, Smt KK in the number of cases and as a part Shailaja urged all medical of improving the capacity to test the practitioners who were on leave to samples taken from suspects and rejoin duty. To tackle the issue of contacts, more number of laboratories shortage of staff, the government from the public sector were entrusted appointed doctors on a temporary to carry out the test. As per the basis in every district. By March 24, guideline dated March 25, 2020, nine the Health Minister announced the laboratories were designated to appointment of 276 doctors to help conduct tests of the samples ease the crunch of hospital staff in collected from their allotted districts. the State. It was also decided to By April 24, the State augmented the extend the work time of all PHCs to testing infrastructure and there were six in the evening. Regulations were 14 testing facilities in the State; one imposed in the Regional Cancer for each district. Centre, Trivandrum to ensure the The establishment of a sentinel safety of high-risk patients. Along surveillance system 3 was planned with with these preventive measures and PHCs and Taluk hospitals to take containment strategies, the State random cases of fever and cough in government, LSGs and ci vi l soci ety
3. A sentinel surveillance system is used when high-quality data is needed about a particular disease. Selected reporting units, with a high probability of seeing cases of the disease, good laboratory facilities and experienced well-qualified staff identify and notify certain diseases. The system involves a limited network of carefully selected reporting sites. 1 4 KERALA MODEL OF RESPONSE TO COVID-19 organisations launched awareness KEY FACTS drives to ensure the cooperation of 54 % Internet Penetration in the public in containing the virus. Kerala During this period, the State Smart Phone government also decided to provide 65 % Penetration nutrients listed in the mid-day meal scheme for the Anganwadi children at Internet Subscription Per their homes. Under normal 70 per 100 100 Population circumstances, mid-day meals are given during the academic year from By early March, the need for improved June to March. However, the Internet speed became evident. With government, considering the people having to work from home, situation, decided to extend it over increase in online financial the months of April and May to transactions and the educational guarantee food security. institutions being forced to transition As reported in India Today, the to online classes, there was a growing decision has benefited approximately demand for better Internet 3.75 lakh children from the age of 3-6, infrastructure. It was found that the under the mid-day meal scheme of majority of Internet consumption in 33,115 Anganwadi centres. Students Kerala is made available through local up to Class 8 who are covered under servers, hence the demand could be the mid-day meal scheme were met swiftly. The then IT Secretary, provided with provision and rice kits. M Shivashankar held talks with Approximately 26 lakh students in service providers to augment the government and government-aided capacity to meet the growing demand schools across the State are and steps to increase the network expected to benefit from this. bandwidth by 30 to 40 per cent were initiated. The IT department also KEY FACTS demanded daily reports from the various service providers. 33,115 Total Anganwadi Centres Every Panchayat created, on an average, six squads consisting of Number of Anganwadi 33,115 Health staff, Police and volunteers to Workers assist families in isolation or under
Number of Helpers quarantine. Families could reach out 32,986 in Position to these squads or directly contact the District Control Room or even the Number of Students Ministers for any assistance. 4,27,789 Enrolled Counsellors and social workers
1 5 KERALA MODEL OF RESPONSE TO COVID-19 trained in mental healthcare were the way forward to prevent the continuously making phone calls to all spread of Covi d-19. On Apri l 4, GoK individuals isolated due to their consti tuted an expert commi ttee to quarantine period. The story of a devel op a strategy towards easi ng family from Pathanamthitta who the l ockdown. The 17 members allegedly hid their travel history and expert commi ttee was headed by ended up testing positive was K. M. Abraham, former Chi ef highlighted in the media leading to Secretary to the Government of criticism on social media. One of the Keral a and consi sted of emi nent family members had come forth to personal i ti es from vari ous fi el ds. discuss the help these counsellors The commi ttee recommended a had provided to the family in wi thdrawal strategy that shoul d be overcoming the stigma. gradual , phased and cal i brated to As per the Order dated March 24, ensure that the casel oad i s al ways 2020, from Ministry of Home Affairs, bel ow the capaci ty of the heal thcare Government of India, the Prime system to deal wi th i t. Among minister (PM) decided that an expert others, i t al so suggested setti ng up task force be constituted to advise on protocol s for assi stance (between a strategy towards easing the ci ti es and states) to avoi d Lockdown restrictions. The PM asked unnecessary di vi si ons at the hei ght the States to give their opinions on of the cri si s.
2.2.1 Contact Tracing
The term ‘Contact tracing’ became Together wi th the decentral i sed familiar to the general public in Kerala system of governance and the during the Nipah outbreak of 2018. avai l abi l i ty of manpower i n the form The efficiency in contact tracing of Kudumbasree and ASHA workers helped the State to prevent a second al so pl ayed thei r part i n effecti vel y wave of Nipah. It is clear that a i mpl ementi ng the gui del i nes for template for the same was available traci ng out the contacts of a COVI D- and it was scaled up or redesigned to 19 posi ti ve pati ent. suit the needs of COVID-19.
As per the guideline from the Kerala Health department dated March 12, 2020, a contact is a person who is involved in any of the following: Providing direct care without proper Personal Protective Equipment (PPE) for COVID-19 patients. Staying in the same close environment of a COVID-19 patient (including workplace, classroom, household, gatherings). Travelling together in close proximity (within 1m) with a symptomatic person who later tested positive for COVID-19. Further, contacts are classified into high-risk and low-risk categories based on different criteria which helped the ground-level workers to prioritise more on the high- risk contact tracing. Risk-based criteria were formulated to test, trace, quarantine and treat these contact cases.
1 6 KERALA MODEL OF RESPONSE TO COVID-19
The procedure of contact traci ng detai l s were col l ected by the State starts by keepi ng the i nfected as the control centre and overal l reference poi nt and others are coordi nati on for contact traci ng was reached through them. The contacts carri ed out by the State cel l whi ch as per the above defi ni ti on were eased the burden on the di stri ct traced out through vari ous means teams. and kept under quaranti ne ei ther at A strong grassroots network thei r respecti ve houses or i n consi sti ng of Kudumbashree i nsti tuti onal faci l i ti es i ncl udi ng members, ASHA workers, Juni or hospi tal s arranged by the Publ i c Heal th Nurses, medi cal government. The most i mportant part offi cers and even bl ock-l evel i n the procedure was a personal offi ci al s was al ready avai l abl e i n the i ntervi ew of the pati ent for mappi ng State and became the frontl i ne the travel hi story and the peopl e workers i n the contact traci ng came i n contact wi th the i nfected. process. Route maps were made wi th Fi ndi ng the contacts j ust wi th the detai l s col l ected from the pati ent hel p of an i ntervi ew was a tedi ous and the respecti ve pri mary contacts task as i t sol el y depended on the were publ i shed through medi a and memory of the reference person. other sources. Route maps wi th Thus, vari ous other methods and detai l s of ti me and l ocati ons al so techni ques were used to fi l l the gaps hel ped to col l ect the mi ssi ng l i nks i n i n traci ng out the contacts. Fi el d- contact traci ng as i t prompted l evel teams were set up to vi si t each peopl e to approach authori ti es to of the pl aces the pati ent vi si ted to have thei r heal th checked. track the possi bl e pri mary and The route maps of the pati ents secondary contacts of the i nfected. publ i shed by the di stri ct authori ti es CCTV vi sual s of the pl aces i n the consi st of the fol l owi ng detai l s. approxi mate ti me frames were col l ected and, i n some cases, the 1. Pl aces vi si ted by the pati ent SI M cards were traced. 2. Approxi mate ti me at whi ch the person arri ved at each of the More than 1200 pri mary and l ocati ons secondary contacts were i denti fi ed 3. Modes of travel adopted by the and quaranti ned si nce the fi rst three pati ent duri ng that ti me cases were reported i n the second 4. The day and date i n whi ch the wave. Together wi th these acti ons, pati ent underwent quaranti ne and the pri mary and secondary contacts the day of admi ssi on i n the were al so i ntervi ewed to fi nd out hospi tal . mi ssi ng l i nks, i f any. Technol ogi cal support and detai l s from the ai rport Further, i t al so asks the general authori ti es and other passenger publ i c who vi si ted those pl aces
1 7 KERALA MODEL OF RESPONSE TO COVID-19 menti oned i n the route map at the ai rport was such a scenari o. menti oned ti me to approach the I nstructi ons were gi ven to the heal th authori ti es to get thei r heal th authori ti es i mmedi atel y and the eval uated. Detai l s such as the mode pati ent al ong wi th al l other boarded of transport used by the pati ent to passengers were deboarded and sent travel from each l ocati on, the pl aces to get thei r heal th eval uated and where he/she hal ted, the date on brought under observati on. The whi ch the pati ent went under contacts of the UK ci ti zen were quaranti ne and the date of admi ssi on traced out and a possi bl e route map i n the hospi tal are al so menti oned i n was publ i shed wi thi n days. The the route map. i nformati on avai l abl e from the
Local news channel s and soci al Ernakul am di stri ct medi cal team medi a pl ayed a cri ti cal rol e i n conveys that around fi ve separate publ i shi ng and faci l i tati ng the teams were consti tuted for traci ng outreach of these publ i shed route out the contacts of thi s parti cul ar maps. Together wi th fi l l i ng the pati ent. Several such scenari os mi ssi ng l i nks i n contact traci ng, thi s happened, but the coordi nati on step al so hel ped i n checki ng the between the departments and spread of the fake news. The effecti ve communi cati on al ong wi th experi ence of usi ng soci al medi a to a system for contact traci ng generate awareness among the avai l abl e at the ground l evel coul d publ i c duri ng the peri od of Ni pah reduce the damage up to an extent. outbreak i n 2018 and the two The cl ose and compl ete i nvol vement consecuti ve fl oods woul d have made of the pol i ti cal l eadershi p and i t easi er for the authori ti es to government at al l l evel s, the very meti cul ousl y pl an such awareness di fferent heal th-seeki ng behavi our, generati on measures. hi gh l i teracy rate and the awareness
There were scenari os i n whi ch the l evel among the general publ i c mi ght pati ents vi ol ated the i nstructi ons or have al so hel ped i n executi ng any the quaranti ne gui del i nes whi ch procedure as deci ded. Acti ve created many si tuati ons enabl i ng a i nvol vement and cooperati on from communi ty transmi ssi on. The UK the soci ety duri ng any cri si s has ci ti zen who tested posi ti ve for been the si gnature of the Keral a COVI D-19 sl i pped the authori ti es and Model , a qual i ty whi ch has been boarded a fl i ght from Nedumbassery achi eved over the years.
1 8 KERALA MODEL OF RESPONSE TO COVID-19
2.2.2 GIS Mapping
Keral a al so harnessed the potenti al confi rmed pati ents traced and of Geographi c I nformati on System i denti fi ed on a l i ve geo-map, as the (GI S) i n mappi ng the spread of the news channel NDTV reported on di sease and gui di ng the government March 12, 2020. Thi s enabl ed agenci es to make sound deci si ons offi ci al s to i denti fy hi gh-ri sk zones whi l e acti ng swi ftl y. The Keral a State to acti vate contai nment measures. Di saster Management Authori ty and Addi ti onal l y, i nformati onal l ayers Heal th department offi ci al s col l ated such as the data on i sol ati on wards, di sease survei l l ance data wi th l ab faci l i ti es, etc were added to pri mary and secondary contacts of arri ve at i nformed deci si ons.
2.2.3 Testing Strategy
As per the revi sed gui del i nes aggressi ve testi ng i . e. , out of publ i shed by the Keral a Heal th and 35, 000 tests conducted al l over Fami l y Wel fare Department on March I ndi a 6034 tests were done by Keral a 12, 2020, a testi ng strategy based whi ch sums up to more than 17 per on the ri sk assessment came i nto cent of the total number of tests. force. Thi s gui del i ne stated that j ust The average testi ng rate of Keral a l i ke other vi ral i nfecti ons, COVI D-19 was around 6. 85 ti mes hi gher than wi l l resol ve by i tsel f i n the maj ori ty that of the nati onal average duri ng of pati ents. Epi demi ol ogy of COVI D- thi s peri od. By mi d-Apri l , there was a 19, SARS and MERS States that the consi derabl e di p i n the testi ng rate hospi tal s act as an ampl i fyi ng centre as there was a reducti on i n the for the epi demi c. To prevent such number of cases detected whi ch l ed condi ti ons, a ri sk categori sati on to the wi despread cri ti ci sm of the method was adopted where pati ents government’ s testi ng strategy by are di vi ded i nto three di fferent the medi a and the opposi ti on. categori es based on thei r heal th Together wi th the mai nstream condi ti ons and symptoms. The testi ng process, a senti nel and testi ng and treatment strategy was augmented survei l l ance was i n formul ated accordi ngl y. Detai l s of process to test the hi gh-ri sk ri sk categori sati on are added as persons such as Pol i ce personnel , Annexure 5. frontl i ne medi cal workers,
I n the i ni ti al peri ods of the i nfecti on newspaper boys, etc. As stated by a duri ng March, the State was doi ng key i nformant of the study, a
1 9 KERALA MODEL OF RESPONSE TO COVID-19
Mi ni ster wi th GoK, the government I mmuni zati on at WHO stated, strategi sed to keep the Test “Keral a’ s strategy i s not about Posi ti vi ty Rate 4 (TPR) bel ow 2 per conducti ng i ndi scri mi nate testi ng cent. The rate of posi ti vi ty i s an but rather on keepi ng the TPR l ow. i mportant i ndi cator as i t provi des The strategy has been to ‘ Trace, i nsi ghts on whether a communi ty i s Test, I sol ate, Treat’ ”. The experts’ conducti ng enough tests to detect communi ty however stands di vi ded new cases. I f a communi ty’ s on the testi ng strategy as l ow test posi ti vi ty rate i s hi gh, i t i ndi cates posi ti vi ty does not necessari l y that the communi ty i s l argel y testi ng account for the l ow preval ence of onl y the si ck pati ents and mi ssi ng COVI D-19. I f the procedure out on mi l der or asymptomati c pri ori ti ses a certai n category of cases. On the other hand, a l ower peopl e such as the travel l ers, posi ti vi ty rate suggests that the frontl i ne workers and el derl y, then communi ty i s testi ng asymptomati c there i s a great possi bi l i ty that the pati ents as wel l . The WHO has stated testi ng excl udes many cases that that countri es shoul d have thei r fal l outsi de the desi gnated category. posi ti vi ty rate at 5 per cent or l ower Thi s i s the concern that i s now for at l east a peri od of 14 days. fl agged by many i n Keral a, as the
The former Coordi nator of the State gears up to fi ght the thi rd Expanded Programme on wave.
