In India, the labor market in the healthcare sector runs in acute supply shortage. The doctor-patient ratio is 1:1248 and there are only 1.5 nurses available per thousand patients. Public health capacity is inadequate and mostly asymmetrically distributed across states. While there are 38.3 government hospitals for a million people in Kerala, there are only 6.8 government hospitals against a million people in Uttar Pradesh.1 This can be a cause of worry, if the coronavirus infection spreads rapidly in states with inadequate and compromised public health infrastructure.
Since health is a state subject under the Constitution of India, how quickly and effectively the battle against Covid-19 will be won will depend on individual state capacity. However, the eradication of the disease from the country will require horizontal and vertical support across states and from the center, respectively, through an efficient and effective utilisation of healthcare workers. To this effect, two changes, inter alia, are essential.
The first: Extensive investment in provision of PPE to all
health workers on priority
Recently, instances of doctors using raincoats and helmets instead of prescribed personal protective equipment while testing and treating Covid-19 patients have been reported.2 Doctors all across the country have raised their concern about shortage of adequate protective equipment in the hospitals. 90 healthcare workers have been tested positive for coronavirus already and are undergoing treatment.3 The urgency in ensuring safety of all healthcare workers can be explained through basic high school math.
A healthcare worker in India works for 12 hours a day, which is their average duration for work under normal circumstances. This number is expected to be higher during the pandemic.
Once a healthcare worker tests positive for coronavirus, he/she will have to spend at least 14 days in quarantine and will be unable to serve on the field.
The probability of a healthcare worker getting infected without adequate protective equipment is likely to be very high, given the highly contagious nature of the disease. Let’s assume this as 0.9.
Then, the expected value of lost doctor duty hours would be 151.2 (0.9*12*14), i.e. 6.3 doctor duty days (151.2/24).
Proper personal protective equipment with headgear, goggles, face mask, gloves and body cover will lower the probability of doctors getting infected. If this is provided, the probability of the doctor getting infected drops to, let’s say, 0.3.
expected value of duty hours lost due to infection will be 50.4 (0.3*12*14)
i.e. 2.1 days. As we can see, provision of high-quality PPE in sufficient
quantity is likely to ensure their safety and at least 4 extra duty days per
If 90 doctors have already tested positive and have been quarantined, this means we are going to lose 15,120 doctor duty hours. Simply explained, at least 630 (15,120/24) doctor days of labor. Furthermore, this number can be higher depending on the degree of infection and the ability of the body to fight it. Extra space capacity for quarantines and hospital beds may need to be acquired too. In some cases, it may cost us the lives of doctors. Given the current situation, this can lead to a crisis as India does not have the bandwidth to lose existing health professionals amid persistent supply shortage in the market.
According to Reuters, India would need 38 million masks and at least 6.2 million PPE kits to fight the global pandemic.4 However, the government is struggling to expand in-house capacity to meet the existing demand because of lack of raw material and insufficient machine capacity amidst import constraints during global lockdown. Given the present resources, India can ramp up its capacity to supply 30 thousand kits per day which will be far below its requirement of 100 thousand kits per day. N95 mask production in the country also remains lower than the required target. Further, 50 thousand out of 170 thousand kits imported from China have failed quality tests at Defense Research and Development Organization (DRDO). In an emergency like this one, the government should purchase the entire domestic produce and adopt channels of effective redistribution. Limited supply will require the government to prioritize the use of N95 masks for those personnel who are at the highest risk of contracting infection. Use of N95 masks should be banned among all individuals except health professionals. The government must enable partnerships with varied textile manufacturers who produce raincoats and other leisure waterproofs as the hot air seam sealing machinery used to stitch these fabrics is the same as used to stitch PPE suits.
