Health is a state subject, but the reins of India’s Covid battle have been with Centre since Day One. However, Centre says all decisions were made in consultation with states and UTs.
India, it is often said, lives in many centuries. It often appears to be many different countries, too, and at no point has this been more stark than in the past 16 months during India’s battle against Covid-19.
On 1 April 2020, for example, just 211 of the 750-odd districts in the country had Covid-19 cases. Currently, 10 states/union territories — Maharashtra, Uttar Pradesh, Chhattisgarh, Delhi, Karnataka, Tamil Nadu, Madhya Pradesh, Gujarat, Rajasthan and Kerala — account for 80.80 per cent of new cases.
Even so, much of India’s response to the pandemic — from the vaccination drive to the Covid lockdown last year — has followed a one-size-fits-all approach.
The eligibility guidelines for vaccination are the same in Maharashtra, which has been leading the Covid surge in the new wave, as in Arunachal Pradesh, where all of 10 cases were reported on 14 April.
So was the case during the lockdown. At a time when the 500-odd infections were restricted to less than 50 districts, the entire country was put under a two-month complete lockdown. In the later stages, states/UTs were allowed some legroom to fine-tune the restrictions, but a nationwide bar continued in a few arenas, like public places of worship, metro trains, cinema halls and malls, among others. States/UTs were allowed more agency during Unlock.
The insistence on contact-tracing 30 people per infection — when there are 1,60,000-plus cases every day (daily cases breached the 2-lakh mark Thursday), with huge variations between states/UTs — is another example.
Experts say India’s propensity to use the entire nation as the drawing board instead of adopting solutions tailored to individual states/UTs is among the factors that has spoilt its pandemic report card. Even among government insiders, the “top-down approach” is seen as a serious problem.
While health is a state subject, the reins of India’s Covid battle have been controlled by the central government since Day One. However, the central government has time and again clarified that all decisions with respect to the pandemic have only been made in consultation with states and UTs.
ThePrint reached the Union Ministry of Health and Family Welfare for a comment but there was no response by the time of publishing this report.
Top-down approach in vaccinations
Ever since the first two Covid-19 vaccines were approved for use in January 2021, India’s vaccination programme has been a tightly controlled affair with all the switches in the hands of the central government.
States have been barred from striking deals with vaccine companies, and have to wait for supplies from the central government, based on criteria decided by the latter. They cannot decide whom to vaccinate either — throughout the immunisation drive, the central government has set the eligibility criteria.
Starting with health and frontline workers (16 January), the drive was expanded to the elderly and those aged above 45 with comorbidities (1 March), and eventually to everyone aged 45 and above (1 April).
There have been suggestions for door-to-door vaccination from Delhi and Maharashtra, but they were shot down.
Uttarakhand has been an exception in announcing vaccination for journalists by classifying them as frontline workers, and so has Ludhiana in Punjab, which has extended the definition to include teachers, bankers, judges as well as journalists.
The central government has been sending vaccines to states/UTs based on their eligible population, without taking into account their individual disease burden, say officials in the know of the vaccine allocation process. At the same time, through multiple communications to states/UTs, it has been asking them to prioritise vaccination in the worst-hit districts.
In a letter to Maharashtra on 15 March, Union Health Secretary Rajesh Bhushan wrote: “You are kindly requested to direct the concerned officials to undertake necessary action for increasing the pace of Covid-19 vaccination in the districts showing rising trend of Covid-19 cases as one of the interventions aimed at containment of pandemic.”
On its part, the government has defended its approach by saying its priority is to reduce mortality among the people deemed most vulnerable.
In a scathing statement last week, Union Health Minister Dr Harsh Vardhan sought to call out opposition-ruled states on their allegations of vaccine shortage.
The Government of India, he said, “has been frequently and transparently updating all the state governments about the demand-supply dynamics and the resultant vaccination strategy that has been adopted”.
“In fact, the vaccination strategy has been drawn up after extensive deliberations and consultations in partnership with all state governments. The same has also been a matter of public record for several months now. Nonetheless, it bears repeating that the primary aim of vaccination is to reduce mortality among the most vulnerable people, and enable the society to beat the pandemic,” he added.
The letter made no mention of the disease burden being taken into account while deciding on allocations.
“It is also to be noted that vaccination is completely free of cost for anyone getting vaccinated in government medical facilities. So long as the supply of vaccines remains limited, there is no option but to prioritise,” he added. “This is also the established practice around the world, and is well known to all state governments.”
The norm, Bhushan said at a Covid briefing this week, is to give big states vaccine supplies for 3-4 days at one go and smaller ones for about a week. But, say state government officials, the supplies are way too meagre and have to be replenished so often that it is a logistical nightmare.