Figure 5: Test Positive Rate in Indian States with 100+ Confirmed COVID- 19 Cases on May 25, 2020
4. The Test Positivity Rate (TPR) is the percentage of tests conducted whose results are positive.
2 0 KERALA MODEL OF RESPONSE TO COVID-19
On 11 April, a guideline (Annexure 6) was published by the Department of Health and Family Welfare to conduct tests in the State to detect community transmission. The overall charge for the implementation of the process was entrusted with the District Collector. The tests to detect community transmission were done on priority groups and the categorisation of priority groups is as follows:
Priority group 1 All patient handlers among the health staff—doctors, nurses and paramedics, and all those who are in direct contact with confirmed/potential patients. Government/associated functionaries with maximum public contact—policemen on enforcement duty, field-level health workers, personnel deployed by LSG departments, Anganwadi workers together with those special categories among the Priority group 2 public with maximum exposure like a.Persons working in ration shops b.Persons involved in delivering food and grocery c.Persons involved in running community kitchens
Priority group 3 Persons put under home quarantine.
Priority group 4 Vulnerable sections of the population such as persons over 63 years of age.
Further, the gui del i ne i nstructed 4. One assi stant each di stri ct to form separate 5. One dri ver senti nel survei l l ance teams for each The DMO i s entrusted wi th provi di ng of the pri ori ty groups and these travel l i ng faci l i ti es to the team, groups shoul d be formed by the ensuri ng that the team i s provi ded Di stri ct Medi cal Offi cer (DMO) wi th wi th enough personal safety each group compri si ng the fol l owi ng equi pment such as N95 masks and members appoi nted by the DMO of PPE ki ts. They are trai ned to use the the respecti ve di stri cts. equi pment. The DMO i s al so 1. One doctor responsi bl e for arrangi ng the 2. One nurse (wi th added experi ence equi pment for sampl e col l ecti on and i n col l ecti ng a pharyngeal swab the safe transportati on of the for PCR anal ysi s) sampl e to the central faci l i ty of the 3. One l ab techni ci an to perform the di stri ct. anti body test.
2.2.4 Quarantine Facilities and Strategies
Keral a’ s extensi ve testi ng of the second wave of i nfecti on. Gui del i nes symptomati c cases, ri gorous contact for enforci ng stri ct home quaranti ne traci ng process and sel f-i sol ati on or for those wi th travel hi story to Chi na quaranti ni ng of the pri mary and were publ i shed on February 1, 2020. secondary contacts worked i n The responsi bi l i ty for ensuri ng home fl atteni ng the curve duri ng the quaranti ne of the suspects was
2 1 KERALA MODEL OF RESPONSE TO COVID-19 entrusted to the l ocal PHCs, Tal uk support for them. To ensure the Head Quarter Hospi tal s, General avai l abi l i ty of cooked food to the Hospi tal s and Medi cal Col l ege persons under sel f-i sol ati on, the Hospi tal s. The deci si on of whether a vol unteers of the LSG bodi es suspected pati ent shoul d be kept del i vered food to them as per the under home quaranti ne or requi rement. i nsti tuti onal quaranti ne i n To ensure that publ i c adheres to government-desi gnated centres was quaranti ne measures, a sl ew of taken based on the establ i shed ri sk measures were undertaken at the categori sati on. di stri ct l evel . A WhatsApp number As per a government order dated was rel eased by the di stri ct March 20, 2020 from the Department admi ni strati on for the l ocal publ i c to of Local Sel f-governance, LSG bodi es report any i nstance of quaranti ne were gi ven speci fi c responsi bi l i ti es vi ol ati ons. I n case of vi ol ati on, a wi th respect to peopl e undergoi ng team from the Heal th department home quaranti ne. was sent to attend the i ssue. On 1. Conveyi ng detai l s regardi ng those certai n occasi ons of vi ol ati ng who came from forei gn countri es government orders and quaranti ne to the Heal th department. protocol s, Pol i ce personnel 2. Systemati c moni tori ng of the i ntervened to ensure thei r sel f- peopl e under sel f-i sol ati on i n i sol ati on. A medi a survei l l ance team thei r homes. Thi s was done by the was functi oni ng from the di stri ct Ward-l evel Rapi d Response Teams control centres who l ooked i nto the (RRT) whi ch functi on under the vari ous pri nt, vi sual and soci al medi a respecti ve Ward member. pages to i denti fy the needs of the 3. Creati ng awareness among the peopl e under quaranti ne. Reports on fami l y members about the the unavai l abi l i ty of food and water gui del i nes and other i nstructi ons or of soci al harassment faced by gi ven by the Heal th department. those who are under quaranti ne were 4. Ensuri ng necessary communi ty tracked and i nformed to the counsel l i ng for them. authori ti es accordi ngl y. I n addi ti on 5. Ensuri ng the avai l abi l i ty of the to ensuri ng the avai l abi l i ty of essenti al s such as food and essenti al s, thi s process al so hel ped medi ci nes for those who are i n curbi ng the spread of fake news.
under sel f-i sol ati on. I n the fi ght agai nst COVI D-19, face Besi des, the LSGs were al so masks and hand sani ti sers became responsi bl e for general moni tori ng of the strongest precauti onary those under observati on and weapons. However, i n Keral a, the ensuri ng necessary soci al and moral shortage of masks and sani ti sers
2 2 KERALA MODEL OF RESPONSE TO COVID-19 was sl owl y emergi ng as a seri ous l ogi sti cs and suppl y chai n i ssue. By March, Authori ti es from the management. One of the maj or Drugs Control department and responsi bi l i ti es of KMSCL was to offi ci al s from the Al l Keral a make avai l abl e personal protecti ve Chemi sts and Druggi sts Associ ati on gear such as PPE ki ts, N95 masks, had di scl osed that the shortage was surgi cal masks, gl oves and hand probabl y due to pani c buyi ng and sani ti sers to the frontl i ne hoardi ng. Another probabi l i ty bei ng heal thcare workers. A report i n the the non-avai l abi l i ty of raw materi al s Outl ook stated that the corporati on from Chi na and the l i mi ted was abl e to ensure adequate suppl y procurement of hand sani ti sers by of equi pment wi thout l andi ng i n the retai l ers. Manufacturi ng uni ts scarci ty despi te the gl obal suppl y were faci ng a shortage of i sopropyl chai n di srupti on due to raw materi al al cohol , a maj or component used i n shortage from Chi na. KMSCL al so hand sani ti sers, due to a sharp fal l i n pl ayed a rol e i n the ‘ Break the Chai n’ i ts i mport. However, two campai gn by mobi l i si ng over 500, 000 manufacturi ng uni ts i n the State l i tres of WHO-approved hand were noti fi ed to i ncrease producti on sani ti sers through i ts si ster concern to meet the demand. The Uni on Keral a State Drugs & government and State governments Pharmaceuti cal s Ltd. Another cruci al ordered bul k purchases of these operati on of the corporati on was to essenti al s to ti de over the shortage. strengthen the l aboratory networks Government-run Publ i c Sector for vi rus survei l l ance through Undertaki ngs rol l ed out tenders to Reverse Transcri pti on-Pol ymerase meet the nati onwi de demand. Chai n Reacti on (RT-PCR). I ni ti al l y,
A State government company under the approved l aboratori es i n the the Heal th and Fami l y Wel fare State had onl y one or two PCR Department, Keral a Medi cal Servi ces machi nes, whi ch l i mi ted the number Corporati on Ltd (KMSCL) al so pl ayed of tests conducted i n a day. The a pi votal rol e i n Keral a’ s fi ght corporati on shi fted RT-PCR machi nes agai nst COVI D-19. The government avai l abl e at vari ous uni versi ty l abs entrusted the corporati on wi th the to approved testi ng l abs across the task of materi al procurement, State i n a ti me-bound manner.
2. 3 Contracti ng of Heal th Data
Keral a coul d accel erate i ts traci ng, depl oyed at many fronts. One of the survei l l ance and quaranti ne components that assi sted the heal th procedures due to the technol ogy system of Keral a was the use of
2 3 KERALA MODEL OF RESPONSE TO COVID-19 servi ces provi ded by Spri nkl r, a US- i n the soci ety. based technol ogy company. The 5. Detai l s of the peopl e under State government’ s I T di vi si on and observati on, whi ch were col l ected Spri nkl r si gned a contractual by the heal th workers responsi bl e agreement for col l ecti ng, processi ng for moni tori ng them. and anal ysi ng heal th data of These tech-dri ven measures taken Keral i tes to manage the survei l l ance by the State however were mi red i n effecti vel y. As per a press rel ease many controversi es as the dated February 14, 2020 by the I T arrangement rai sed concerns about department, the software was used bypassi ng i ndi vi dual consent and to process a l arge amount of breachi ng ci ti zen’ s sensi ti ve heal th unstructured heal th data that comes data. The i ssue was taken up by the from vari ous sources. Thi s Hi gh Court of Keral a whi ch di rected unstructured data i s processed i n a the government to provi de onl y short span by the software based on anonymi sed data to Spri nkl r and i n i ts i mportance and accordi ng to the future to take speci fi c consent from pri ori ty. Fi ve types of data were the ci ti zens to the effect that thei r col l ected usi ng the software and data so col l ected wi l l not be they are as fol l ows. accessed by Spri nkl r or any other 1. I nformati on regardi ng the peopl e thi rd party. The I T department of the comi ng from forei gn countri es. Keral a government l ater i ssued a 2. I nformati on of the peopl e arri vi ng ci rcul ar on the col l ecti on of personal from other States. i nformati on and general gui del i nes 3. Detai l s of heal th workers who for data col l ecti on. come i n cl ose contact wi th the pati ents. 4. Detai l s of the vul nerabl e secti ons
2 4 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 3 FOOD AND SOCIAL SECURITY
The Food and Social Security initiatives of the Section government aimed at being inclusive. Food security Snippets was ensured at all levels in the State through collaborations with agencies at the ground level.
Public Distribution System Community Kitchen
Door delivery of essentials for Started community kitchen the vulnerable groups across the length and breadth of Free ration for all the State Distribution of essential items Ensured the availability of cooked kit for all free of cost food for the needy The initiative was Implemented by local bodies with the help of Janakeeya Hotels Kudumbashree and registered volunteers A chain of hotels were started in Migrant Rehabilitation : " Leaving No the State under Kudumbashree One Behind" where they provided food for Rs.20/- 20,000 safe homes for the migrant labours were setup throughout the State Local bodies were given the Kudumbashree responsibility of monitoring Awareness programmes in their native Played a prominent role languages were initiated in implementation of Local bodies community kitchen and Janakeeya hotels across Powers at the local level were entrusted to local the State bodies Provided food for those They monitored the people under observation and ensured the availability of essentials who were under Played a major role in implementation of institutional quarantine community kitchen and ensured food security Supplied masks, during the lockdown Presence of Disaster Management Committees sanitisers and hand in Panchayat level enabled Rapid Respose at washes local level
Others
Children below 6 years were distributed nutritious meal through free mid day meal programme through anganwadis Mobile vegetable truck services made available to help local vendors & to ensure door delivery of vegetables Volunteer Support Force was created: 3,33,000 volunteers were registered for supporting government institutions in various activities An integrated Supply Chain Management System was developed by Indian Institute of Technology and Management, Kozhikode, for smooth delivery of essential items
2 5 KERALA MODEL OF RESPONSE TO COVID-19
3.1 Public Distribution System in Kerala
The Public Distribution System 5 (PDS) came into existence in 1965. The Civil Supplies department working under the Department of Food, Civil Supplies and Consumer Affairs, Kerala Government, is responsible for the implementation of PDS. There are many wholesale and retail outlets under the Civil Supplies department to distribute food materials. Kerala State Civil Supplies Corporation (SupplyCo), the Government-owned company under the Department of Food, Civil Supplies and Consumer Affairs plays a significant role in regulating the market price of essential
Source: The New Indian Express commodi ti es.
Tabl e 1: PDS system in Kerala:
C a r d h o l d e r Ration during COVID-19 Times Pre-COVID Times
Yellow Card 35 kg ri ce 30 kg ri ce, 5 kg wheat
Pi nk Card 15 kg ri ce, 3 kg wheat 4 kg ri ce, 1 kg wheat (2 per kg for each)
Bl ue Card 15 kg ri ce 2 kg ri ce (non-priority with subsidy) (per person at ₹4 for each kg)
Whi te Card 15 kg ri ce 2 kg ri ce (non-priority, non-subsidy) (per person at ₹10 for each kg)
Food security during the COVID The local bodies like Kudumbashree, times was ensured at all levels in Panchayat, etc were responsible for the State through collaborations ensuring that the food supplies wi th agenci es at the ground l evel . reach the needy.
5. Public Distribution System (PDS) is a government-sponsored chain of shops entrusted with the work of distributing basic food and non-food commodities to the needy sections of the society at a very cheap price. Wheat, rice, kerosene, sugar, etc are a few major commodities distributed by the PDS. Food Corporation of India, a government entity, manages the PDS.
2 6 KERALA MODEL OF RESPONSE TO COVID-19
3.1.1 Food Security during the Lockdown
Kerala has 14, 281 active fair price financial status, which cost it around shops across the State serving more ₹1000. These food kits were than 88 lakh cardholders.6 Every distributed through the fair price neighbourhood has a fair price shop shops under the PDS. The State serving that locality with good last- endeavoured to make people- mile connectivity with the inclusive plans which also included households. This has proved to be temporary housing and food crucial in the successful distribution facilities for transgender, who are of food materials during this crisis. often neglected from the social
The distribution of free ration began security benefits. on Apri l 1. To avoid overcrowding, Free kits were distributed by the supplies were distributed based on Food and Civil Supplies department the last digit of the ration card which consisted of salt, sugar, oil, numbers.7 For those people who did pulses, spices, etc. Supplyco-Maveli not have a ration card, the food stores under the Food and Civil supplies were delivered based on the Supplies department were Aadhaar card and mobile number responsible for the distribution of along with an affidavit. Fines were these kits. The emergency family also imposed on people submitting kits included soap, masala powders false affidavits. Ward members as and other essential commodities. well as volunteers were involved to These kits were also distributed to avoid crowding and maintain social 25, 000 non-cardholders and other distancing by allowing only five welfare organisations. The State people at a time. Volunteers were government had allocated ₹350 allotted to ensure distribution of crore for ensuring food availability. ration through door delivery to Kerala Consumerfed which is the people who were unable to physically apex body of consumer cooperatives go to get the ration from the shops. in Kerala is also active in the retail The shop owners were also market. Triveni supermarkets under empowered to start a token system the Consumerfed sell commodities at to avoid overcrowding at the shops. 18–40 per cent lower than their On Apri l 8, the government also maximum retail prices. During the started supplying food kits with 17 lockdown, Consumerfed started the essential commodities to every online sale of grocery kits and home househol d irrespective of thei r delivery systems.