Provision of personal protective equipment for healthcare
workers should be the top-most priority of the government. Social and risk
costs associated with non or inadequate provision of PPE are likely to be much
higher than their purchase price. If hospitals are a war field, the safety of
our health professionals with high-quality defense (in this case protective) equipment
will be a prerequisite to win the war. If we keep losing doctor duty days amid
furious spread of infection, the risk of high mortality and slow recovery among
infected patients will also rise due to poor treatment.
relieve final-year junior residents and deploy them on the field with more
freedom and mobility
Incidence of Covid-19 infection in India has coincided with the examination time of nearly 50,000 final-year junior residents. The Medical Council of India has currently authorized institutions to conduct examinations whenever they deem fit but keep the workforce on backup until a new batch of first year students joins.6 The issue here is that not all private institutions are testing and treating patients of Covid-19. Also, all other healthcare services have been suspended as resources are focused on battling with the pandemic. Hence, this subset of healthcare workforce in private institutions is underutilized and sitting on idle capacity in times when there are hospitals across states facing shortage of healthcare staff.
This workforce can be relieved of their home institution
and liberated to work in areas of acute shortage to work as senior
residents, without a formal examination, under two
If the district is not
a hotspot of infection
If the private
institution is not managing Covid-19 patients
All the other final-year residents in private and government institutions, serving on the field must be relieved of their examination and their duty should be considered as a test of their competency. This will shed the additional burden of examinations currently on their shoulders and motivate them to serve with full resilience. Italy scrapped examination of final-year residents to address the shortage of doctors. This brought additional 10,000 doctors on the field to fight Covid-19.7 While India is nowhere close to Italy in the number of cases, a delayed decision can cost India more lives than it otherwise would.
The need of the hour is to set the right incentives for healthcare workers to ensure they don’t shirk. Lack of safety and added mental stress can be detrimental to their duty. Moreover, efficient deployment of doctors and interns will help the country overcome shortage on the field and cope with acute imbalances in healthcare infrastructure across states.
Rhythm Behl is an economist by training with M.Sc. Economics from Gokhale Institute of Politics and Economics, Pune. She has worked for 3 years in the area of data analytics, policy and legislative research and analysis. Rhythm has also worked as a Legislative Assistant to a Member of Parliament (LAMP) fellow for a year. The author is currently a public policy scholar at the Indian School of Public Policy.
2020 has been a year of immense learning for policymakers across the globe. As Covid-19 unfolded, new social, political, healthcare, and economic challenges came to the forefront. W.r.t healthcare challenges, older adults remained disproportionately affected.1 The problems of the old have not received adequate attention in a young country like India. India is home to 134 million older people and by 2026, this number is expected to rise to 173 million.2 The share of people above 60 years of age in India’s population stands at nearly 10% today and is rapidly growing.3 As fertility rates fall and a large proportion of the population ages, policymakers will increasingly face new challenges in terms of delivery of healthcare.
The government of India launched the National Programme for the Health Care of Elderly (NPHCE) in 2010-11.4 The NPHCE recognizes the deficiencies of the primary healthcare system and its inability to meet the long-term care needs of older people. It also recognizes the importance of the availability of care closer to the place of residence for older people given high levels of disability. Nevertheless, the policy limits healthcare provision for older people mainly to the existing healthcare settings. The proposal for home visits by trained healthcare workers is constrained by limited personnel. Besides, the regional diversity in demographics, economics, socio-politics is vast enough to call in question a universal policy solution. This clearly calls for policy debate on how to get effective solutions in place before the health of older adults turns from being a problem to a crisis. A decentralized policy option with an underlying principle of intergenerational solidarity is more likely to be efficient. A rural community-based, women-led, low-cost model, like the ones facilitated by Self-Help Groups (SHGs), can potentially be integrated with long-term healthcare services. We examine the healthcare needs of older people in India through the lens of demography and propose utilizing India’s social capital, in form of Self Help Groups (SHGs), to deliver significant components of healthcare to older adults.
Key demographic trends in relation to healthy ageing in India
The policy challenges of the changing demographic structure of the world vary sharply between regions. For more affluent countries, where the problem of population ageing was detected earlier and social security nets were put in place, the key challenge remains allocation of resources fairly between and within generations. For the rapidly ageing developing regions though, resources are scarcer and institutions have a shorter time frame to adapt to the changing population pyramid. India is a case in point.
