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India’s COVID-19 balancing act

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A healthcare worker checks the temperature of a woman using an electronic thermometer during a check up campaign for the coronavirus disease (COVID-19) at a slum area in Mumbai, India 8 July, 2020 (Photo:Reuters/Francis Mascarenhas).

In Brief

India has a federal governance structure where the delivery of healthcare services is primarily the responsibility of state governments. The central government formulated national policies to manage the outbreak of COVID-19, including instituting four consecutive national lockdowns and establishing testing protocols and travel advisories. But the experiences of individual citizens in India is largely a function of local state and district administrative capacities.

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India imposed a stringent national lockdown and banned international travel when the total national case count was below 1000. This is unlike what was observed in Europe and the United States where lockdowns were imposed only after case counts rose significantly. While this decision has been questioned, its practicality is rooted in India’s poor health infrastructure.

Strict physical distancing measures should slow the spread of a virus by limiting contact among people. This provides nations and states with time to bolster health infrastructure and prepare for the eventual surge in demand for hospital facilities. In the last three months, almost every district in India has reported dedicated COVID-19 facilities and every state has built testing laboratories.

The total count of COVID-19 cases is increasing in every state. India as a whole is reporting record daily case numbers with over 888,000 total cases. India is now ranked third globally, only behind the United States and Brazil. There are 644 cases per million people, significantly lower than other hotspot countries. But this figure is steadily rising each day. Approximately 40 per cent of all new cases come from two states of Maharashtra and Tamil Nadu. Delhi’s prevalence rate is more than nine times that of the national rate and similar to that of Italy.

Knowledge of the spread is driven by the extent of testing being carried out across all states. While testing levels have been scaled up significantly across states, the infection remains ahead and this is reflected in the rising test positivity rate. There is tremendous public scrutiny as the level of testing has become a popular proxy for the government’s effort to manage the pandemic. Media reports have focussed on testing and citizens and civil society groups are keenly following the number of daily tests in each state.

There is also significant pressure on state governments due to constant cross-state comparisons, in particular between states under different political parties. Competitive federalism and a democratic governance structure have therefore ensured greater data transparency in India compared to several authoritarian countries. Every state is carrying out more tests and reporting on key variables like total case count, number of active cases, recovered cases and COVID-19-related deaths.

Despite these efforts, limited state capacity in research and data systems has translated into limited knowledge about the virus. India needs granular data on critical variables like the incubation period, serial interval and reproduction rates which are estimated regularly by states. Containment policies must be framed in accordance with these indicators. Knowledge of these indicators is necessary to move away from general lockdowns towards precision lockdowns targeting cities and districts.

Antibody surveys across major cities globally have revealed that the true extent of the virus is much wider than what is picked up by common tests. This is also true for India — confirmed by antibody surveys done by the Indian Council of Medical Research.

COVID-19-related deaths are best analysed as deaths per million people rather than by the case fatality ratio which is limited by the level and accuracy of testing. On 13 July, India was reporting a death rate of 17 per million, which is significantly lower than European countries like the United Kingdom (660) and Italy (578), or the United States (416). There may be under-reporting of deaths in India due to lower testing rates or high incidences of domiciliary deaths in many states with poor health infrastructure, but even then, it is still a fraction of the death rates in global hotspots countries.

A decline in new cases will depend on the effectiveness of the containment strategy within each state. Subsequent lockdowns have made a significant impact on slowing the spread of the virus in the country.

But lockdowns are a blunt policy instrument with substantial opportunity costs. India witnessed a large reverse exodus of migrant labour from its industrial states towards poorer, rural states. After three months, many workers are now ready to return to work. Businesses have been operating at lower capacity for months and future forecasts for the economy predict large contractions. The growing economic burden of the lockdown is pushing against the growing infection rate.

Successful policy intervention at each level of government will require balancing these twin compounding phenomena. In recognition of this grim reality, major economic policy announcements from the central government have focussed on humanitarian support in the form of food grains, cash transfers and health insurance for the bottom quintile of the population. Economic stimulus has targeted the micro, small and medium enterprise sector which employs the majority of Indians outside the agriculture sector. India is bracing itself for a long recovery — from both the virus and the economic slowdown.

Shamika Ravi is an economist based in New Delhi and former member of Prime Minister’s Economic Advisory Council, India.

This article is part of an EAF special feature series on the novel coronavirus crisis and its impact.

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