6. PDS. Accessed July 28, 2020. https://civilsupplieskerala.gov.in/. 7. The ration cards with numbers ending in 0 and 1 were distributed ration on April 1, 2 and 3 on April 2, 4 and 5 on April 3, 6 and 7 on April 4, 8 and 9 on April 5. 2 7 KERALA MODEL OF RESPONSE TO COVID-19
The food commodi ti es were sourced Keral a Cabi net on Apri l 29 to survi ve from suppl i ers under the Keral a the cri si s wi thout havi ng to rel y on State Ci vi l Suppl i es Corporati on and the nei ghbouri ng States for i ts food the Nati onal Agri cul ture Cooperati ve needs and scal e the agri cul tural Marketi ng Federati on of I ndi a. The producti on wi th the hel p of the State funds from the Chi ef Mi ni ster' s Agri cul ture department and l ocal Di stress Rel i ef Fund were uti l i sed bodi es. I n order to i mprove vegetabl e for these i ni ti ati ves. Li st of the producti on, the government i tems i n the essenti al food ki t i s promoted cul ti vati on i n empty pl ots added as Annexure 7. by groups or l andowners duri ng the
As a strategy for ensuri ng food pandemi c. The Agri cul ture securi ty i n future, a 3000 crore department i n Keral a had di stri buted ₹ 8 acti on pl an was approved by the 50 l akh seeds.
3.1.2 Community Kitchen
Another i mportant strategy adopted Thus, when the di recti ve was i ssued, was setti ng up of communi ty the message was swi ftl y ki tchens al l over the State. communi cated to al l stakehol ders Kudumbashree representati ves and they al l sprang i nto acti on. i ntervi ewed for the study sai d the I ni ti al l y, the l ocal bodi es and obj ecti ve of thi s i ni ti ati ve was to Kudumbashree uti l i sed thei r exi sti ng provi de cooked food for the needy. funds to set up communi ty ki tchens. Di stri ct admi ni strators were gi ven Subsequentl y, vari ous groups and the responsi bi l i ty to moni tor thi s pol i ti cal parti es sponsored meal s. Al l i ni ti ati ve wi th the hel p of LSG and safety and hygi ene measures Kudumbashree i n managi ng the i ncl udi ng physi cal di stanci ng were di stri buti on and l ogi sti cs. The order i mpl emented whi l e cooki ng and for establ i shi ng communi ty ki tchens del i veri ng meal s. The meal s were was i ssued on Apri l 3 and by Apri l 20, packed i n banana l eaves to ensure a total of 339 communi ty ki tchens easy di sposal of waste. Thi s enti re were set up i n 249 Panchayats process was carri ed out through a across the state. There al ready robust vol unteer system (expl ai ned exi sted an extensi ve communi cati on i n the ensui ng secti on). Apart from network on WhatsApp because of the thi s, a chai n of 1000 l ow-cost take State’ s pri or experi ence i n away counters or hotel s whi ch respondi ng to the aftermath of the served l unch for ₹20 were set up by fl oods as wel l as the Ni pah outbreak.
8. "How COVID-19 Steered Kerala on the Path to Food Security." Accessed August 3, 2020. https://www.onmanorama.com/news/columns/straight-talk/2020/05/22/subiksha-keralam-covid-food-security-cpm.html. 2 8 KERALA MODEL OF RESPONSE TO COVID-19
Kudumbashree as al l the restaurants weekl y basi s. i n the State were shut. Door del i very of essenti al food i tems The government al so ensured that was faci l i tated by the government chi l dren bel ow 6 years were wi th the hel p of State-run retai l er di stri buted nutri ti ous meal s through Horti corp under the State a free mi d-day meal programme as an Agri cul ture department. Local i ni ti ati ve under the I ntegrated Chi l d vegetabl e vendors i ni ti ated mobi l e Devel opment department of the vegetabl e truck servi ces to State through Anganwadi s. The faci l i tate easy access to frui ts and Women and Chi l d Devel opment vegetabl es. Li st of essenti al department of the State was tasked servi ces was decl ared by the State to suppl y essenti al raw materi al s to as per the Keral a Essenti al Servi ces the fami l i es through Anganwadi s on a Mai ntenance Act, 1994 on March 25.
3.1.3 Supply Chain Management
As part of ensuri ng food securi ty i n devi sed on a pri ori ty basi s i n j ust the State, an i ntegrated suppl y chai n fi ve days and further wi l l be appl i cati on was devel oped by the upgraded usi ng advanced anal yti cs. I ndi an I nsti tute of I nformati on The E-Way bi l l was used to get the Technol ogy and Management Keral a. i nformati on about the trader, the The purpose of the appl i cati on was quanti ty l oaded i n the truck and the to moni tor the stock l evel s of al l val ue of produce. Data rel ated to whol esal e and retai l traders i n every both buyer and sel l er i s avai l abl e i n di stri ct i n Keral a on a dai l y basi s. the bi l l . As the traders coul d update The dashboard i s used to ensure that the stock posi ti on, the State coul d regul ar del i very of essenti al track the accurate stock posi ti on as commodi ti es i n every di stri ct wel l as the pri ce fl uctuati on. happens i n coordi nati on wi th the The State Agri cul ture department l ocal body. The Ci vi l Suppl i es and pl anned l ocal procurement through Consumer Affai rs department keeps vari ous agenci es and pressed for track of the stock l evel s i n every rel axi ng the l ockdown norms for di stri ct. Before the l ockdown, the transporti ng essenti al commodi ti es Tal uka offi cer worki ng under the Ci vi l and agri cul ture products as per the Suppl i es department used to col l ect norms i ssued by the Central the i nformati on manual l y from the government. The State government traders of essenti al commodi ti es strategi sed these pol i ci es and updates at the State l evel were del ayed. Thi s appl i cati on was consi deri ng cri ti cal factors l i ke the
2 9 KERALA MODEL OF RESPONSE TO COVID-19 consumeri st status of the State and the revi val of the agri cul ture sector i ts pursui t of food sel f-rel i ance, i n Keral a. reverse mi grati on of NRKs as wel l as
3. 2 Mi grant Rehabi l i tati on
Keral a has a huge number of mi grant communi cate and create awareness worker popul ati on. I t i s esti mated to among the mi grant l abourers i n thei r be around 2. 5 Mi l l i on. The State l ocal l anguages whi ch are mostl y government had adopted vari ous Hi ndi , Bengal i , Ori a and Assamese. measures to ensure food avai l abi l i ty Speci al hel p desks for attendi ng the for the mi grant popul ati on al so as cal l s from mi grant l abourers were part of i ts pol i cy of “l eavi ng no one al so set up at the Di stri ct Labour behi nd”. Keral a was one among the Offi ce.
12 States that al l owed i nterstate Al l the l abour uni ons, communi ty portabi l i ty of rati on cards so that groups, bui l ders & contractors mi grants from other States coul d associ ati ons, etc were urged to al so get the rati on al l ocated by the conduct awareness generati on State. programmes for the mi grant workers. The State set up nearl y 20, 000 Assi stant Labour Offi cers were camps to provi de them cooked food responsi bl e for the mappi ng of or materi al s accordi ng to thei r pl aces that were densel y popul ated choi ce. These camps were moni tored due to housi ng of mi grant workers. by the LSG representati ves to At each l ocati on, at l east one ensure hygi ene and avoi d mi grant worker wi th an androi d phone overcrowdi ng. Revenue department i nstal l ed wi th WhatsApp was wi th the hel p of l ocal bodi es i denti fi ed and reported to the arranged housi ng faci l i ti es for the Di stri ct Labour Offi cer and Joi nt mi grant workers. The Di stri ct Labour Labour Commi ssi oner pl anni ng as the Offi cers hi red dai l y wagers to spokesperson for communi cati on.
3. 3 Rol e Pl ayed by the LSGs
The LSGs’ presence was predomi nant headshi p of l ocal governments i n the response measures taken by i ncl udi ng Panchayats, Muni ci pal i ti es, the government. The State Muni ci pal Corporati ons, etc. government adopted a communi ty- Kudumbashree pl ayed an acti ve rol e based approach wi th the support and i n the i mpl ementati on of vari ous
3 0 KERALA MODEL OF RESPONSE TO COVID-19 i nterventi ons across al l the 14 Kudumbasree workers and Ward di stri cts. More than 3, 33, 000 members was arranged by the State vol unteers were regi stered to offer government through manual s and support for the State to fi ght the el ectroni c cl asses to prepare them pandemi c. Each i nterventi on was for the process. The powers at the pl anned and i mpl emented as ground l evel were mostl y entrusted operati on mode under the l eadershi p on the LSG bodi es and cl osel y of Ward members; squads were moni tored by the Di stri ct Col l ectors formed and tasks were del i berated. at the mi d-l evel and Chi ef Mi ni ster Speci al capaci ty bui l di ng for the hi msel f at the top l evel .
The general responsi bi l i ti es noti fi ed by the State government i ncl ude: Identification of people under homequarantine and ensuring food and supply availability with the support of autoand taxi drivers. LSGs were assigned to submit timelyreports to district collectors. Community resource persons and youthclubs were engaged in ensuring food delivery. LSGs were assigned to devolve workto the elected representatives and other officers with respect to ensuring foodsecurity interventions and food distribution through Anganwadis. Joint Labour Commissioners of Labour Commissionerate will beresponsible for submitting reports related to issues faced by migrant workers.
3. 4 Vol unteeri sm
From the 2017 Ockhi cycl one and Fi gure 6: Di stri ct-wi se Di stri buti on of 2018 fl ood to the pandemi c i n 2020, the Regi stered Vol unteers i n Keral a the vol unteers i n Keral a have pl ayed a vi tal rol e i n ti mes of cri ses. To formal i se thi s arrangement, an order (Annexure 8) was i ssued by the GoK to form a soci al vol unteer body (Sannadhasena). The pl an of the vol unteeri ng body was announced by Chi ef Mi ni ster Pi narayi Vi j ayan after a revi ew meeti ng on March 25, 2020. The deci si on was to form a body whi ch consi sted of vol unteers Source: Sannadhasena spread across Keral a from Kasargod https://sannadhasena.kerala.gov.in
3 1 KERALA MODEL OF RESPONSE TO COVID-19 to Thi ruvananthapuram. Accordi ng to vol unteers. I ni ti al l y, a master thi s order, there wi l l be one trai ni ng group was i denti fi ed for thi s vol unteer for every 100 ci ti zens i n purpose. The trai ni ng structure, the State. So far, 3. 5 l akh vol unteers pattern and the content were pre- have been regi stered across al l approved by the steeri ng commi ttee. di stri cts i n Keral a. Di stri ct-wi se There were a total of 700 trai ners i n di stri buti on of the regi stered Keral a wi th each di stri ct havi ng 50 vol unteers i s gi ven i n Fi gure 6. trai ners. A mi ni mum of 10 di fferent
Basi c trai ni ng was provi ded to al l centres woul d be chosen i n each those who were sel ected, to di stri ct where the trai ni ng wi l l take confront chal l enges posed by nature pl ace. Revi ew of the performance of or any other vi tal threats faced by each member was done accordi ng to the State. And the avai l abi l i ty of whi ch there were rearrangements these vol unteers was assured for based on thei r effi ci ency. ci ti zens at any ti me of the day. Any The programme i s based on person from the age of 16 to 65 wi th vol unteershi p and no form of sound heal th was el i gi bl e to be part i ncenti ves are provi ded to the of the vol unteer body. The onl y members. There i s a separate fund restri cti on put forth was that thi s al l ocati on i n the budget for thi s person shoul d not be a ful l -ti me di rectorate and al l the expenses empl oyee at any other organi sati on. rel ated to the soci al servi ces of thi s Thi s vol unteer group was trai ned by a vol unteeri ng body are di sbursed from master trai ni ng commi ttee to gui de thi s speci al fund. The vol unteer them through the rul es and programme i ncorporates a scheme regul ati ons to be fol l owed whi l e wherei n the students who are faced wi th chal l engi ng si tuati ons. vol unteeri ng for the same benefi t by State-l evel Di rectorate, consi sti ng recei vi ng a certi fi cate; these of the heads of the Fi re & Safety, certi fi cates can be consi dered al ong Pol i ce department, State Di saster wi th thei r academi c curri cul um. Management Authori ty, Revenue I nterested candi dates have to department, LSG department, NCC, regi ster through an onl i ne portal , set NSS and ORC acted as a steeri ng up by the Keral a State Di saster commi ttee. Several steps were taken Management Authori ty (KSDMA). up to carry out the trai ni ng for the
3 2 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 4 FINANCIAL INTERVENTION
To tide over the crisis, the State government Section announced financial packages which covered Snippets welfare pensions, loan assistance, arrear clearance and employment assuarances.