“India has traditionally relied on multigenerational families to provide for the needs of older people.”5 Sathyanarayana et al draw attention to the increasing reversal of this trend. Particularly, rural and illiterate elderly women are likely to age alone, raising concerns about policy responses for their welfare.6 Also, analysis of morbidity shows an expansion of morbidity with ageing, starting as early as 45 years of age.
Changing Living Arrangements
The Census (2011) showed that three out of four elderly people reside in rural areas. However, most of the health infrastructure is situated in urban areas.7 This creates a barrier to healthcare access for older adults. Sathyanarayana et al (2014) compared data from two National Family Health Surveys – first (1992-1993) and third (2005-2006). The proportion of single-member older adult households went from 2 percent to 5 percent and two member households with at least one older adult went up from 8 percent to 15 percent. Thus, more older persons are living alone or with a single caregiver. This increase accompanies a reduced proportion of total households with older adult members, which means that a lesser proportion of older people live with their family. The percentage of older adults living alone has gone up from 2.6 to 5 percent; with wide regional disparities. These trends indicate a disintegration of the multigenerational household, the legally obligated care-providers for older people in the country.8 A legal obligation to care falls short of addressing the capacity to care for the family. The care providers of old people are part of the 22.5 percent of the population living on less than 1.90 dollars a day.9 Financial constraints on providing long term care to older adults is significant. Moreover, India’s labour market is predominantly informal. The sector lacks comprehensive social security nets like old-age pensions and job security, which restricts time and finances for care provision. With a high prevalence of unskilled, high physical intensity, low-paying jobs, both the caregiver and the elderly workforce become disadvantaged in the present and the future. This also creates a vicious cycle of poor health and unhealthy ageing. Healthcare policies designed for rural areas, with a specific focus on the marginalized social classes, will thus be more helpful especially given the expansion of morbidity with ageing.
Expansion of morbidity
Arokiasamy and Yadav draw attention to the exceptional rise in the non-communicable disease prevalence in older adults.10 Prina et al (2020) corroborate these findings with their assessment of Disability Free Life Expectancy.11 The lowest estimates for India were 11.5 years in men and 11.7 years in women. “With the concomitant increase in life expectancy at age 60 to 16.7 and 18.9 years for males and females respectively, older adults will thus live longer with chronic diseases”.12 The demographers also highlight early onset of morbidity, soon after 44 years of age.
While developed countries have seen a clear shift from infectious to chronic diseases, India faces a dual burden of disease.13 The pattern is reflected in the older adults’ disease patterns too, with significant morbidity associated with infectious diseases and their sequelae. In the face of high morbidity, questions about availability, affordability, and access to long-term care services for older adults in India beg discussion.
Availability, access, and affordability of healthcare in India
In addition to physical barriers to healthcare access, mobility issues and distance to the healthcare system; older adults in India face significant social barriers. As Dey et al highlight in their study, gender, religion, caste, socioeconomic status, stigma impede access to healthcare for older adults.14 While availability and quality of care vary widely among regions; older people, in general, receive less care commensurate to their level of morbidity even where available. Affordability of healthcare was an additional access barrier. With only 15 percent of the population covered under insurance, resulting in 62 percent expenditure on health coming from out of pocket payments.15 Such over-reliance on out of pocket payments creates impediments for access to quality healthcare, especially for the marginalised sections of communities. Let’s take the health of older women for instance. ‘Feminization of the older population’ is a prevalent phenomenon across the globe. This is more apparent in rural India. The rate of homebound older people is approximately 70 per 1000 persons in India, and even higher for women.16 Despite reporting worse health, older women are less likely to be hospitalized. A patriarchal society, accumulation of malnutrition, and life-long poverty compounded by high morbidity pose challenges to healthy ageing of Indian women.
