Containing a pandemic with public actions and public trust: the Kerala story

Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19

BACKGROUND

In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state's health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19.

METHODS

A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30-63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts - transliterated into English-were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

RESULTS

LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services.

CONCLUSION

Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

COVID-19 and Multiple Inequalities The Case of a Coastal Community in Kerala

Despite the overall achievements, Kerala's handling of its first case of community transmission in the coastal village of Poonthura came under severe criticism. In this article, the potential pathways to the resistance raised by the fisherfolk in Poonthura are explored, thereby placing their responses as historically and politically embedded ones.

Analyzing the factors affecting the attitude of public toward lockdown, institutional trust, and civic engagement activities

The early 2020 witnessed Coronavirus disease 2019 (COVID-19) pandemic followed by a nationwide lockdown in the whole history for the first time. The entire world had to go for nationwide lockdown to curb the spread of such contagious and deadly disease. In short, the coronavirus outbreak and the subsequent lockdown had created a storm in the world giving rise to change in public with respect to parameters like trust in the government institutions, civic engagement, and so on. In this raising dilemma, multiple countries have acknowledged the significance of trusting institutions, especially during lockdown. It is also widely accepted that lives of individuals had been undergoing change ever since the spread of COVID-19. Likewise, public's trust in the institutions is directly related to the civic engagement. Civic engagement is commonly understood as a phenomenon that develops a difference in an individual's civic life by combining values, skills, motivation, as well as knowledge. Different forms of civic engagement include national service, volunteering, societal services, and so forth. The main focus of this article is to examine the influence of COVID-19 outbreak on general attitude of the citizens of Malaysia and India, their trust on the governing institutions, and the civic engagement. In other words, this study tries to assess the impact of the pandemic on variables such as attitude toward the lockdown, trust in institutions, and civic engagement. For this, the study adopted cross-sectional community questionnaire survey in two countries-Malaysia and India. The respondents selected for the study was 1437. The respondent's demographics, attitude toward lockdown, trust in institutions, and civic engagement during the lockdown were collected by means of convenience sampling technique. Later the collected data were measured in terms of descriptive statistics and regression analysis. Findings of the study stated that public's trust in the institution can be increased by enhancing the civic activities and implementing policies that govern and build the society.

Pandemic resilient cities: Possibilities of repairing Polish towns and cities during COVID-19 pandemic

Cities, due to population density and the complexity of human interactions, experience specific problems arising from their functioning in the era of the Covid-19 pandemic. Many scientists who publish their findings in contemporary literature agree on the need to shape pandemic resilient cities by making changes to the functional-spatial structure and preparing cities for rapid revitalization [regeneration] in the post-pandemic period. The main objective of the research is to identify the most important problems regarding service infrastructure deficiencies in the nine medium-sized Polish cities selected for research located in the Warsaw agglomeration, which are well connected with Warsaw. The research was based on: analysis of selected GIS spatial data, demographic data from the Polish Central Statistical Office, surveys among residents, on their needs during pandemic constraints. The focus was on three important aspects of development in the era of the pandemic: access to first-need services, access to greenery and active recreation areas, accessibility and transport efficiency problems. The research revealed changes in the way people travel and do their essential shopping, inadequate cycling infrastructure and problems with the availability of essential services close to where they live. The research programme varies, although the diagnosis and the possibility of transforming the functional-spatial structure of the cities studied as typical medium-sized cities in the impact zone of a large centre dominate. The conclusions provide examples of proposals for tactical urbanism planning solutions that could rapidly improve the quality of residence in a low-budget way. Finally, the proposals and guidelines for creating sustainable pandemic resilient cities are described. The article investigates the aspect of urban resilience related to transport, services, relaxation, while using the method of tactical urbanism as a remedy for cities' pandemic problems.