Announced 20,000 Cr Stimulus Package
₹14,000 cr for clearing the arrears in different sectors ₹500 cr for health packages ₹2000 cr loans through Kudumbashree in the nature of consumer loans for the COVID 19 affected ₹2000 cr for village employment assurance schemes ₹1320 cr for welfare pensions ₹100cr for providing 1000/- for BPL and Antyodaya families who are not eligible for welfare pensions ₹100cr for providing free ration to both APL and BPL families
Deferred Salary of Government Employees
Released ordinance empowering the government to defer 6 days of salary of government employees for a period of 6 months
Requests by the State to Central Government
Requested to use State Disaster Management Fund for relief work Requested to increase the State borrowing limit Requested to enable CMDRF eligible for CSR funding
3 3 KERALA MODEL OF RESPONSE TO COVID-19
4. 1 The 20, 000 crore Package
To ti de over the cri si s, the GoK had announced a ₹20, 000 crore sti mul us package on March 19, 2020 i n hopes of revi vi ng the economy. Thi s makes the State the fi rst i n the country to announce an economi c package. A total of ₹500 crore had been excl usi vel y set asi de to support the publ i c heal th i nfrastructure. Apart from thi s heal th package, the pl an presented by the Chi ef Mi ni ster covered wel fare pensi ons, l oan assi stance, arrear cl earances as wel l as rural empl oyment assurances. ₹14, 000 crore had been al l otted to cl ear out al l the pendi ng arrears i n several sectors. Source: Hi ndustan ti mes
I mpl emented on the l i nes of the scheme was taken i n a meeti ng wi th 9 ‘ Resurgent Keral a’ l oan scheme offi ci al s from the Kudumbashree whi ch was i ntroduced after the Mi ssi on, Cooperati ve department and fl oods, the State government has the State’ s Bankers Commi ttee. The now faci l i tated ₹2, 000 crore worth Kudumbashree offi ci al i ntervi ewed l oans to needy fami l i es. The stated that “si nce post-2018 fl oods, i mpl ementati on of the Chi ef l oan scheme was successful l y Mi ni ster’ s Hel pi ng Hands Loan i mpl emented; the government has Scheme (CMHLS) wi l l be through the confi dence i n thi s mechani sm. sel f-hel p group Kudumbashree’ s Moreover, Kudumbashree hol ds a network, further expandi ng the hi gh rate of repayment. ” The government' s mi cro fi nanci ng government has noti fi ed that the wi ndow. El i gi bl e benefi ci ari es amount sancti oned by banks so far i s recei ved a mi ni mum of 5000 wi th ₹ ₹17, 5711. 02 l akh wi th 78. 39 per the banks chargi ng 9 per cent cent NHG (Nei ghbourhood Group) i nterest whi ch i s covered by the i ncl uded i n the scheme. government. The deci si on on the l oan
9. Resurgent Kerala Loan Scheme was an interest-free loan facility for flood-affected families. As per the scheme, a maximum of ₹1 lakh was given to the applicant. The repayment period is fixed as 36–48 months. As per the eligibility criteria, the applicant should be a member of the Kudumbashree Mission. 3 4 KERALA MODEL OF RESPONSE TO COVID-19
The soci al wel fare pensi on for the cost the State government ₹23. 61 month of Apri l was di stri buted i n crore. The government announced March i tsel f to about 50 l akh peopl e the establ i shment of a stri ng of across the State; for thi s earl y 1, 000 l ow-cost hotel s, provi di ng di sbursal of the two-month pensi on, food at ₹20 across the State by the government had al l otted ₹1, 320 Apri l . For the ci nema i ndustry, an crore. Those bel ongi ng to the bel ow entertai nment tax wai ver was poverty l i ne (BPL) and Antyodaya, decl ared. who are not el i gi bl e for soci al Keral a Fi nance Mi ni ster Thomas securi ty pensi on, were gi ven ₹1, 000 I saac penned an arti cl e for each. The pl an had earmarked ₹100 MoneyControl respondi ng to the crore for the same. Another ₹2, 000 numerous questi ons on the crore was di stri buted as part of a i mpl ementabi l i ty of the ₹20, 000 vi l l age empl oyment guarantee crore package to revi ve the State programme for the months of Apri l economy. The moti vati on behi nd thi s and May. As part of ensuri ng food package was to put money i n the securi ty for both APL and BPL hands of the peopl e. Wi th fami l i es, the government had empl oyment and i ncome decl i ni ng, al l otted ₹100 crore for 10 kg free the government deci ded to frontl oad rati on. These measures were i ts annual borrowi ng. To battl e the announced to boost the purchasi ng resource crunch, the State avai l ed power of the l ower-i ncome groups. ₹6, 000 crore from the sancti oned The government al l owed a one-month l i mi t of ₹24, 000 crore through open extensi on for the payment of water market borrowi ngs for the current and el ectri ci ty bi l l s. I t al so wai ved fi nanci al year. On Apri l 7, the State off the ‘ fi tness’ charges for taxi and offered an i nterest rate of 8. 96 per auto dri vers, who have been seei ng cent for the amount avai l ed for thei r i ncomes dry up al armi ngl y State Devel opment Loan for a peri od duri ng the l ockdown. I n the case of of 15 years. The Fi nance Mi ni ster buses, both stage and contract al so fl agged the concern that the carri ers had thei r tax amount wai ved State coul d be faci ng a fi nanci al off. Stage carri ers were not requi red cri si s by mi d-2021 because of the to pay the tax for the month of Apri l , cl osure of i ts revenue and exci se whi l e contract carri ers pai d a l ower streams, such as Bevcos, l otteri es tax amount for the months Apri l to and other busi nesses. June. Thi s wai ver i s esti mated to
3 5 KERALA MODEL OF RESPONSE TO COVID-19
4.2 MSME Package
To further resuscitate the economy, KEY FACTS on May 14, the State government Kerala's Estimated Number 23.79 Lakh announced a special package of of MSMEs (in lakh) ₹3, 434 crore aimed at reviving micro, small and medium enterprises Estimated Number of 44.64 Lakh (MSMEs). This financial package was Employees approved by the Cabinet and Female: 13.77 Lakh implemented by the Industries Female Male: 30.86 Lakh department. Under the package, 30.9% existing MSMEs were offered interest exemption for additional loans, Kerala State Industrial Development Corporation Ltd (KSIDC) and Kerala Industrial Male 69.1% Infrastructure Development Corporation (KINFRA) offered one- time settlement on loans and a six Fi nanci al Corporati on (KFC), Keral a month-extension on repayment of State I ndustri al Devel opment loans and interest. Furthermore, the Corporati on (KSI DC) and Keral a Bank announcement informed that KSIDC al ong wi th secretari es from will offer a moratorium on loans and concerned departments l i ke interest to all operating units for Agri cul ture, Local Sel f Governi ng three months without penal interest. Department (LSGD), I ndustri es as Additionally, KINFRA will also grant wel l as representati ves from MSMEs loans above ₹50 l akh. i ndustry associ ati ons such as To monitor the flow of benefits into Confederati on of Real Estate various sectors of the State Devel opers Associ ati on of I ndi a economy, the government (CREDAI ). The purpose of thi s established a monitoring cell in the commi ttee i s to moni tor MSME, real Finance department headed by estate and other sectors’ access to Additional Chief Secretary (Finance) several schemes announced by the with representatives of State Level State as wel l as the Uni on Bankers Commi ttee (SLBC), Keral a government.
3 6 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 5 AWARENESS PROGRAMMES
Kerala's COVID-19 response had a robust Section participation of Private media supplementing Snippets Government's awareness campaign.
Break the Chain Daily Press Briefing
To create awareness among the general Press briefings were held on public about the necessity of washing hands daily basis either by the Chief in frequent intervals. The responsibility was minister or the health minister entrusted upon the LSG bodies of the State in which all the Taking actions to discourage crowding at details regarding the pandemic, public places, ensuring availability of measures taken by the sanitisrs at ATMs etc were part of the government, directions for campaign various authorities etc were announced. DISHA Helpline A group of trained professionals, Technological Interventions social workers and counsellors were entrusted with the responsibility of A webiste "dashboard.kerala.gov.in" helping the people in clearing doubts was released in which all data on COVID-19 related issues regarding the COVID-19 was included Launched mobile application to Use of Social Media increase the awareness and release real time data to people to prevent the The government used social media for spread of fake news effective information dissemination and spreading awareness among the general public. The social media Transmedia Storytelling handles of allmost all the authorities Usage of multiple platforms were used for this to disseminate important Role of Private Media information This helped in conveying the News media concentrated on conveying message to a wide range of credible information and drew the population. Video released attention of the State government by Kerala police towards towards the unnoticed issues and creating awareness about ensured maximum inclusivity washing hands is an example
3 7 KERALA MODEL OF RESPONSE TO COVID-19
The State adopted a mul ti -pronged strategy to spread awareness among the general publ i c on di fferent aspects of the pandemi c and the safety measures to be adopted for control l i ng the spread of the di sease. Thi s i ncl udes the dai l y press bri efi ng by the Chi ef Mi ni ster of the State and rol l i ng out a mobi l e appl i cati on whi ch di ssemi nates real - ti me data about the pandemi c.
Keral a was the onl y State i n I ndi a that hel d and conti nues to hol d a dai l y press bri efi ng l ed by the Chi ef Mi ni ster of the State i n whi ch vari ous data regardi ng the pandemi c are shared and the measures the made avai l abl e to the general publ i c. State i s goi ng to adopt i n response GoK Di rect mobi l e appl i cati on to the probl em are announced. A l aunched by the Keral a government di stri ct-wi se di vi si on of the number was another such measure ai mi ng to of cases (i nfected, recovered and i ncrease awareness among the publ i c deceased), number of hotspots per and to rel ease real -ti me data to di stri ct, the status of a parti cul ar peopl e whi ch can al so hel p i n curbi ng di stri ct (red, orange or green zone), the spread of fake news. The di recti ons for the di stri ct appl i cati on was rel eased i n March authori ti es, changes i n the prevai l i ng whi ch can be downl oaded and used norms, i f any, are announced duri ng vi a smartphones. Al ong wi th that, these press bri efi ngs. there i s a faci l i ty to get the Together wi th that, a dashboard was i nformati on as text messages for al so publ i shed duri ng thi s ti me i n ordi nary phone users. The app wi l l whi ch al l the data rel ated to COVI D- i ncl ude news, government 19 such as the dai l y number of noti fi cati ons, hel pl i ne members, i nfecti ons, acti ve cases, quaranti ne protocol s, advi ce to recovered cases, mortal i ty, etc are vi si tors and awareness to travel l ers.
3 8 KERALA MODEL OF RESPONSE TO COVID-19
5. 1 DISHA (Di rect Interventi on System for Heal th Awareness) Hel pl i ne Number
DI SHA i s a j oi nt venture l aunched by a day showed a drasti c i ncrease Nati onal Heal th Mi ssi on (NHM) and duri ng thi s peri od. The members of Department of Heal th and Fami l y DI SHA are mostl y trai ned Wel fare i n 2013 to provi de gui dance professi onal s, soci al workers and and counsel l i ng on physi cal and counsel l ors who were entrusted wi th mental heal th probl ems. I t acts as a the responsi bi l i ty of hel pi ng the hel pl i ne number duri ng i ssues such peopl e i n cl eari ng doubts on COVI D- as an epi demi c outbreak or a 19 rel ated i ssues. Descri bi ng the cal ami ty as i n the case of Ni pah procedures at the ai rport, steps to outbreak or the fl oods. General l y, be taken and detai l s regardi ng the DI SHA works i n two shi fts wi th fi ve authori ti es to be i nformed were or si x staff at a ti me and the some of the maj or topi cs they were col l ected data i s entered i nto the deal i ng wi th. Further, they passed system whi ch i s accessi bl e to the i nformati on regardi ng the persons whol e team and the Heal th arri vi ng from COVI D-19 i nfected departments of vari ous di stri cts. areas to the concerned Heal th
As the COVI D-19 i nfecti on started departments. Other than COVI D-19 spreadi ng i n the State from the fi rst rel ated matters, they al so hel ped week of March, DI SHA i ncreased the peopl e wi th thei r doubts on travel number of staff consi derabl y and restri cti ons, concerns on heal th and started to work i n three shi fts. The even the di ssati sfacti on on the avai l abl e data shows that the government mechani sm were al so number of cal l s they recei ved duri ng deal t up to an extent by DI SHA.
5. 2 LSG Bodi es’ Rol e i n Awareness Programmes
As per the order from the LSG i nstructi ons gi ven by the Heal th department dated March 20, 2020 al l department. Awareness on subj ects the LSG bodi es were i nstructed to l i ke reasons for the spread of the work al ong wi th the Heal th di sease, response measures to be department i n the fol l owi ng adopted, the rel evance of contai ni ng acti vi ti es: the spread of the di sease, etc are to The l ocal bodi es are gi ven the charge be undertaken by the l ocal bodi es. I t of runni ng awareness programmes i n i s al so menti oned that the fol l owi ng the soci ety accordi ng to the categori es of the popul ati on have to
3 9 KERALA MODEL OF RESPONSE TO COVID-19 be gi ven more attenti on i n the due ‘ Break the Chai n’ physi cal di stanci ng process. campai gn. 1. El derl y and other vul nerabl e 1. Create awareness among the secti ons of peopl e publ i c about the necessi ty of 2. Schedul ed castes and Schedul ed washi ng hands i n frequent tri bes who resi de i n col oni es i nterval s usi ng sani ti ser/hand 3. I nhabi tants of the coastal area wash/soap. 4. Sl um-dwel l ers 2. Take acti ons to di scourage the 5. I nhabi tants i n care homes crowdi ng of peopl e i n publ i c 6. MGNREGA l abourers spaces such as audi tori ums, 7. Kudumbasree members markets, etc. 8. Mi grant workers ( Guest workers 3. Create awareness among taxi as they are cal l ed i n the State) dri vers, newspaper and mi l k Further, the responsi bi l i ty to create di stri butors. awareness about the “Break the 4. Ensuri ng the avai l abi l i ty of Chai n” campai gn l aunched by the sani ti sers i n ATM counters and i n government was al so entrusted upon l i fts. the LSG bodi es. They were gi ven 5. Ensuri ng the avai l abi l i ty of i nstructi ons to ensure the fol l owi ng personal protecti on equi pment as part of effecti vel y i mpl ementi ng such as masks and sani ti sers.
5. 3 Use of Medi a
Keral a had al ready wi tnessed the the heads of the l ocal bodi es pl ayed effi ci ent use of soci al medi a and an acti ve rol e i n thi s. Together wi th vi sual medi a duri ng the two that, adverti sements for government consecuti ve fl oods i n 2018 and awareness campai gns were publ i shed 2019, and duri ng the Ni pah outbreak through pri nt and vi sual medi a to i n 2018. Di fferent medi a sources ensure maxi mum awareness were used to spread awareness, outreach. Arti sts and di fferent curbi ng the fake news and for organi sati ons have taken up the di ssemi nati ng rel evant and real ti me chal l enge and made use of wal l s, data to the publ i c. The soci al medi a roads and fenci ng wal l s whi ch were handl es of al most al l the authori ti es free to pi cturi se i mages that wi l l rangi ng from the Chi ef Mi ni ster to hel p i n awareness generati on.
5.3.1 Transmedia Storytelling
The method used by Keral a to usi ng tradi ti onal and new medi a. Thi s successi vel y di ssemi nate heal th- usage of mul ti pl e pl atforms to rel ated i nformati on i s by effecti vel y di ssemi nate parti cul ar i nformati on
4 0 KERALA MODEL OF RESPONSE TO COVID-19 to the general public to create way to wash hands. During the awareness among them is called course from March to May, the Kerala transmedia storytelling. Apart from Police media cell has come up with print and digital media, awareness videos, talks and even announcements in different songs. languages like Hindi and Bengali in Awareness about the situation and areas having high migrant the necessity of following the populations were used. Transmedia guidelines was created through trolls storytelling includes the creation of and memes which were shared by such content that has the potential many of the official social media to deal with a wide variety of handles. Again, the official Facebook population. In this perspective, a handle of Kerala Police is an example notable initiative has been done by as it is one of the most followed the Kerala Police department to Police department Facebook pages create awareness about the across the world with around 1. 4 importance of washing hands. A million followers. One of the major video which was created by the advantages of using this approach in Kerala Police Media Cell where a spreading awareness is its wider group of policemen dancing to the reach compared to the other media beat of a very popular Malayalam song by demonstrating the correct
5.3.2 Involvement of Private Media
The active involvement of the media these crises and concentrated on —both print and television—in the conveying credible information to State during the time of the crisis the public. Many of the interventions should not be undermined. From the done by the media played a critical 2018 floods to the current COVID-19 role in drawing the attention of the outbreak, most of the media houses State government towards unnoticed in Kerala followed the path of i ssues. constructive journalism in the face Separate news sessions were of crisis. Kerala with its high literacy conducted by many of the media and the peculiar socio-political houses to find out the fake atmosphere is one of the highest information spreading in the social news consuming societies in India media and to bring out the reality and the news media plays a vital role behind such information. The in shaping public perception. The increased real-time coverage of the Malayalam news media mostly situation from critical locations focused on solution-based brought out the social realities rather than news sni ppets wi th journalism i n the face of al l
4 1 KERALA MODEL OF RESPONSE TO COVID-19
Communication strategies adopted by the government have been consistent with the WHO outbreak risk communication steps mentioned in the handbook Managing Epidemics, 2018. It presented three main strands involved in outbreak risk communication, namely
Talk: Authorities to relay accurate information using Mass Media Channels.