While many have to continue working in their old age, their incomes remain meagre. One in three elderly people lives below the poverty line, with another one living just above the cut-off of the poverty line.17 Social security in India is inadequate. The state pension scheme is not universal. Even among expected beneficiaries, less than 10 percent receive assistance.18 Moreover, rural to urban migration of youth leaves older parents more vulnerable. As Sinha and Batniji point out, “At times of illness, people on low-incomes in general often respond by foregoing their children’s education, selling limited assets (including those used to make a living), borrowing from informal sources at exorbitant rates, or foregoing medical treatment.”19 An average rural older adult can thus expect to live with higher morbidity and multiple chronic conditions miles away from quality healthcare, which also happens to be out of her budget.
Trends in Policy Response to Ageing in India
India first formulated a National Policy for Older Persons in 1999.20 The NPOP aims to ensure healthcare, financial, and social well-being of older people. It also focuses on the feminization of ageing and the importance of intergenerational solidarity. It puts the onus on individuals and families to ensure “healthy” ageing with minimal state intervention. While the policy document quotes the changing demographic structure to emphasize the importance of population ageing, it fails to look beyond aggregate numbers or take into account major factors which interact with demography and shape the experience of ageing.
The policy attributes challenges of ageing to the breakdown of families. The homogenization of ageing and its challenges forecloses a proper role for the state to take in designing welfare policies. To quote from the policy, “Welfare is intended primarily for the extremely vulnerable elderly who are disabled, infirm, and chronically sick and without any familial support” (NPOP, 1999). The national policy centres on the highly debated idea of successful ageing, putting the onus of care on individuals and extending it to families. The concept of “successful ageing” has been heavily criticized as it fails to account for differences in socioeconomic status and gender disparities, thus decontextualizing individual choices towards “healthy ageing”.21 With the breakdown of multigenerational households and a vicious cycle of poverty, neglect and poor health in old age, this approach of completely relying on families without offering extensive state support seems more and more unfeasible.
With recommendations made in the National Policy on Older Persons (NPOP) as well as the responsibility of the Government under the Maintenance & Welfare of Parents & Senior Citizens Act, new changes were suggested. It stated that older individuals in rural areas and older women require more attention and medical technology needs to be factored into the ageing policy. The suggestions fall short of addressing challenges of the feminization of the older population, and an increasing role of the state. Besides, medical technology and assistive devices have influenced the population ageing much less than the existing gender, regional, income, and class disparities. The National Program for Health Care of the Elderly (NPHCE) is based on the objectives of the National Policy for Older People. Similar biases are thus reflected in the NPHCE model. The NPHCE clearly outlines promoting “healthy” or “active” ageing in a “society for all ages” as its vision. Its specific objectives include easy access to health promotion, disease prevention, and curative and rehabilitative health services for older people. Its proposed strategy includes home health visits, dedicated services for elderly at all levels of the healthcare system, training of healthcare workers, and Information, Education and Communication (IEC). However, there are some serious limitations to the stated objectives.
First, the policy fails to account for existing patterns of healthcare-seeking in rural India where most older people live. As Das et al. identify most of the healthcare in villages is provided by informal, untrained private providers.22 Second, even if the existing healthcare workforce is trained, the urban-rural ratio of health workers remains 3:1 with three doctors in urban areas for each one in a rural area.23 The policy thus fails to address the basic problem of access to healthcare, which is further complicated in the case of older adults as explained previously. Third, if the problem of access is solved, the challenge of affordability remains. The limited budget allocated to healthcare focuses more on maternal and child-care services.24 Households with older adults thus spend 3.8 times more out of their pocket to meet healthcare needs. This spending is catastrophic for poorer elderly households).25 Alternative approaches can thus be explored to deliver healthcare to older people, especially in rural areas. We suggest Self-Help Groups, already existing in rural areas, as possible delivery points of healthcare for older adults.
We base our proposition on harnessing the principle of social capital in rural India, which has been effective in successful microfinance interventions for decades. Self-Help Groups can provide an alternative to deliver parts of the NPHCE in rural areas under the budgetary, social, and geographical constraints. The suggested policy response does not come without limitations, which are also discussed below.