Chhattisgarh Health Minister T.S. Singh Deo told ThePrint last week: “This restricted supply line also means that every day from the districts one van has to go to collect the vaccines. We have told the Union health minister that if that’s what is needed, we will do it, but give us a plan so that we do not get to a point where people come to get the shot and are told we have run out.”
Centre wants 30 contacts traced per positive case
In multiple meetings and communications with states/UTs, the Union Ministry of Health has emphasised the need to trace 30 contacts per Covid patient in order to bring the pandemic under control.
The blanket instruction has left epidemiologists even within the government system flummoxed. It seems easy enough to implement in Nagaland, where 13 new cases were reported on 14 April, or even Goa, with 473 new cases on the same date (according to the Covid-19India.org dashboard). But in Delhi, which reported over 17,000 cases on 14 April and Maharashtra, with 58,952 new infections that day, it is seen as a tall order to say the least.
“There is a time for everything. There is a time for contact tracing and there is a time for mitigation. Do you think it is possible to trace 30 contacts every day for 1,60,000 plus cases?” said a senior epidemiologist in the central government.
“Leave that aside. Just take Delhi. Even at 10,000 cases per day, that means 3 lakh per day. So, for a 15-day period, which is the time these people need to be under surveillance, that is 45 lakh people. Do you think the state has that kind of resources? It is the states who are reporting a few hundred cases may be, where contact tracing would work,” the epidemiologist added.
Asked why the instructions went out despite clear reservations from domain experts, the official said: “It is a collective decision-making process.”
According to the official, it is the time for specific localised interventions.
Another count on which the government’s Covid strategy has come into question is the directive to maintain a 70:30 ratio of RT-PCR tests, whose results take up to a day, and rapid antigen tests, which can give results in a matter of minutes but are less reliable because of their potential to yield false negatives.
“Does it make sense in a surge state? It does not because the immediate need is to contain the infection — what is the point if, during the waiting period for the RT-PCR result, a person continues to spread the disease? Also, on what basis are you giving this instruction? Tamil Nadu has been doing almost 100 per cent RT-PCR and yet it is one of the states of concern,” the official said.
When the clock struck midnight on 24 March 2020, all of India went into lockdown. Described as the strictest lockdown in the world, it saw all office work either suspended or moved online. Migrant labourers rendered jobless were forced to return to their villagers, lakhs of them on foot, and almost all commercial establishments were shut down except those catering to food, medicine and other essential services.
The impact on the economy was acute. There were multiple reports of job losses and pay cuts, and hurdles in education as classes moved online even for those without the requisite access to gadgets and the internet.
The single-stroke lockdown meant that districts with no trace of Covid at the time also went through the same economic hardships as those that had the disease and for the same duration. As a result, when the disease eventually reached those districts and numbers started skyrocketing, the legroom for announcing another such measure had shrunk.
In retrospect, experts say, the government should have opted against such an all-round lockdown.
“In retrospect, I felt that, instead of the countrywide lockdown announced on 24 March, localised lockdowns would have been much better. The rural areas, eastern India, with the exception of Kolkata, the northeast, were all relatively untouched by the virus,” said Dr K. Srinath Reddy, president of the Public Health Foundation of India and Adjunct Professor of Epidemiology at Harvard School of Public Health.
“The lockdown should have been announced in the affected cities and staggered. It is possible that media reports about the state of Europe etc, the images of dead bodies piling up, made the magnitude of the problem in the Indian context seem bigger than it actually was,” he added.
“It seemed we were headed for a catastrophe and that could have triggered the announcement, he said. “This is hindsight that we cannot use to judge the actions of a year ago.”
A former civil servant who was an important cog in the government’s Covid-19 management wheel in 2020 concedes that the idea of a nationwide lockdown does seem slightly incongruous with the spread of the disease then.
“In hindsight, you can debate that more than 60 per cent of the states were free of the virus and it was too generic a response… the problem perhaps is that when the thought process is so driven by a single nucleus, rationality weakens,” the former civil servant said.
“There was also panic at that point and may be even a genuine belief that we can stop it with a lockdown. Or else who would like to take this chance.”
Anand Krishnan, professor of community medicine at AIIMS, noted that “it has been said time and again that management of the pandemic needs a more decentralised approach”.
“There is too much centralisation. Traditionally, our localised units of administration are districts but the capacity to think and plan is low at that level. They are primarily implementers,” he added. “But that is not good enough. The bureaucratic approach of trying to devolve an across-the-board solution is not the way forward. Guidelines need to be customised.”