Listen: Authorities, responders and experts must quickly assess the fears, concerns and perception of the people.
Managing Rumours: Responders should find ways to curb rumours and misinformation.
preconcei ved edi tori al pol i ci es. hel ped the State government to Added to that, the medi a houses bri dge many gaps. pl ayed a vi tal rol e i n the Keral a’ s strategi es have attempted di ssemi nati on of i nformati on from to ful fi l al l the communi cati on the authori ti es and bui l di ng checkl i sts that an outbreak ri sk awareness among the general publ i c. communi cati on necessi tates. Thus We coul d al so wi tness a scenari o of far, i t has been abl e to establ i sh news channel s runni ng paral l el strong l i nes of communi cati on and hel pl i ne numbers where the publ i c di al ogues wi th the ci ti zenry. coul d rai se thei r concerns whi ch al so
4 2 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 6 THE RESURGENCE
Source: Gul f News
The fol l owi ng chapter sheds l i ght on the current devel opments i n the State around COVI D-19. Owi ng to the dynami ci ty of the si tuati on, the chapter i s l i mi ted to provi di ng i nformati on on the present state of affai rs. I t i s i ncl uded onl y for the purpose of mai ntai ni ng conti nui ty. A l i mi ted assessment onl y i s done for thi s stage as the authors of the report bel i eve i t i s too earl y for an assessment.
Whi l e Keral a recei ved much prai se for the organi sed efforts agai nst COVI D- 19 i n the second wave, i t i s now faced wi th a chal l engi ng task to contai n the surge that the State i s wi tnessi ng of l ate. The thi rd wave of COVI D-19 i nfecti on started on May 8, 2020 and i t i s ongoi ng at the ti me of wri ti ng thi s report.
Si nce May 7, I ndi a has been undertaki ng one of the worl d' s l argest repatri ati on operati ons cal l ed the Vande Bharat Mi ssi on to bri ng Non- Resi dent I ndi ans (NRI s) to I ndi a. I n the fi rst two months, as many as 5, 03, 990 stranded I ndi ans returned to I ndi a as reported by the Mi ni stry of External Affai rs (MEA) on Jul y 3. The l argest number of stranded I ndi ans who returned by the Vande Bharat Mi ssi on fl i ghts i s from the UAE at 57, 305, fol l owed by Kuwai t, Qatar, Oman, Saudi Arabi a and the US. The Gul f regi on parti cul arl y has been confronted wi th a twi n shock of the pandemi c and oi l cri si s hi tti ng i ts economy. Thi s has al so resul ted i n the exodus of many I ndi an
4 3 KERALA MODEL OF RESPONSE TO COVID-19 di aspora from thei r host countri es. The Chi ef Mi ni ster of the State i n hi s Nearl y 94, 085 stranded I ndi ans have dai l y press bri efi ng on Jul y 21, 2020 returned to Keral a through announced that a total of 6, 20, 462 repatri ati on fl i ghts i n the fi rst two NRKs have arri ved i n the State from months. Wi th that, the State has other I ndi an States and countri es been the bi ggest benefi ci ary of the after the rel axati on i n the l ockdown. mi ssi on so far. There are many porous routes al ong
The Uni on government l i fted i ts the Keral a-Tami l Nadu and Keral a- nati onwi de l ockdown and i ntroduced Karnataka borders where peopl e can condi ti onal rel axati ons starti ng from enter; such travel l ers sl i p through May 4, 2020. By earl y June, the the screeni ng processes of the Mi ni stry of Home Affai rs (MHA) State, resul ti ng i n di ffi cul ty i n i ssued gui del i nes on reopeni ng I ndi a tracki ng and traci ng i f any al ready wi th the obj ecti ve of restarti ng the COVI D posi ti ve tested pati ents had economy. The i nter-state travel chosen these unoffi ci al routes. restri cti ons were al so l i fted i n the The flattened curve of COVID in Kerala Unl ock phase. Many NRKs from other was hit with the inflow of the NRKs. I ndi an States started returni ng to With the lockdown completely lifted Keral a. Wi th the Unl ock 1. 0, Keral a from May 31, the State has been al so opened the markets and witnessing a steady increase in the shoppi ng centres as per the number of positive cases. As on gui del i nes i ssued by the MHA, GoI . August 11, 2020 the cumulative Thi s i ncreased the chances of mass number of confirmed cases in the contact and the publ i c fai l ed to State is 35,515; and active cases are mai ntai n soci al di stanci ng as 12,737, with an overall death of 115. advi sed. A sudden change i n the Starting from June to this date status quo mai ntai ned for a month (August 11), the State has seen a was chal l enged i n a few days wi th huge drift in the source of COVID the onset of Unl ock 1. 0. infection. Currently, the spread of Compl acency was al so set i n duri ng COVID through local contact is at thi s peri od, possi bl y due to the earl y 61.61 per cent while the import case success tasted by the State i n the stands at 38 per cent. With daily fi rst two phases. Al ong wi th thi s, the cases breaching the 1000 mark and testi ng strategy was not revi sed for increasing cases of local spread, qui te someti me ti l l the numbers experts are now pointing out the fault started peaki ng i n the thi rd phase, lines in the Kerala Model of COVID-19 whi ch was cl earl y not refl ecti ng the containment strategy since the gl obal experi ence as per the medi a strategy adopted all the while has reports. been through its experience of dealing
4 4 KERALA MODEL OF RESPONSE TO COVID-19
Fi gure 7: COVID-19 Stati sti cs of Keral a as on August 11, 2020
wi th the Ni pah outbreak. However, were made to ensure soci al the epi demi ol ogy of Ni pah and di stanci ng among the students, COVI D-19 i s di fferent and thi s has travel faci l i ti es for them, not been accounted for i n the di si nfecti ng the cl ass rooms and so handl i ng of COVI D-19. on. Even a separate team of
Some of the deci si ons taken by the teachers was entrusted wi th the GoK have come under severe duty of scanni ng students usi ng cri ti ci sm from the general publ i c. thermal scanners and those havi ng The government conducted two hi gher temperature were made to si t publ i c exami nati ons duri ng thi s i n separate rooms for wri ti ng exams. peri od. The 10th and 12th standard Two months l ater i n Jul y, as the board exami nati ons were conducted si tuati on turned gri mmer wi th a dai l y duri ng the l ast week of May. Duri ng ri se i n the number of l ocal cases, the thi s ti me, Keral a had 670 acti ve Keral a Engi neeri ng Archi tecture cases and 61 confi rmed cases. Over Medi cal (KEAM) entrance 10 l akh students across the State exami nati on was conducted wi th the attended the SSLC and Hi gher parti ci pati on of around 1 l akh Secondary Exami nati ons, whi ch students. The KEAM Entrance recei ved accol ades from vari ous exami nati on was hel d on Jul y 16, ci rcl es as al l the students who 2020. At the ti me, the confi rmed attended the exami nati ons turned cases stood at 9553. Speci al test negati ve. Large-scal e arrangements centres were opened i n the
4 5 KERALA MODEL OF RESPONSE TO COVID-19 contai nment zones for students parents and vari ous organi sati ons. i nsi de the zone to attend the test Ami dst the surge i n case, Keral a al so wi thout movi ng out from the wi tnessed mass protests across the contai nment zone. Speci al State hel d by the opposi ti on parti es arrangements were al so made for i n the recent context of Gol d- students who were under quaranti ne smuggl i ng case. The protests saw or those who came from red zones. parti ci pati on by a l arge number of But the ground report says that party workers; news medi a have soci al di stanci ng norms were reported i nstances of vi ol ati ng vi ol ated at some test centres. The physi cal di stanci ng norms. reports of parti ci pants and parents Subsequentl y, the Hi gh Court of crowdi ng at a test centre i n Keral a gave an order on a pl ea Thi ruvananthapuram rai sed much seeki ng to prevent publ i c protests cri ti ci sm. Around fi ve students who and huge gatheri ngs throughout the attended the test turned out to be State, vi ol ati ng the COVI D-19 COVI D-19 posi ti ve. The deci si ons on Protocol s. conducti ng exami nati ons came under cri ti ci sm from the opposi ti on,
6. 1 Communi ty Transmi ssi on
A spurt i n unknown cases of became the fi rst State i n the i nfecti on was observed i n the country to decl are a communi ty coastal haml ets of transmi ssi on i n the coastal regi ons Thi ruvananthapuram Di stri ct i n of Poonthura and Pul l uvi l a i n Keral a whi ch si gnal l ed that the Thi ruvananthapuram. The GoK i nfecti on i s establ i shed i n the announced a few measures i n communi ty. On Jul y 17, Keral a response to the ri si ng cases.
6.1.1 Additional Measures Taken by the State
6 . 1 . 1 . 1 G u i d e l i n e o n T e s t i n g a n d The pri mary obj ecti ve was to fi nd out I s o l a t i o n the posi ti ve cases and to i sol ate them at the earl i est to prevent Wi th the detecti on of l arge further transmi ssi on of the di sease. communi ty cl usters i n the coastal vi l l ages of Thi ruvananthapuram, A two-prong strategy was adopted speci fi c testi ng and i sol ati ng 1. Al l symptomati c i ndi vi dual s were strategy was brought i n as per the tested usi ng anti gen testi ng gui del i ne rel eased on Jul y 18, 2020. methods. Those tested posi ti ve
4 6 KERALA MODEL OF RESPONSE TO COVID-19
1. were managed as per the by the Ministry of Health and Family protocols, while those who tested Welfare (MoHFW), GoI. According to negative in antigen tests were the MoHFW guideline, all the retested using RT-PCR method for patients except the severe cases confirmation. can be discharged after 10 days of 2. Strategy 2 included testing of the symptom onset without conducting vulnerable sections in the any test. community clusters, with or without symptoms with an 6 . 1 . 1 . 3 Roping in the Private objective to prevent mortality S e c t o r and severe morbidity. They are The achievements made by Kerala in tested using antigen testing health ranking is equally attributable methods. In case the tests come to the Private hospitals in the State. negative, they are advised to The healthcare facilities in the undergo reverse quarantine and private sector surpass the facilities get tested again even at the in the government hospitals of onset of mild symptoms. Kerala. At a time when the public healthcare system is at a risk of 6 . 1 . 1 . 2 Discharge Policy being overwhelmed, engaging the Adopted by the State private sector has become a With a looming fear of the public necessary course of action. The health system being overwhelmed, Kerala government, in a shift in the State revised some of its policy, decided that people who test guidelines to avoid operational positive have the choice to go to a del ay. In the first and second waves, private healthcare institution. the GoK fol l owed the gui del i ne of However, there is an air of having two RT-PCR tests to turn scepticism among private negative for patients’ discharge. institutions about the government This was amended in the government meddling with the price structure. order dated July 21, 2020, where The State has also augmented the asymptomatic COVID-19 patients can testing facilities by engaging private be discharged from hospitals if one sectors. As on July 5, 2020, the antigen test result turns negative State has 44 testing facilities after 10 days from the date of including laboratories from the testi ng posi ti ve. The protocol private sector which carry out followed by Kerala has been different types of tests. different from the gui del i ne i ssued
4 7 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 7 EVALUATION FRAMEWORK
Source: i nshort. com
For the purpose of eval uati on and assessment, a tabul ar representati on of i nterventi ons was desi gned to consol i date the State’ s i nterventi ons (Tabl e 2) i n a structured format and understand the i nvol vement of the vari ous stakehol ders to tackl e the cri si s. The framework enl i sts al l the government i nterventi ons and i nsti tuti onal structures i nto a tabul ar format. Based on the repl i cabi l i ty, we categori sed the acti ons i nto i mmedi ate, medi um-term and l ong-term. I n thi s study, the i mmedi ate acti ons are those i nterventi ons that can be sui tabl y carri ed out i n a span of one month si nce the emergence of the outbreak. Medi um-term acti ons can be carri ed out between two to three months. One caveat i n the use of these nomencl atures i s that some of the i nterventi ons that were i mmedi atel y i mpl emented i n Keral a may not necessari l y be repl i cabl e for al l States. I t vari es from State to State dependi ng on thei r i nsti tuti onal capaci ty.