Self-Help Groups for Rural Healthcare Delivery: A Possibility
Microfinance is the provision of capital in the form of small loans, savings opportunities, insurance, and similar products designed explicitly for the poor has been a debated strategy to reduce poverty. The Ministry of Finance supports providing microfinance to self-help groups of older persons so that they can undertake income-generating activities.26 Microfinance programs in several instances have bundled health education or insurance towards better public health and increased profits. No program has tested health promotion or basic healthcare service delivery to older adults through microfinance groups. Self-Help Groups (SHGs) of younger people can be trained and supported for rural healthcare delivery tailored towards older people. Moreover, as Sinha and Batniji point out microfinance is more suited to address basic health and disability care needs; two of the most important healthcare needs of older people.
Haldar and Stiglitz provide a theoretical basis to the debate, experiences, and a way forward for microfinance. The concepts of “social capital” and “institution” are of specific value.27 The economist duo looks at institutions as “emergent and localized reactions to collective action problems”. Designing long term care is heterogeneous and it needs local responses. In this scenario, microfinance can be looked at as a potential opportunity for policymakers. The confidence in the effectiveness of microfinance for successful rural ageing stems from its reliance on “social capital” to be successful. Social capital sees individual well-being “closely related to connectedness, and maintaining the affection and respect of those with whom one is closely connected, as an essential aspect of advancing an individual’s own sense of well-being”. The authors trope that non-reliance on social capital played a major role in the failure of microfinance institutions to help broadly define how microfinance can be utilized for healthy rural ageing. We emphasize on Self-Help Groups as women provide most of the caregiving needs across the world.
Incorporating SHGs in rural ageing is in line with the social trends of a rural area. A strong sense of community, relatively strict divisions between social classes and social capital as described above can ensure effective delivery of healthcare interventions. Lorenzetti et al. state, “The leading microfinance institution Grameen Bank’s preconditions for loaning under microfinance include- all members must be “poor”, live close to one another in the village, have no blood-ties, and be from roughly similar economic conditions.28 Achievement of such homogeneity can help deliver culturally appropriate and accepted healthcare.” For instance, health promotion in older adults is a major focus of the NPHCE.29 Based on the Census (2011), the literacy rate is 39.8 percent for the oldest age cohort. This varied from 22.2 percent in Jammu and Kashmir to 76.9 percent in Kerala. As younger cohorts have higher literacy rates and are embedded in the social fabric of the community, health promotion interventions through SHGs will likely be more effective for older cohorts. Indeed, interactive sessions on HIV/AIDS, prevention of non-communicable diseases, water, and sanitation have been effective through this approach in India, Ghana, and Peru. Sessions for fall prevention, urinary incontinence, and information regarding available social schemes can be accomplished through the SHGs. Thus widening the availability of healthcare for rural older adults.
The largest proportion of healthcare expenditure in India relates to the purchase of drugs. With the expansion of morbidity mostly driven by non-communicable diseases, long-term medical management of the condition is an essential and costly affair for progressively impoverishing rural older adults. Micro-franchise distribution of affordable, essential drugs can address some of these access to healthcare challenges. With the potential to be adapted to each setting and the decentralized nature of microfinance, it can increase the uptake of healthcare in the most marginalized of older adults. Approach to healthcare for older adults has traditionally been “holistic” and “team-based”. The same approach, supported by the principle of social capital in rural communities, can help provide appropriate healthcare to older adults.
Critique of microfinance stems from the evaluation of interventions failing to demonstrate growth in income or gender empowerment. The microfinance crisis in the state of Andhra Pradesh in India,30 where 57 microcredit debtors committed suicide in 2010, is not lost on the writers.31 As Haldar and Stiglitz’s (2014) analysis of the failure of the model of microfinance points out, the flaws can be overcome with adherence to limited profit margins, the essentiality of social capital, and strong vertical and horizontal ties at all levels of the institution. With the Malegam committee’s proposal for a regulation of the microfinance sector, the risks of another crisis can be reduced.32 The essay does not advocate decontextualized use of microfinance; for example, the bundling of health insurance with a separate loan.33 It rather advocates a community-based approach to rural healthy ageing, delivered not by a single healthcare worker under a state-dependent structure, but developed, financed, and led by the community itself. If designed properly, microfinance backed Self-Help Groups may change the healthcare of rural older adults for the better. Especially in current times, given the restrictions to healthcare access and employment opportunities the Covid-19 pandemic has imposed, traditional financing and healthcare setups need the support of non-traditional ones, like microfinance to protect the interests of the most disadvantaged.