Socioeconomic determinants of COVID-19 in Asian countries: An empirical analysis

The spread of coronavirus disease, 2019, has affected several countries in the world including Asian countries. The occurrences of COVID infections are uneven across countries and the same is determined by socioeconomic situations prevailing in the countries besides the preparedness and management. The paper is an attempt to empirically examine the socioeconomic determinants of the occurrence of COVID in Asian countries considering the data as of June 18, 2020, for 42 Asian countries. A multiple regression analysis in a cross-sectional framework is specified and ordinary least square (OLS) technique with heteroscedasticity corrected robust standard error is employed to obtain regression coefficients. Explanatory variables that are highly collinear have been dropped from the analysis. The findings of the study show a positive significant association of per capita gross national income and net migration with the incidence of total COVID-19 cases and daily new cases. The size of net migration emerged to be a potential factor and positive in determining the total and new cases of COVID. Social capital as measured by voters' turnout ratio (VTR) in order to indicate the people's participation is found to be significant and negative for daily new cases per million population. People's participation has played a very important role in checking the incidence of COVID cases and its spread. In alternate models, countries having high incidence of poverty are also having higher cases of COVID. Though the countries having higher percentage of aged populations are more prone to be affected by the spread of virus, but the sign of the coefficient of this variable for Asian country is not in the expected line. Previous year health expenditure and diabetic prevalence rate are not significant in the analysis. Therefore, people-centric plan and making people more participatory and responsive in adhering to the social distancing norms in public and workplace and adopting preventive measures need to be focused on COVID management strategies. The countries having larger net migration and poverty ratio need to evolve comprehensive and inclusive strategies for testing, tracing, and massive awareness for sanitary practices, social distancing, and following government regulation for management of COVID-19, besides appropriate food security measures and free provision of sanitary kits for vulnerable section.

Connecting the dots: Kerala's use of digital technology during the COVID-19 response

Digital tools are increasingly being applied to support the response to the ongoing COVID-19 pandemic in India and elsewhere globally. This article draws from global frameworks to explore the use of digital tools in the state of Kerala across the domains of communication, surveillance, clinical management, non-clinical support, and core health system readiness and response. Kerala is considered India’s first digital state, with the highest percentage of households with computers (24%) and the internet (51%) in India, 95% mobile phone penetration, 62% smartphone penetration and 75% digital literacy. Kerala has long been a model for the early adoption of digital technology for education and health. As part of the pandemic response, technology has been used across private and public sectors, including law enforcement, health, information technology and education. Efforts have sought to ensure timely access to health information, facilitate access to entitlements, monitor those under quarantine and track contacts, and provide healthcare services though telemedicine. Kerala’s COVID-19 pandemic response showcases the diverse potential of digital technology, the importance of building on a strong health system foundation, the value of collaboration, and the ongoing challenges of data privacy and equity in digital access.

Regional disparity of covid-19 infections: an investigation using state-level Indian data

Using the state-level panel data for India, we establish that Covid infections are clustered in more urbanized, and prosperous states. Poverty lowers cases showing evidence of herd immunity of poor which stands in sharp contrast with the developed part of the world. Our dynamic panel regression results indicate that Covid infections are persistent across states and unlocking has aggravated the infections. We also find that richer and more urbanised states with better health infrastructure and governance perform more tests. The policy lesson from this exercise is that the authorities should monitor immunization and Covid protocols in densely populated urban areas.

Comparison between two different successful approaches to COVID-19 pandemic in India (Dharavi versus Kerala)

Various factors interplay when it comes to successful containment of pandemic. In last one year, we have witnessed various countries formulating and practicing their own unique ways to tackle coronavirus. We have seen the most developed countries failing terribly and unable to slow the COVID-19 spread, but at the same time also endorsed the comparatively less resourceful countries outperforming in terms of reduced disease morbidity and mortality. Current review is about two regions from India (Dharavi and Kerala) who were different in their approach as compared to rest of the country and were able to keep the COVID-19 cases to the minimum.

Relying on serendipity is not enough

The novel coronavirus has caused a global public health crisis, and impacted countries irrespective of their development status. The health system preparedness has varied across countries, necessitating a hard look at how resilient health systems can be built to withstand the onslaught of sudden pandemics and epidemics. India has been grappling with the onslaught of COVID-19 since the last 6 months of the current year, bringing into focus the ability of its health system to withstand the pressures of dealing with such a pandemic. In this context, the paper analyses India's health sector by focusing on infrastructure, personnel, financing and governance, to enable a better understanding of the extent of resilience in India's health system. Using data from the latest household survey on health, the paper also looks at the disease profile of care seekers to illustrate why COVID transmission is likely to be rapid in the country, the potential impact of COVID care on non-COVID care, the groups that are most likely to forego care due to the lockdown and the diversion of resources to COVID care, choice of providers and out-of-pocket expenditure evidenced from such choice. The paper concludes that a country cannot effectively deal with a pandemic and reduce its socioeconomic impact by trying to fix its health system in real time. The lesson from the COVID era would be for India to immediately start with the much delayed health sector reforms, beginning with a substantial jump in public health financing, if impact of future epidemics and pandemics are to be minimised.