The i nterventi ons are graded i n bl ue shades to i ndi cate the extent of repl i cabi l i ty. Li ghter shades represent i mmedi ate and medi um-term that can be scal ed up or remodel l ed for States to i mpl ement. The darker shade of bl ue represents measures that requi re a strong i nsti tuti onal network. They are general l y l ong-term i n nature. The rows hi ghl i ght the vari ous i nterventi ons that are cl ubbed together under the umbrel l a categori es namel y, heal th i nterventi ons, mul ti -sectoral i nterventi ons and communi cati on
4 8 KERALA MODEL OF RESPONSE TO COVID-19 strategi es. The col umns l i st the mechani sm of Keral a presented a stakehol ders engaged i n response cross-sectoral and cross- operati ons and are cl ubbed together organi sati onal col l ecti ve acti on. I t under the umbrel l a categori es garnered col l ecti ve effort, from the namel y, Departments, grassroots l evel ri ght through to Organi sati ons/Bodi es/Members, Non- top-down l egi sl ati ve acti ons. As Governmental enti ti es and l egal evi dent from the eval uati on matri x, acti ons. The cel l s i n the matri x the LSG bodi es and Kudumbashree ei ther have a ti ck symbol or no have pl ayed a maj or rol e i n al l areas symbol dependi ng on the of the State’ s response to the i nvol vement of the rel evant COVI D-19 pandemi c. Thi s stakehol der i n the executi on of a decentral i sed system has i ts roots parti cul ar i nterventi on. i n the peopl e-centri c governance
The cumul ati ve ti cks i n a row gi ve us model adopted by the rul i ng an i nsi ght i nto the i nter- di spensati ons over the years and the departmental coordi nati on (i f any) i n soci o-pol i ti cal envi ronment that executi ng an i nterventi on. The exi sts, whi ch i s very much i ntri nsi c cumul ati ve ti cks i n a col umn to the State. Even though many hi ghl i ght the number of factors are State-speci fi c, there are i nterventi ons a parti cul ar measures/i nterventi ons made by stakehol der i s i nvol ved i n, gi vi ng us Keral a duri ng thi s peri od that can be a hol i sti c vi ew of the extent of the remodel l ed to sui t the soci o-pol i ti cal parti ci pati on of stakehol ders. and economi c setti ng of other States. I t i s observed that the response
4 9 KERALA MODEL OF RESPONSE TO COVID-19
Tabl e 2: Evaluation Framework Tabl e 2: Evaluation Framework
K E R A L A M O D E L O F R E S P O N S E T O C O V I D - 1 9
Tabl e 2: Evaluation Framework
Non-Governmental Departments Organisation/Bodies/Members Legal Actions Agencies Civil General Information Kudumba- ASHA Local PHC/CHC/ Registered Private Media : NGOs/ Social Government Health LSG PWD Revenue Police Labour Finance Notification Guideline Acts Circular Supplies Administration & PR shree workers bodies TH/GH/MCH volunteers Print and Visual CSOs Media Order Early Screening and Qurantining of Travellers
Contact Tracing
Route Mapping
Kerala Epidemic Disease Ordinance
Health Risk-based Treatment Interventions Psychosocial Support
Home Quarantine
Community Kitchen
Effective Quarantining Mechanism
Universal Ration
Volunteer Support Force Integrated Supply Multisectoral Chain Intervention Migrant Worker Rehabilitation
Financial Package
Janakeeya hotels
Awareness Campaigns
Efficient use of private/social media Communication Strategies Daily Press Briefing
Media Cell
5 0 KERALA MODEL OF RESPONSE TO COVID-19
7. 1 Best Practi ces from the Keral a Model of Response to COVID-19
7.1.1. Immediate Actions
7 . 1 . 1 . 1 E a r l y R i s k A s s e s s m e n t set the course for a constantl y evol vi ng publ i c heal th cri si s. Keral a Pandemi cs can have di sastrous was l argel y effi ci ent i n i ts swi ft and consequences for soci ety as a methodi cal response to the whol e. I t i s cruci al to prepare for and anti ci pated chal l enges. The mi ti gate the i mpacts of di sease i mmedi ate acti ons of rapi d and mass outbreaks and for thi s a careful ri sk- testi ng, stri ct contact traci ng, based approach i s vi tal to check the transparent and ti mel y publ i cati on of preparedness of a State. I ni ti al route maps, survei l l ance of studi es on any epi demi c di sease i ncomi ng passengers i nto the State outbreak are characteri sed by a l ack vi a ai r or rai l ways, home survei l l ance of wel l -rounded knowl edge. of quaranti ned househol ds, Therefore, i t i s necessary for the publ i cati on of quaranti ne gui del i nes States to prepare for the worst-case and thei r stri ngent compl i ance scenari o. Keral a sprang i nto acti on ascertai ned by the urban l ocal as on a war foot and put a bodi es and Anganwadi workers were comprehensi ve pl an i n pl ace much cruci al i n curbi ng the spread of the before the WHO decl ared COVI D as a deadl y vi rus and setti ng a sol i d Publ i c Emergency. foundati on for future contai nment Keral a i ssued an addendum on measures. testi ng and quaranti ni ng as earl y as The i mmedi ate acti ons undertaken by January 5, 2020. I t al so formed a the government need to be bol d and response commi ttee and i ssued target suppressi on of the di sease gui del i nes on screeni ng, ensuri ng preparedness of the State systems combi ned wi th mi ti gati on measures. i n the worst-case scenari o. Thi s These deci si ve steps ensured that proacti veness gave Keral a the the capaci ty of the heal thcare advantage to contai n the fi rst case system was preserved and the (reported on January 30, 2020) mechani sm to effecti vel y tackl e the wi thi n i ts boundari es. transmi ssi on of the vi rus was wel l - establ i shed. 7 . 1 . 1 . 2 T e s t i n g , T r a c i n g , S u r v e i l l a n c e a n d Q u a r a n t i n e 7 . 1 . 1 . 3 H e a l t h C a r e M a n a g em e n t
The i ni ti al contai nment strategy can The abi l i ty to act, execute and
5 1 KERALA MODEL OF RESPONSE TO COVID-19 establ i sh cl i ni cal protocol s i s the grassroots about the di sease necessary for a rapi dl y evol vi ng and urge them to adopt preventi ve envi ronment. As an i mmedi ate measures. Such vol unteers hel p i n acti on, Keral a consti tuted medi cal bui l di ng a posi ti ve vi ew of the boards i n al l medi cal col l eges and response measures by underscori ng Government hospi tal s on February 2. schemes and exhi bi ti ng thei r The boards, consi sti ng of experts, transparency. Studi es show that were entrusted to set protocol s on ci ti zens who parti ci pate i n pati ent management. Thi s awareness programmes end up usi ng establ i shed a standard heal thcare preventi ve measures much more than management system at the l ocal those who do not. l evel . The State al so expanded access to care and attempted to 7 . 1 . 1 . 5 D i v e r s e C o m m u n i c a t i o n meet the cri ti cal surge i n demand for S t r a t e g i e s t o C r e a t e A w a r e n e s s PPEs and sani ti sers by engagi ng Studi es hi ghl i ght that trust i n the mul ti pl e agenci es l i ke KMSCL. Upon government can determi ne the real i si ng the shortage caused due to success of cri si s response and suppl y chai n di srupti on, i t entrusted behavi oural i nsi ghts i ndi cate that Keral a State Drugs and the communi cati ons strategy i n Pharmaceuti cal to produce publ i c heal th cri ses pl ays a cri ti cal sani ti sers on a l arge scal e and rol e i n determi ni ng thi s. di rected texti l e corporati ons on sourci ng raw materi al s l ocal l y. The Chi ef Mi ni ster of the State addresses ci ti zens for one hour dai l y 7 . 1 . 1 . 4 F o s t e r i n g K n o w l e d g e and a bul l eti n i s rel eased dai l y on the a n d A w a r e n e s s offi ci al websi te of the Keral a government to appri se ci ti zens and The spread of COVI D-19 requi res a empower them regul arl y wi th correct broad response that goes beyond i nformati on. These strategi es have terti ary medi cal care and been consi stent wi th the WHO i ncorporates preventi ve care. I n gui del i nes on outbreak ri sk Keral a, pre-exi sti ng communi ty communi cati on. networks were used extensi vel y to ki ndl e awareness through The medi a outreach campai gn of the programmes l i ke ‘ Break the Chai n’ , State pl ayed a key rol e i n maki ng onl i ne qui zzes and a comprehensi ve ci ti zens aware of the ground-l evel gui de on i nformati on about the si tuati on by reachi ng every ci ti zen, di sease. NGOs, Kudumbashree bri ngi ng awareness and conveyi ng vol unteers and LSG i nsti tuti ons were correct i nformati on about the cri si s. depl oyed as part of outreach Keral a has a vi brant l ocal medi a and programmes to educate peopl e at the State government uti l i sed
5 2 KERALA MODEL OF RESPONSE TO COVID-19
Radi o, TV and Newspapers to convey made i n Hi ndi and Bengal i correct i nformati on and update consi deri ng the 10 per cent mi grant ci ti zens. Besi des pri nt and vi sual popul ati on i n Keral a. medi a, announcements were al so
7.1.2. Medium-term Actions
7 . 1 . 2 . 1 L e v e r a g i n g L o c a l the need for more workforce, a N e t w o r k s vol unteeri ng body was announced on March 25, 2020. The deci si on was to Keral a was successful i n fol l owi ng a form a vol unteer force coveri ng the communi ty-based approach under l ength and breadth of Keral a and the stewardshi p of l ocal engagi ng them i n response governments and the l eadershi p of measures. More than 3, 00, 000 vi l l age Panchayats, Muni ci pal i ti es vol unteers regi stered to assi st and Muni ci pal Corporati ons were government i n the fi ght agai nst i nstated. Local networks such as COVI D-19. Vol unteers were depl oyed ASHA, Kudumbashree and Angawadi for feedback and outreach acti vi ti es. workers were cl osel y i nvol ved i n Thi s has not onl y assured peopl e of ensuri ng that the government conti nued support but al so i nvoked a servi ces reach peopl e at the sense of camaraderi e and conformi ty grassroots l evel . Through these to gui del i nes. These ti mel y and networks, the State coul d al so mul ti -pronged i ni ti ati ves are cruci al del i ver medi ci nes to pati ents on to bui l d a resi l i ent and cooperati ve pal l i ati ve care and those wi th NCD. communi ty at the mi croscopi c l evel . Kudumbashree workers were al so engaged i n produci ng masks and 7 . 1 . 2 . 3 E n g a g i n g A c a d e m i a a n d sani ti sers to address shortages i n N o n - g o v e r n m e n t a l A c t o r s suppl i es. Recogni si ng the l ocal communi ty as part of the sol uti on Keral a was al so abl e to engage can pl ay a paramount rol e i n teams of pri vate professi onal s and i mprovi ng resi l i ence duri ng l arge- vol unteers from mul ti di sci pl i nary scal e di sease outbreaks. backgrounds i n devel opi ng a hol i sti c tool for tracki ng, tel emedi ci ne, 7 . 1 . 2 . 2 E x p a n d i n g C a p a c i t y medi ci ne del i very network, ambul ance network, knowl edge and t h r o u g h V o l u n t e e r F o r c e awareness, and vol unteer Keral a was abl e to capi tal i se on the management. To ensure smooth strength of i ts vol unteer force del i very of food suppl i es, the State duri ng the pandemi c. Recogni si ng partnered wi th I I TM Kozhi kode to
5 3 KERALA MODEL OF RESPONSE TO COVID-19 devi se a suppl y chai n management needs of the desti tute were system. Thi s al l owed for a pri vate establ i shed. The government roped engagement i n probl em-sol vi ng and i n LSG i nsti tuti ons to rehabi l i tate i n i denti fyi ng and ful fi l l i ng the needs the desti tute and the homel ess by of the soci ety at the grassroots openi ng up communi ty ki tchens and l evel . Kudambashree hotel s that were accessi bl e to every ci ti zen and 7 . 1 . 2 . 4 L e a v i n g N o O n e B e h i n d served thousands of meal s dai l y. Recogni si ng that the wi despread Keral a was one among the few l ockdown, uncertai nty of i nfecti on, States to cal l for a l ockdown. ci rcul ati on of mass i nformati on on Fol l owi ng i ts announcement, the the di sease, and heal th and fi nanci al State mapped the vul nerabl e worri es can cause mass hysteri a and stakehol ders such as the mi grant stress, the State al so made l abourers, el derl y, gi g-economy provi si ons to establ i sh a hel pl i ne for workers, homel ess and the desti tute counsel l i ng to face the unfol di ng and ensured thei r survi val through cri si s. Some of these measures had the fol l owi ng measures. the engagement of LSG and i . Uni versal Rati on Kudumbashree network whi ch i i . Desti tute Rehabi l i tati on accel erated the operati ons. i i i . Mi grant Rehabi l i tati on However, these measures can be i v. Psycho-soci al support undertaken by remodel l i ng as per Temporary mobi l e shel ters equi pped each State’ s i nsti tuti onal strengths wi th a communi ty ki tchen to cater to and contextual advantages. the food and cl ean dri nki ng water
7.1.3 Building Long-term Institutional Capacity from the Grassroots
Effecti ve l eadershi p at State l evel i s around COVI D-19. The reason Keral a i mportant to effecti vel y del i ver the coul d mobi l i se the grassroots needs of the peopl e, but i f the communi ty i s attri butabl e to the i nsti tuti ons on the ground are not sustai ned peopl e-centri c pl anni ng. robust, executi ons di rected from the Strengtheni ng i nsti tuti ons and top wi l l be futi l e. I nsti tuti onal capaci ty bui l di ng have been a focus capaci ty shapes the outcomes of of Keral a si nce the i ncepti on of the soci ety and the prevai l i ng State. The present cri si s responses envi ronment. Keral a had a response have underscored the advantages of team at every l evel . I ts i nsti tuti onal bui l di ng soci al i nsti tuti ons for publ i c arrangements were abl e to qui ckl y acti on. respond to the emergi ng chal l enges
5 4 KERALA MODEL OF RESPONSE TO COVID-19
7 . 1 . 3 . 1 L o c a l i s e d L e a d e r s h i p system, a three-ti er system of sel f- governance was establ i shed. Thi s One of the features that di sti ngui sh approach to decentral i sati on si nce Keral a from other I ndi an States i s i ts the mi d-1990s l ed to the formati on rel ati vel y wel l -functi oni ng of an effi ci ent i nsti tuti onal decentral i sed system. The 73rd and mechani sm for effecti ve governance 74th amendments of the from the top to the root. Consti tuti on i n 1993 gave i mpetus to the State to carry out the reforms 7 . 1 . 3 . 2 . K u d u m b a s h r e e i n the area of decentral i sati on at both urban and rural l evel s. I n Keral a, One cruci al outcome of the LSGs are meani ngful l y empowered democrati c decentral i sati on and the through admi ni strati ve powers and Peopl e’ s Pl an process was the transfer of resources. Kudumbashree mi ssi on—a poverty
Keral a’ s decentral i sati on story has eradi cati on and women empowerment not j ust been about devol uti on. I n mi ssi on l aunched i n 1998. The 1997, the government took i ni ti ati ve gender di mensi on that had been bui l t of transferri ng power, fi nance and i nto the pl anni ng process, al ong wi th experti se to LSG i nsti tuti ons to the Women Component Pl an (WCP) execute devel opmental operati ons at contri buted to the Kudumbashree the grass roots. I t ai med at maki ng i dea. Gender as a theme became peopl e parti ci pate i n day-to-day si gni fi cant i n the pl anni ng process i n governance and pl anni ng. A notabl e the context of reservi ng one-thi rd of aspect i s the fi scal decentral i sati on, the seats and offi ces i n the LSG where 40 per cent of the State’ s bodi es to women. Thi s made the l ocal annual pl an outl ay i s al l otted to the governments across the State to l ocal governments di rectl y. thi nk about the concerns of women and ways to i mprove thei r status, The LSG bodi es are entrusted wi th a whi ch i n turn l ed to the i ntroducti on cruci al rol e i n prepari ng proj ects and of WCP as an i ntegral part of l ocal pl ans that l ead to l ocal economi c government-l evel devel opment pl ans devel opment and soci al j usti ce. i n both urban and rural areas. The Si nce 1996, l ocal bodi es are pl ayi ng State government made i t mandatory a parti ci patory approach i n the for l ocal government i nsti tuti ons to pl anni ng and i mpl ementati on of the earmark 10 per cent of thei r annual l ocal devel opment pl ans. The pl an funds excl usi vel y for women’ s programme was l aunched under the proj ects from the second year of the name of ‘ Peopl e’ s Campai gn for ni nth fi ve-year pl an. Parti ci patory Pl anni ng’ al so cal l ed Peopl e’ s Pl an, duri ng the tenure of From runni ng communi ty ki tchens to the ni nth fi ve-year pl an. Under thi s conducti ng awareness programmes
5 5 KERALA MODEL OF RESPONSE TO COVID-19 at the grassroots l evel , promoti ve and rehabi l i tati ve heal th Kudumbashree has pl ayed a i nterventi ons—pl ayed a cruci al rol e si gni fi cant rol e i n many of the i n transformi ng PHCs. Another State’ s i nterventi ons for contai ni ng i mportant i nsti tuti onal mechani sm the pandemi c. Keral a has been abl e that proved effecti ve duri ng the to desi gn and strengthen the pandemi c was the State’ s i ni ti ati ve capaci ty of such i nsti tuti ons that cal l ed DI SHA to provi de gui dance, are adaptabl e i n response to counsel l i ng and i nformati on on unexpected shocks. physi cal and mental heal th i ssues. I t acts as a hel pl i ne duri ng an outbreak 7 . 1 . 3 . 3 P u b l i c H e a l t h N e t w o r k or cal ami ty. I t al so has “Di al a Doctor’ servi ce that hel ps peopl e i n Keral a’ s model i s i ncompl ete wi thout seeki ng advi ce from doctors the menti on of i ts robust publ i c tel ephoni cal l y. Wi th the outbreak of heal th system. The State has been a coronavi rus, they have been acti vel y consi stent outl i er proj ecti ng better engaged i n hel pi ng the publ i c. The heal th outcomes i n a number of State conti nues to rel y on DI SHA i n areas compared to other I ndi an i ts battl e agai nst COVI D-19. States. The gai ns i n heal thcare are attri buted to the strong emphasi s 7 . 1 . 3 . 4 E d u c a t i o n a n d S o c i a l the rul i ng governments have l ai d on publ i c heal th and PHCs. Consequent D i v i d e n d s to the Peopl e’ s Pl an Campai gn, the Peopl e’ s cooperati on duri ng the State government decentral i sed pandemi c has been wel l - governance i n al l sectors i ncl udi ng acknowl edged by the State i n i ts Heal th. Under the new system, the efforts to contai n the di sease. PHCs and sub-centres were brought Keral a’ s success i n creati ng under the j uri sdi cti on of the vi l l ages awareness among the publ i c has i ts to cl osel y moni tor and respond to roots i n the earl y i nvestments the l ocal heal th needs. Thi s State made i n the educati on sector. decentral i sati on has resul ted i n I t pri ori ti sed Educati on much before medi cal professi onal s and the furore of Ri ght to Educati on communi ty members worki ng caught the rest of I ndi a. Wi th a vast together to bri ng faci l i ti es to I T i nfrastructure and hi gh di gi tal address the communi ty’ s evol vi ng penetrati on, the State coul d heal th pri ori ti es. generate di gi tal awareness among Over the years, Keral a strengthened i ts ci ti zenry. i ts pri mary heal thcare through I n sum, many of Keral a’ s outcomes i ncremental changes. The Aardram are a resul t of consi stent pl anni ng. mi ssi on—ai med at gi vi ng preventi ve, For establ i shi ng a strong
5 6 KERALA MODEL OF RESPONSE TO COVID-19 i nsti tuti onal network, sound forward-l ooki ng arrangements have admi ni strati ve frameworks and si gni fi cantl y contri buted to the l egi sl ati ons coupl ed wi th grassroots State’ s response and outcomes mobi l i sati on are i mperati ve. These around COVI D-19.