Population ageing is a process and will continue to pose a challenge to income security, work and retirement, health, and social care policymaking. This is magnified in the context of ageing in India, which is heavily populated with a predominantly informal economy, near absence of social security, and wide disparities in public health and healthcare systems. With the constraints on the younger population, a more responsive rather than punitive system will likely benefit the ageing population most. With changing family structures, the country needs to expand social security for an ageing population with context-relevant, decentralized measures. Foremost, it is important to collect and analyze good quality data on demography to facilitate policy making. To reverse trends in the expansion of morbidity, the newly introduced healthcare program for older adults needs to redirect its resources where the morbidity lies – in rural, feminized, deprived populations of older adults. Provision of healthcare for healthy rural ageing through Self-Help Groups can be explored as a contextually relevant, decentralized, low-cost option for better health outcomes.
The views expressed in the post are those of the author and in no way reflect those of the ISPP Policy Review or the Indian School of Public Policy. The picture on the header for this article has been clicked by Umesh Jadhav. Other images via open source.
Kowsalya, B. and Sundara Raj, T., (2020) Challenges Of Elderly People In The Covid-19 Pandemic. European Journal of Molecular & Clinical Medicine, 7(03), p.2020.
United Nations Population Fund (2017) ‘Caring for Our Elders: Early Responses’ – India Ageing Report – 2017. UNFPA, New Delhi, India
Rajan, S.I. and Mishra, U.S., (2020) Senior citizens of India: Emerging challenges and concerns. Springer Nature.
Lillypet, Santham.( 2011). 8324324521 Operational Guidelines NPHCE final. Directorate General of Health Services Ministry of Health & Family Welfare Government of India
Arokiasamy, P. and Yadav, S., (2014). Changing age patterns of morbidity vis-à-vis mortality in India. Journal of biosocial science, 46(4), p.462.
Prina, A.M., Wu, Y.T., Kralj, C., Acosta, D., Acosta, I., Guerra, M., Huang, Y., Jotheeswaran, A.T., Jimenez-Velazquez, I.Z., Liu, Z. and Llibre Rodriguez, J.J., (2020) Dependence-and disability-free life expectancy across eight low-and middle-income countries: a 10/66 study. Journal of aging and health, 32(5-6), pp.401-409.
Dey, S., Nambiar, D., Lakshmi, J.K., Sheikh, K. and Reddy, K.S., (2012). Health of the elderly in India: challenges of access and affordability. In Aging in Asia: Findings from new and emerging data initiatives. National Academies Press (US).
Katz, S. and Calasanti, T., (2015) Critical perspectives on successful aging: Does it “appeal more than it illuminates”?. The Gerontologist, 55(1), pp.26-33.
Das, J., Daniels, B., Ashok, M., Shim, E.Y. and Muralidharan, K., (2020). Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy. Social Science & Medicine, p.112799.
Anand, S. and Fan, V., (2016) The Health Workforce in India: Human Resources for Health Observer Series No. 16. Geneva: World Health Organization, p.85.
Ministry of Health and Family Welfare (MOHFW), Government of India. (2009). National Health Accounts India 2004–05.
Mohanty, S.K., Chauhan, R.K., Mazumdar, S. and Srivastava, A., (2014) Out-of-pocket expenditure on health care among elderly and non-elderly households in India. Social indicators research, 115(3), pp.1137-1157.
