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Year : 2020  |  Volume : 64  |  Issue : 6  |  Page : 99-101  

Kerala's response to COVID-19

CEO, Health Systems Transformation Platform, New Delhi, India

Date of Submission04-May-2020
Date of Decision18-May-2020
Date of Acceptance18-May-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Rajeev Sadanandan
Health Systems Transformation Platform, New Delhi - 110 070
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_459_20

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The response of Kerala state to COVID-19, led by the health department, was nested in larger social mobilization. Kerala has developed a strong government health system. Learning from managing the Nipah outbreaks, Kerala took effective prevention measures early. Local governments, actively involved in public health in Kerala, played an active role in controlling the epidemic and in cushioning the impact on the poor. Transparency in information and willingness of the government to take the people into confidence has contributed to enhancing trust in the government. These strengths will stand Kerala in good stead as it prepares to manage the next wave of COVID-19 infections.

Keywords: COVID-19, health systems, Kerala, trust

How to cite this article:
Sadanandan R. Kerala's response to COVID-19. Indian J Public Health 2020;64, Suppl S2:99-101

How to cite this URL:
Sadanandan R. Kerala's response to COVID-19. Indian J Public Health [serial online] 2020 [cited 2023 Mar 25];64, Suppl S2:99-101. Available from:

   Introduction Top

The response of Kerala state to COVID-19, while centered around the health system, involved mobilization of many other sectors. To control a pandemic that uses social activities central to the functioning of the society to spread and is communicated between geographies based on the interaction of their populations, the response had to be broader than the health system to be effective. Since the disease uses core functions of the society to spread, control measures may threaten normal functioning of the society, causing loss and disruption of lives. They can be effectively implemented only when the entire society is co-opted into the response. Part of such collaboration may be achieved by the common threat which persuades citizens to “rally around the flag.” However, for behavior strong enough to withstand the disruption control measures will bring to the society, it has to be based on near-universal understanding and acceptance of the need for such measures, social capital that supports subordination of individual needs to collective good, and trust in the government and reciprocal willingness of the government to take the citizens into confidence. The core element of Kerala's response to COVID is the strong social contract between the people and the state, based on awareness of the population, high social capital, and trust in government.

   Role of the Government Health System Top

The government health system in Kerala has attracted global attention for achieving good health outcomes in spite of poor economic growth.[1] Faced with serious public health threats during two outbreaks of Nipah virus disease ( -emergency- information-risk-assessment/surveillance-and -risk-assessment/nipah-virus-outbreak-in-kerala) and possible epidemics after two floods, the state health system proved its ability to manage shocks, demonstrating its resilience. Health system resilience has been described as “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath.”[2] Such capacity has internal and external dimensions. Internal strength requires that an adequate number of health workers are recruited and trained well, infrastructure and equipment updated, drugs are available, and the safety of health workers ensured. Externally, a health system is strong when it is valued and supported by the community. Both are symbiotic. For many years now, at the national level and in many states, the public health system has been derided as inefficient and of poor quality, starved of funds, and neglected. This has created an underfunded, understaffed, and demoralized government health system. When a demoralized workforce is asked to show commitment in a crisis, when their services have never been adequately valued in the past, their numbers are inadequate and are asked to work without ensuring their safety, quality of care would suffer which would be reflected in case fatality rate. A major lesson from the COVID-19 response is that states that do not nurture the government health system are compromising their capacity to respond to a crisis.

The government health system has always been highly valued in Kerala. Initiated by the princely rulers in the early nineteenth century, nurtured over time by successive governments postindependence (except during brief periods of fiscal stress), kept on their toes by an alert civil society, and actively supported and supervised by the local governments, the government health system in Kerala has grown in strength over time. In 2016, the government reiterated the intention to strengthen the government health system by launching the Aardram mission to transform primary care and to upgrade facilities in government hospitals. More than 5289 posts were added in government hospitals, and substantial improvement of infrastructure and equipment was done. In addition, the government invested INR 2266 crores through a special purpose vehicle for improving government health infrastructure (Government of Kerala, 2020).[3] Initial results are promising: the percentage of persons using government facilities went up from 34% in the 71st round of National Sample Survey Office[4] to 48% in the 75th round.[5]

   Learning from Nipah Virus Disease Top

Two Nipah outbreaks gave Kerala health system valuable training and confidence to handle COVID-19. At the macrolevel, it trained managers to estimate a threat, identify resources in the system that could be repurposed to deal with an emerging crisis, and to use data analytics to manage the crisis. The skills of tracing and tracking, supportive management of highly infective critical patients, analysis of data to determine how the epidemic is progressing, prevention of health-care-associated infections, psychosocial support to persons who are under quarantine or on treatment, working with media to avoid panic, and managing misinformation campaigns were picked up by the system during the first outbreak and rehearsed during the second. Their success gave health system confidence in their ability and made influencers, decision-makers, and the public trust the health system. These have now been augmented by their success in managing the first wave of COVID-19.