5 7 KERALA MODEL OF RESPONSE TO COVID-19
CHAPTER 8 OVERALL ASSESSMENT OF KERALA’S RESPONSE
Source: onmanorama
The response of the Keral a government i s i nterdependent wi th many factors such as pol i ci es of the past havi ng a beari ng on the present acti ons, the contextual setti ng i ncl udi ng the prevai l i ng envi ronment, i ts cul tural and soci al fabri c, etc. Wi th COVI D-19, Keral a had a strong i nsti tuti onal memory bui l t from the past that gui ded i ts present deci si ons. I t had experi ences to draw on from the Ni pah epi sode; addi ti onal l y, the State’ s earl y and sustai ned i nvestments on soci al sectors l i ke publ i c heal th, educati on, decentral i sed governance and communi ty parti ci pati on al so enabl ed Keral a to tai l or i ts responses by l everagi ng i ts contextual advantage.
The much-accl ai med Keral a response had one addi ti onal factor that suppl emented i ts contai nment efforts—the i nterstate mobi l i ty restri cti ons i nduced by the nati onwi de l ockdown. The chal l enge at hand was, therefore, l ess daunti ng gi ven that nati onwi de l ockdown overl apped wi th the State' s response mechani sms, creati ng a favourabl e setti ng for effecti ve contai nment. The State’ s strong i nsti tuti onal apparatus coupl ed wi th i ts coordi nated acti ons hel ped i n fl atteni ng the curve i n the i ni ti al two phases. Subsequentl y, the government opened up the economy i n a phased manner, wi th the obj ecti ve to revi ve the stressed economy.
5 8 KERALA MODEL OF RESPONSE TO COVID-19
The thi rd wave hi t the fl attened communi ty transmi ssi on i n the curve of COVI D i n Keral a wi th the coastal regi ons of Keral a. Whi l e the return of NRKs and resi dents from i nterventi ons of Keral a have many other States. The gradual openi ng up el ements of success to boast of, i t of the economy coi nci ded wi th the i s al so necessary to be mi ndful of return of expatri ates i n l arge the l i mi tati ons of the State. On numbers, l eadi ng to a surge i n cases assessi ng the overal l response, wi th very l i ttl e si gns of respi te i n there are a few i denti fi ed the i mmedi ate future. By the end of i mprovements that can be practi sed June, Senti nel Survei l l ance i ndi cated for better outcomes.
8. 1 Narrati ves that Infl uence Peopl e' s Percepti on
The bri efi ngs, gui del i nes and that the nature and the i mpact of i nterventi ons rol l ed out i n the the vi rus are sti l l under di scovery, second wave underscored the any narrati ve that bui l ds a spi ri t of vul nerabi l i ty of certai n categori es of compl acency among peopl e i s j ust as peopl e. Keral a set four pri ori ty dangerous to soci ety. groups i denti fi ed as vul nerabl e to The messagi ng and narrati ves need the di sease namel y, the frontl i ne to be i ncl usi ve of al l peopl e. Keral a, workers, the el derl y, those wi th gi ven i ts densi ty, cannot ‘ reverse comorbi di ti es and pregnant women. quaranti ne’ i ts ‘ vul nerabl e These messages, however, i nfl uence popul ati on’ . Messages, narrati ves the publ i c' s ri sk percepti on and ri sk and acti ons are i mportant reducti on responses duri ng a heal th components that shape the emergency l i ke COVI D-19. I t i s understandi ng of ri sk among the probl emati c i f a l arger secti on of the peopl e. A ri ght communi cati on of ri sk soci ety fal l s outsi de these defi ned i s vi tal i n persuadi ng peopl e to groups, carryi ng a percepti on that i t cooperate i n ti mes of cri si s. I t affects onl y the el derl y and those requi res coordi nated efforts from wi th comorbi di ti es. The subsequent everyone, regardl ess of age, i n rel axati on i n the economy combi ned managi ng the pandemi c; and the wi th a premature cel ebrati on of message needs to be cl ear and Keral a’ s success further added to i ncl usi ve. thi s sense of compl acency. Gi ven
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8. 2 Testi ng Oddi ty
Testi ng strategi es are central to i ndi cati ng undetected cases. control the contagi on of any Keral a’ s testi ng has been l argel y outbreak. A suppressi on of i nfecti on focussed on returnees and thei r essenti al l y requi res the Test-Track- contacts. Therefore, the proj ecti ons Treat Strategy. Keral a’ s test rate are based on the data obtai ned has been wel l above the nati onal through the survei l l ance of i mported average wi th a cumul ati ve TPR of 2. 6 cases and thei r contacts. Wi th the per cent as of Jul y. However, some l ocal transmi ssi on taki ng a l arge factors ecl i pse the accurate pi cture share of total cases of l ate, there i s of the testi ng i n Keral a. a need to reconsi der the survei l l ance
I n Keral a, sampl es are taken from strategy of Keral a. An addi ti onal symptomati c persons whi ch come concern i s regardi ng the effi ci ency under Routi ne Sampl es sent. of anti gen testi ng that i s wi del y Besi des, sampl es are al so taken from used for detecti ng communi ty pri ori ty groups defi ned earl i er. Total transmi ssi on. Whi l e a posi ti ve sampl es tested are the sum of al l anti gen test i s consi dered accurate, i ncl udi ng repeated sampl es taken there i s an i ncreased chance of from the same person. Unl i ke the fal se-negati ve resul ts under thi s gui del i ne proposed by Centre’ s procedure whi ch may resul t i n the MoFW, Keral a di scharges a pati ent further spread of i nfecti on to after a mandated anti gen test others. There i s no data avai l abl e i n turni ng negati ve. I n case a pati ent the publ i c domai n to study the tests posi ti ve agai n, retests wi l l be accuracy of al l the tests conducted performed every al ternate day unti l i n Keral a. To get a cl ear pi cture of the the resul ts come negati ve for test numbers and the accuracy of di scharge. Whi l e thi s i s a good the tests’ resul t, GoK shoul d practi ce that ensures pati ents are consi der maki ng the data more ful l y recovered, i t al so i ncreases the speci fi c. Fi rstl y, the testi ng fi gures testi ng fi gures si gni fi cantl y. The shoul d proj ect detai l s of the number testi ng fi gures, therefore, may not of retests performed i n a day. present a correct pi cture of the Secondl y, the bi furcati on of types of si tuati on as i t potenti al l y l eaves out tests conducted and the number of many undetected cases. tests turni ng posi ti ve/negati ve under each type of test. The dai l y TPR fi gure has cl i mbed to 4. 6 per cent i n the l ast week of Jul y
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8. 3 Use of IT Pl atforms
Keral a depl oyed tech-dri ven servi ces Store Purchase Manual 2013, to accel erate i ts heal thcare pl anni ng cl auses 2. 2 and 7. 3—was and response mechani sm. undersi gned by the Secretary of the Contracti ng wi th pri vate enti ti es for I T department wi thout due procurement of servi ces i s authori sati on by the Governor i nevi tabl e for every modern state (Sathyapal an and Sreeparvathy and i ts sub-nati onal agenci es to 2020). The whol e arrangement rai sed del i ver the publ i c functi ons. One concerns about bypassi ng i ndi vi dual such contractual arrangement was consent and breachi ng ci ti zen’ s between the State government’ s I T personal data. di vi si on and a US-based tech From the experi ence of Keral a’ s company, Spri nkl r, for col l ecti ng, uti l i ty of I T pl atform and data stori ng and processi ng the heal th processi ng, i t i s recommended that data of Keral i tes. The l ack of the State government shoul d come transparency observed i n Keral a' s up wi th a gui del i ne on data col l ecti on management of heal th data vi a before the depl oyment of Spri nkl r came under publ i c scruti ny. technol ogi es i n order to serve the From the facts avai l abl e i n the publ i c i nterest of affected publ i c wi thout domai n, the Spri nkl r agreement, i n compensati ng the potenti al benefi ts the form of a purchase order— of the technol ogy. carri ed out under the provi si ons of
8. 4 Need for Publ i c Heal th Cadre
Responses to publ i c heal th been cri ti ci sed for arti fi ci al l y emergenci es need to be backed by reporti ng l ow numbers of cases to sci enti fi c evi dence i n order to conceal thei r pol i ti cal i mage. mi ni mi se the l oss of human l i ves. I n Duri ng a heal th cri si s, i t i s necessary a ti me-constrai ned setti ng, many deci si ons by the government may not for the States to be transparent i n necessari l y be the most appropri ate di ssemi nati ng the ri ght i nformati on course of acti on. Addi ti onal l y, there and data to gather the support of i s al ways a ri sk of governments the peopl e. However, pol i ti cal bei ng gui ded by i ts pol i ti cal moti ves often take precedence i n i nterests. Many I ndi an States have deci si ons made by the government.
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Governments undoubtedl y pl ay a and Communi ti es, maki ng i t easi er si gni fi cant rol e i n cri si s for governments i n ti mes of cri si s to management, but to what extent take swi ft acti on backed by shoul d i t be i nvol ved i n setti ng sci enti fi c evi dence. protocol s and gui del i nes on Heal th i s Many countri es have Publ i c Heal th a key questi on to understand. The Agenci es responsi bl e for setti ng up ongoi ng cri si s has exposed I ndi a' s procedures and defi ni ng the rol es of seri ous l i mi tati ons i n handl i ng a stakehol ders duri ng heal th publ i c heal th emergency. I t i s sadl y conti ngenci es. For i nstance, Canada governed by the archai c Epi demi c has a Publ i c Heal th Agency as a part Di sease Act, 1897 whi ch emerged as of the Federal I nsti tuti on to focus on a response to Buboni c Pl ague. The preventi ng di sease and i nj uri es and Di saster Management Act, 2005 i s provi di ng i nformati on to support another l egi sl ati on that deal s wi th i nformed deci si on maki ng. I t val ues Heal th, al bei t, i n a pi ecemeal sci enti fi c excel l ence and provi des manner. Al though these l egi sl ati ons nati onal l eadershi p i n response to and regul ati ons are rel evant i n publ i c heal th threats. fi ghti ng the pandemi c, there are I n I ndi a, the Nati onal Heal th Bi l l , si gni fi cant shortcomi ngs i n the 2009 attempted to bri dge some of defi ni ti on and demarcati on of the l i mi tati ons present i n the responsi bi l i ti es, gi vi ng States exi sti ng l egi sl ati on. I t envi si oned a enormous power to i mpose, Nati onal and State Publ i c Heal th someti mes, despoti c measures under Board to formul ate pol i ci es on heal th Secti on 144 of the I ndi an Penal Code and provi de a response mechani sm (I PC). for heal th emergenci es. However, the i ni ti ati ve never took shape. A These gl ari ng gaps observed i n the framework to establ i sh goal s and exi sti ng l egi sl ati on necessi tates obj ecti ves for i mprovi ng setti ng up an autonomous Publ i c coordi nati on and col l aborati on wi th Heal th Body to oversee matters stakehol ders can prove effecti ve i n associ ated wi th Heal th. I nstead of cri si s hours. wai ti ng for an event to tri gger Keral a’ s experi ence shows that the responses, there i s a need to have a hori zontal and verti cal i nterventi ons ready response and preparedness and coordi nati on among and between mechani sm for worst-case scenari os the vari ous stakehol ders/el ements that can possi bl y emerge. Havi ng a i ncl udi ng the admi ni strati ve speci al i sed autonomous body can mechani sms, i nsti tuti onal formul ate cl ear gui del i nes on arrangements (government and non- possi bl e publ i c heal th threats and governmental ), medi a, soci al defi ne the rol es of the Centre, State
6 2 KERALA MODEL OF RESPONSE TO COVID-19 workers, l aw enforcement agenci es, heal th i nfrastructure and the number technol ogy, domai n experts and of doctors and nurses al one, but a academi a, fi nance & economy, etc permanent cadre compri si ng al l the are cri ti cal for effecti ve strategy- rel evant stakehol ders. maki ng i n tackl i ng a pandemi c l i ke The body shoul d be responsi bl e for COVI D-19. On a cl oser l ook and creati ng a forward-l ooki ng response assessment, i t opens up the debate framework for any publ i c heal th on the need for the establ i shment of eventual i ti es. As the economy and a permanent Publ i c Heal thcare Cadre heal thcare systems try to emerge whi ch woul d be a col l ecti ve of the from the cri si s, there i s a need to stakehol ders stated above. The reconsi der how to bui l d a system COVI D-19 experi ence i n Keral a that i s ready and responsi ve i n order rei terates the poi nt that the publ i c to prevent and protect the publ i c heal thcare shoul d not be confi ned to from emergi ng threats.