Seth, S. M., & Mishra, R. (2011). Comparative analysis of encryption algorithms for data communication 1. chapter 5, p.136
Haldar, A. and Stiglitz, J.E., (2014) The Indian microfinance crisis: The role of social capital, the shift to for-profit lending and implications for microfinance theory and practice. New York, NY: Columbia University.
Lorenzetti, L.M., Leatherman, S. and Flax, V.L., (2017). Evaluating the effect of integrated microfinance and health interventions: an updated review of the evidence. Health policy and planning, 32(5), pp.732-756.
Banerjee, A., Duflo, E. and Hornbeck, R., (2014) Bundling health insurance and microfinance in India: There cannot be adverse selection if there is no demand. American Economic Review, 104(5), pp.291-97.
Public administration is a socially embedded process of relationships, dialogue, and action. The field of public administration straddles an academic component and action component, with each one significantly influencing the other. Both components seek to promote the welfare of the people in the larger context of a welfare state. Public administration, as the action arm, is situated firmly in the context of the state and therefore, strongly influenced by its nature and priorities. This has led to various re-inventions of public administration against the backdrop of social ferment and the nature of the state. For example, the new public administration movement rose in the 1960s in the face of American societal turmoil (John F. Kennedy was assassinated in 1962, the USA lost the Vietnam war, Martin Luther King, Jr. was assassinated in 1968). Another example is that of the new public management movement in the 1980s in the face of an inefficient state and creation of global interlinkages. This gives reason for one to believe that the ongoing Covid-19 crisis, being labelled the worst economic crisis since the Great Depression of 1929, will cause major shifts in the nature of the state and by extension the nature of public administration.
Public administration as an academic discipline has traditionally responded to problems in Anglo-American societies. With the USA and Europe, being ravaged due to Covid-19, one can probably expect the following changes in the academic discipline of public administration.
Public Administration to Fix the Broken State
The financial stress being felt by most European countries, such as Italy, and the United States points to the bloated structures that are running huge deficits. The world’s largest economy, America’s budget deficit hit $3.1 trillion because of the coronavirus spending surge. The American state’s inability to rein in the crisis leading to massive costs to human lives points to a broken public administration system. The re-emergence of Neo-Taylorism in this context seems inevitable. The issue is to figure out how to ensure maximum governance with minimum government expenditure.
Re-emergence of the State
The re-emergence of the state or dependence on the state was visible in most democracies, including India. The arrival of Covid-19 saw many private hospitals being ordered to operate and provide Covid-19 tests and treatment at affordable prices by the state. State control, however, was not limited to providing services; it also imposed strict restrictions on movement in order to curb the spread of the virus. On the other hand, the failure of the American state to control the spread of Covid-19 has exposed the hollowness of a minimal, corporate state. Ronald Reagan’s dictum, “Government is not the solution. Government is the problem,” has been challenged by Covid-19. The administration has since intervened to enforce social distancing norms and provide financial support to vulnerable citizens. Distributing Stimulus checks is one such attempt of the State. America’s Internal Revenue Service distributed stimulus checks up to $1200 to millions of Americans. This was an attempt to bring the economy back to life. The results of this experiment could very well herald the next big paradigm of the discipline. Success could lead to an intellectual consensus towards a proactive state that is reminiscent of the New Public Service of yore, with a focus on democratic governance. Failure could lead to a re-emergence of demand for a state that is more efficient and less fiscally profligate. Either way, the consensus would favour a state that has significant responsibility towards serving its citizens rather than trying to satisfy them as consumers.
Re-assertion of Sovereignty and the Associated Role of Bureaucracy
The de-globalization movement has been picking up steam since the mid-2010s. Covid-19 could be the final nail in the coffin for the globalization frenzy that began in the 1990s. This could lead to stronger national boundaries for people as well as the flow of data, Internet Protocol, etc. Global Governance Institutions like the World Trade Organization, World Health Organization, G20, etc. seem to have been rendered ineffective due to the de-globalization rhetoric and evolving geopolitical rivalries. The significance of WTO will further reduce with declining trends in global trade and the US-China trade war. The World Health Organization helped in evolving guidelines at the beginning of the pandemic, however, as time passed countries enacted their own operating procedures. The European experiment is also facing stress as member states choose to assert sovereignty rather than pooling their resources. As per European Council on Foreign Relations data, 29 percent of the respondents (grouped as “Do-It-Yourself”) believed that after the crisis, geopolitics will see greater self-dependence across nations.