Since Kerala has been alive to the threat of disease from any part of the world, due to its expatriate population and dependence of the economy on international tourism, when the epidemic was reported in China and South East Asia, Kerala started preparations for response in the middle of January. Since the epicenters – from Wuhan to Europe to the Middle East – were known, the health department focused on persons traveling from these regions and their contacts. Returnees were met at the airports, examined and put on home quarantine, followed up twice a day through phone calls, if symptomatic removed to isolation in designated COVID hospitals, tested, and if positive moved to COVID wards for management. The number of persons health department had placed in home quarantine went up from 1471 on January 31 to 171,355 on April 4. Thereafter the numbers started declining. Most of the persons who turned positive were from the persons already under observation, thus preventing an uncontrolled community spread. The entire system worked smoothly thanks to the experience of the state in having managed the Nipah virus disease outbreaks.[6]

   Local Governments Top

This would not have been possible by the health system alone. Kerala has successfully integrated the local governments to the public health system.[7] All primary health centers and most of the secondary hospitals are managed by the three-tiered panchayat system or by urban local governments. Ward members head the Village Health, Sanitation and Nutrition Committees which have the multipurpose health workers as convenors and ASHA and Anganwadi workers as members. They have been leading on prevention measures for infectious diseases. Given the salience that health issues enjoy in the state, most of the gram panchayat members consider health as an area to connect with their voters. Conversely, failure to prevent an epidemic also carries an opprobrium with it. Panchayats are used to using their resources for purchase of medicines, hiring additional workforce, and investing in disease prevention activities. So when, on March 20, the Local Self Government Department issued a set of instructions, it was a successor to a long tradition of circulars issued in the past to manage infectious diseases. Ward members and the alert community also played a large part in ensuring compliance to quarantine.

   Social Mobilization and Mitigation Top

The other pillar of the response has been the support for persons affected by prevention measures. COVID-19 brought out the stark inequities in vulnerability to infectious diseases in India. When the lockdown was imposed peremptorily due to failure of the state to effectively trace, track, and quarantine high-risk population, it was the poor, especially migrant labor, who could not stock up essentials, could not reach their families, and could not maintain social distancing, who paid the price. Kerala successfully intervened to mitigate their hardship through a series of measures, including cash transfers, distribution of free rations, loans to women's self-help groups, and distribution of cooked food to the beneficiaries of anganwadis.[8] Local governments also set up community kitchens to ensure that no needy person went hungry and that migrant workers were protected till they could go home. Of the 23,567 camps opened in India for migrant workers, Kerala accounted for 65%. This was made possible through the effort of the local governments, who raised most of the food materials through donation and Kudumbashree, the women's self-group that has managed food supplementation for the needy, including palliative care patients confined to home.

   Transparency and Trust Top

Role of providing information and taking community in trust to control an epidemic has been recognized since the severe acute respiratory syndrome epidemic in 2003.[9] Since most news during an epidemic is bad news, governments have a political incentive to suppress it. As during the Nipah crisis, the Government of Kerala has been providing accurate information every day. The chief minister reviews reports from different departments involved in controlling the epidemic, synthesizes information, and takes decisions on the next steps. He met the media shortly after the meeting for a live press conference every day when the crisis was serious.

This has reinforced the trust of people in the government and made them partners in controlling the disease. Willingness of the government to provide free testing and good quality treatment, low case fatality rate, and the success in controlling the first wave of infection has reinforced this trust. This will be useful in the future as the state believes that they are about to face a bigger threat of infection with the return of expatriates from almost every country in the world, when international flights resume. All the resources of the state described above will be sorely tested if and when the situation becomes serious and the expected spike goes above the surge capacity of the system. Going by history, Kerala will be able to handle the threat.

Financial support and sponsorship


Conflicts of interest

The author was the secretary of the health department when the management of Nipah outbreak mentioned in the paper was handled.

   References Top

Halstead SB, Walsh JA, Warren KS. Good Health at Low Cost. Proceedings of a Conference Held in Bellagio, Italy, Apr 29-May 3, 1985. New York: Rockefeller Foundation; 1985.  Back to cited text no. 1
Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet 2015;385:1910-2.  Back to cited text no. 2
Government of Kerala. KIIFB: Defining the Future. Government of Kerala, Thiruvananthapuram; 2020.  Back to cited text no. 3
National Sample Survey Office. Key Indicators of Social Consumption in India: Health, NSS 71st Round, January – June 2014. Ministry of Statistics and Programme Implementation, Government of India; 2015.  Back to cited text no. 4
National Statistical Office. Key Indicators of Social Consumption in India: Health, NSS 75th Round, July 2017 – June 2018. Ministry of Statistics and Programme Implementation, Government of India; 2019.  Back to cited text no. 5
India under COVID-19 Lockdown. Lancet 2020;395:1315.  Back to cited text no. 6
Elamon J, Franke RW, Ekbal B. Social movements and health: Decentralization of health services: The Kerala People's Campaign. Int J Health Serv 2004;34:681-708.  Back to cited text no. 7
Vijayanand SM. Kerala's Management of Covid-19: Key Learnings. Ideas for India; 2020. Available from: rnance/kerala-s-management-of-co vid-19-key-learnings.html. [Last accessed on 2020 May 04].  Back to cited text no. 8
Huang Y. The SARS epidemic and its aftermath in China: A political perspective. In: Knobler S, Mahmoud A, Lemon S, Mack A, Sivitz L, Oberholtzer K. editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington D.C: National Academies Press; 2004.  Back to cited text no. 9

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