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REFERENCES
Government Notifications and Guidelines
Disaster Management Department. Government of Kerala. Order 12 February 2020. Available at https://kerala.gov.in/documents/10180/63216aa5-7a97-4782-be56- a176e2210a9a.
General Administration Department, Government of Kerala. 2020. “Formation of Social Volunteer Force.” Available at https://sannadhasena.kerala.gov.in/pdf/go_dmvtf.pdf.
General Administration Department, Government of Kerala. 2020. “Regulations to contain the Covid-19 post lockdown: Expert committee to formulate the guidelines”. 4 April 2020. https://www.pslhub.org/uploads/monthly_2020_05/1339830819_COVIDLOCKDOWNREVERS ALSTRATEGYREPORTSUBMITTEDTOHONCM_pdf.0434764a7c587c4179a43f23ea796011
General Administration of Kerala, Government of Kerala. 23 March 2020. “Statewise Lockdown.”Available at https://static.mygov.in/rest/s3fs- public/mygov_158511610551307401.pdf.
Health and Family Welfare Department. Government of Kerala. 5 January 2020. “Addendum to Testing and Quarantining.” Available at https://dhs.kerala.gov.in/wp- content/uploads/2020/03/add_06022020.pdf.
Health and Family Welfare Department. Government of Kerala. 2020. “Constitution of Medical Board.”Available at https://dhs.kerala.gov.in/wp- content/uploads/2020/03/mb_05022020.pdf.
Health and Family Welfare Department. Government of Kerala. “Sample, Testing, Collection and Transport Guidelines.” 1 February 2020. Available at https://dhs.kerala.gov.in/wp- content/uploads/2020/03/test_05022020.pdf.
Health and Family Welfare Department. Government of Kerala. 2 Feb 2020. “Revised Guidelines for Surveillance.” Available at http://dhs.kerala.gov.in/wp- content/uploads/2020/03/revis_06022020.pdf.
Health and Family Welfare Department. Government of Kerala. “Health Advisory for Tourism Department.”5 Feb 2020. Available at http://dhs.kerala.gov.in/wp- content/uploads/2020/03/hat_05022020.pdf.
Health and Family Welfare Department. Government of Kerala. 12 March 2020. “Guidelines for Testing, Quarantining, Hospital Admission and Discharge for COVID-19.”Available at http://dhs.kerala.gov.in/wp-content/uploads/2020/03/reg_12032020.pdf.
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Health and Family Welfare Department. Government of Kerala. 15 March 2020. “Sequence of Activities at Arrival.” http://dhs.kerala.gov.in/wp-content/uploads/2020/03/Adisory- Airport-arrangements-and-flow-chart-.pdf.
Health and Family Welfare Department. Government of Kerala. 19 March 2020. “Guidelines for Exclusive Arrangements for the Foreign Tourists Coming to Kerala.”http://dhs.kerala.gov.in/wp-content/uploads/2020/03/con_19032020.pdf.
Health and Family Welfare Department. Government of Kerala. 25 March 2020. “Guidelines for Distribution of Laboratories.” https://dhs.kerala.gov.in/wp- content/uploads/2020/03/guide_25032020.pdf.
Health and Family Welfare Department. Government of Kerala. 16 April 2020. “Criteria for Selecting Laboratories for Conducting Antibody Test.” https://dhs.kerala.gov.in/wp- content/uploads/2020/04/G.O.-ABT-pvt_compressed.pdf.
Information and Public Relations Department. Government of Kerala. 25 march 2020. “Order for the Formation of COVID Media Cell, Fake News Monitoring Cell etc and Fixing the Responsibility.” https://kerala.gov.in/documents/10180/5c94887f-a383-4239-baf0- e8a9bffeac47.
IT Department, Government of Kerala, Circular on Collecting Personal Information. 18 May 2020. https://kerala.gov.in/documents/10180/5c94887f-a383-4239-baf0- e8a9bffeac47.
Local Self Government, Government of Kerala. 20 March 2020. “Responsibilities of LSGs”. https://go.lsgkerala.gov.in/files/go20200320_25893.pdf.
Local Self Government Department, Government of Kerala. 20 March 2020. “Government Order on the Actions and Responsibilities to be Undertaken by the Local Self-Government Bodies.” https://go.lsgkerala.gov.in/files/go20200320_25893.pdf.
Ministry of Health and Family Welfare, Government of India “Revised Discharge Policy”https://www.mohfw.gov.in/pdf/ReviseddischargePolicyforCOVID19.pdf
Press Release by Government of Kerala to Clarify the Concerns on the Data Collection for the Containment of the Infection. 14 February 2020. https://kerala.gov.in/documents/10180/3eeb55f8-b499-49bc-b457-20cd02338f07.
Books, Newsletters and Articles
Dinesh, Narayan. 2020. “Is Kerala’s Well-managed Covid-19 Fight Threatening to Unravel?” The Economic Times, July 5, 2020. https://economictimes.indiatimes.com/news/politics-and-nation/is-keralas-well- managed-covid-19-fight-threatening-to-unravel/articleshow/76788706.cms.
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How Kerala Mastered the Art of Contact Tracing to Fight COVID-19, Save Lives.” 2020. The New Indian Express, May 21, 2020. https://www.newindianexpress.com/states/kerala/2020/may/21/how-kerala-mastered- the-art-of-contact-tracing-to-fight-covid-19-save-lives-2146294.html.
John, Sarah. 2018. “Unravelling the Paradox of Kerala’s Health Sector: Relevance of Small Private Medical Institutions to Sustain the Health Care System in Kerala.” Accessed May 31, 2020. https://www.cppr.in/wp-content/uploads/CPPR_Unravelling-the-Paradox-of- Kerala%E2%80%99s-Health-Sector-Relevance-of-Small-Private-Medical-Institutions-to- Sustain-the-Health-Care-System-in-Kerala.pdf.
"Kerala joins 11 other States for ration card portability.” 2020. The Hindu, January 1, 2020. https://www.thehindu.com/news/national/kerala/kerala-joins-11-other-states-for- ration-card-portability/article30454006.ece.
"Kerala Government begins Distribution of Free Ration." 2020. Pune Mirror, April 1, 2020. https://punemirror.indiatimes.com/news/india/kerala-government-begins-distribution-of- free-rations/articleshow/74929755.cms.
Kerala Government’s Response to COVID-19 (January 30, 2020-April 22, 2020). https://www.prsindia.org/theprsblog/kerala-government%E2%80%99s-response-covid- 19-january-30-2020-april-22-2020.
Kerala State Planning Board. 2018. “Perspective Plan-2030.” Accessed July 20, 2020. http://testnew.ncaer.org/image/userfiles/file/Kerala%202030/KPP-2030-Vol-4.pdf.
K. S., Mochish. 2020. “Nipah Virus, Kerala Floods, and now COVID-19: Malayalam Media's Coverage of Crises Offers a Model Worth Replicating for Constructive Journalism.” The First Post, April 25, 2020. https://www.firstpost.com/health/nipah-virus-kerala-floods- and-now-covid-19-malayalam-medias-coverage-of-crises-offers-a-model-worth- replicating-for-constructive-journalism-8299751.html.
M., Athira. “Corona Virus: This Team at Kerala Helpline Desk Work Round the Clock in Fight against the Pandemic.” The Hindu, March 13, 2020. https://www.thehindu.com/life-and- style/the-team-at-disha-the-24x7-helpline-desk-in-kerala-works-round-the- clock/article31059935.ece.
Mathew, Ashlin. 2020. “COVID-19: Experts Worry of Community Transfer in Kerala, Govt Denies It.” The National Herald, May 29, 2020. https://www.nationalheraldindia.com/india/covid-19-experts-worry-of-community- transfer-in-kerala-govt-denies-it.
Nair, S. J. 2020. "Local Bodies Collecting Data of Migrant Workers in Kerala.” The Hindu, April 10, 2020. https://www.thehindu.com/news/national/kerala/local-bodies-collecting- data-of-migrant-workers-in-kerala/article31310706.ece.
Nair, Sujith. 2020. "How COVID-19 Steered Kerala on the Path to Food Security." Onmanorama, May 22, 2020. https://www.onmanorama.com/news/columns/straight- talk/2020/05/22/subiksha-keralam-covid-food-security-cpm.html.
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Nileena, M. S. 2020. “How the Kerala Government is Shaping and Implementing its COVID- 19 Response.” The Caravan, March 28, 2020. https://caravanmagazine.in/health/covid- 19-coronavirus-kerala-vijayan-shailaja-healthcare-system.
NITI AAYOG. 2019. “Health States Progressive India-Report on the Ranks of States and Union Territories”
Panikar P. G. K., and Soman C. R. 1984. Health Status of Kerala, the Paradox of Economic Backwardness and Health Development. Trivandrum: Centre for Development Studies, 39.
Philip, Samuel. 2020. "COVID-19 in Kerala: Staying Ahead of the Curve." Newsclick, May 9, 2020. https://www.newsclick.in/COVID-19-Kerala-Highest-Recovery-Rate-Pandemic.
Puthan Purayil, Mufsin, and Sayani Malakar. 2020. “How a Tiny South Indian State Is Using Transmedia Storytelling to Fight COVID-19.” The Diplomat, April 4, 2020. https://thediplomat.com/2020/04/how-a-tiny-south-indian-state-is-using-transmedia- storytelling-to-fight-covid-19/.
Raman Kutty.2000. “Historical Analysis of the Development of Healthcare Facilities in Kerala Stat, India”. Oxford University Press.
Sathyapalan, Harishankar, and Sreeparvathy Gopala Krishna Pillai. 2020. “Combating COVID-19 by Contracting Out Health Data of Keralities: Some Legal Questions.” CPPR. Accessed June 25, 2020. https://www.cppr.in/wp-content/uploads/2020/04/Combating- COVID19-by-Contracting-out-Health-Data-of-Keralites.pdf/.
Sebastein, Shawn. 2020. "COVID-19 Makes Kerala Aim for Food Self-sufficiency." Down To Earth, April 29, 2020. https://www.downtoearth.org.in/news/food/covid-19-makes-kerala- aim-for-food-self-sufficiency-70787.
Vijayanand, S. M. 2020. “Kerala's Management of Covid-19: Key Learnings." Ideas for India, May 2, 2020. https://www.ideasforindia.in/topics/governance/kerala-s- management-of-covid-19-key-learnings.html.
World Health Organization. 2018. “Managing Epidemics: Key Facts about Deadly Diseases.” 34. https://www.who.int/emergencies/diseases/managing-epidemics- interactive.pdf.
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ANNEXURE
Annexure 1: Guideline on State Medical Board
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Annexure 2: Guideline on Virus Surveillance
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Annexure 3: Health Advisory
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Annexure 4: Revised Guideline on Testing, Quarantining
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Annexure 5: Risk Categorisation of Patients
C a t e g o r y Symptoms M a n a g e m e n t G u i d e l i n e s T e s t i n g
Category A Low-grade fever Patients should inform the DISHA helpline. No testing Mild sore throat No need to come to the designated nodal required Cough centres. Patients should remain in strict home isolation. Doctors from the nearby Rhinitis PHC will telephonically monitor the Diarrhoea progress of the patient to assess the development of red flag signs. Junior Public Health Nurse (JPHN)/Junior Health Inspector (JHI) will assess the adequacy of isolation with a checklist. Patients are advised to take the following : Plenty of warm nourishing oral fluids Balanced diet Adequate sleep and rest Saline gargle for sore throat if present
Category B High-grade fever Patients should come to the designated Testing Severe sore throat COVID-19 treatment centres after required Cough informing the DISHA centre. After clinical assessment, a decision will be taken on OR Category A plus one or testing. Patients will be given more of the following: symptomatic treatment including Lung/heart/liver/kidney/ne treatment of other respiratory pathogens urological disease/blood (like H1N1) wherever applicable and will disorders/uncontrolled either be admitted or sent back to home diabetes/ cancer/HIV-AIDS isolation. If the treating hospital decides on home isolation, the DSO of the On long-term steroids corresponding district should be informed Pregnant lady in the prescribed format for ensuring Age > 60 years home isolation. If sent back for home isolation, the doctor from nearby PHC will telephonically monitor the progress of patients and assess development of red flag signs. JPNH/JHI will ensure the adequacy of the isolation using a checklist.
Category C Breathlessness, drowsiness, Patients will be admitted to the Testing chest pain, fall in blood designated COVID-19 treatment centres. required pressure, haemoptysis and cyanosis (red flag signs) Children with ILI (influenza- like infection) with red flag signs Somnolence, high/persistent fever, inability to feed well, convulsions, respiratory distress, etc. Worsening of underlying chronic conditions.
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Annexure 6: Order on Testing Strategy
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Annexure 7: List of Items in the Essential Food Kit Provided by GoK
Food Items Q u a n t i t y
1. Sugar 1kg
2. Tea 250g
3. Beans 1kg
4. Coconut oil 500ml
5. Sunflower oil 1L
6. Atta 1kg
7. Corn flour 1kg
8. Chilly powder 100g
9. Coriander powder 100g
10. Dal 250g
11. Turmeric powder 100g
12. Fenugreek seeds 100g
13. Mustard 100g
14. Urad dal 1kg
15. Chickpeas 1kg
16. Soaps 2no.
Source: "Local Food Systems and COVID-19; A Gl i mpse on Indi a' s Responses. " 2020. Accessed June 18, 2020. http: //www. fao. org/i n-acti on/food-for-ci ti es- programme/news/detai l /en/c/1272232/.
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Annexure 8: Sannadhasena
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Supported by Prepared by Omi dyar Network Indi a Centre for Publ i c Pol i cy Research