This has major implications for the bureaucracy that would have to adapt to new situations. There would include – limits on bureaucratic power in negotiating with other countries; emergence of newer methods of negotiation and diplomacy at global platforms; and restructuring of processes that have so far been outsourced. The result would be a public administration which is greatly influenced by its domestic ecology and an altered politics-administration balance. It must then build capacity across institutions within this fundamentally altered ecology. How would the corridors of power change and the players inhabiting them respond? This will be an interesting development to observe during the approaching distribution of Covid-19 vaccines. The time ahead is truly interesting and one that will put the efficiency of public administration to test.
The views expressed in the post are those of the author and in no way reflect those of the ISPP Policy Review or the Indian School of Public Policy. Images via open source.
The novel coronavirus has devastated global order, placed public healthcare systems under duress, and prompted massive mobilisation of monetary aid and kind. This article is a speculation on the trajectory foreign monetary aid could take for COVID-19 considering the patterns HICs and LMICs have set during another significant global epidemic, Tuberculosis. The article analyses comparable years of state responses to TB with COVID-19 and studies the underlying political considerations behind foreign aid distribution.
In the wake of COVID-19, our global
public discourse and policy execution measures have frantically adopted
“unprecedented” into routine vocabulary. As the virus rapidly pushes globally
interdependent socio-economic systems into isolation, the notion of “public” in
public health is simultaneously evolving. While our pandemic-centric histories
do not deliver frameworks of certainty, they leave us with room to assess
rapid, delayed and continued global action. The manner in which nations choose to
respond to global public crises is a cumulation of their domestic
infrastructure, national security policies, international economic
interdependence and dynamic foreign relations. While these indicators are
similar throughout the world, the values they occupy vary significantly across
different socio-economic profiles. This is not to simply say that COVID-19 is a
virus that hits everyone differently; it is to note that this pandemic’s
consequent externalities will be different, spatially and temporally. For instance,
25th March 2020 marked the day India announced its first nation-wide lockdown
in the fight against COVID-19. To see it antedate yet another World
Tuberculosis Day (24th March) significantly highlighted the material reality of
borders in borderless crises. Owing to the aforementioned differences, foreign
aid is a commonplace policy response that countries adopt in times of any
public health crisis. While it creates enough room to speculate about political
hegemonies and diplomacy, it is almost always viewed as a functionary in
providing immediate relief. In order to better understand the role of
international cooperation and sustained interdependence in crisis mitigation,
this article charts multilateral and bilateral monetary foreign aid delivery
for COVID-19 and Tuberculosis. These trajectories, coupled with geopolitical
paradigm shifts, lay implications for building global and domestic health
crises mitigation capacity.
Tuberculosis and COVID-19: Is a Comparison Warranted?
Comparing TB as it exists today to the Coronavirus would be a futile exercise. Mycobacterium Tuberculosis (TB) was first isolated over a hundred years ago and has evolved to being one of the top 10 infectious diseases of the world. 1,2 It’s average death count since 2016 stands around a staggering 1.5 million lives lost per year. COVID-19, as all-encompassing as it is, has made a considerable yet smaller dent at 3,55,305 deaths worldwide as of the 28th of May 2020.3 Having said that, what is of most merit to our analysis is the noteworthy similarity that ties TB and COVID-19 together, i.e. their initial disease burden on High Income Countries (HICs). This specific context setting allows one to make predictions for future patterns of COVID-19 relief aid.
Additionally, popular literature on epidemiology, civil society organisations and the development sector investments. support the comparison between TB and COVID-19. Therefore, our selection of TB has not been arbitrary. The authors argue that COVID-19 cannot be effectively compared to other pandemics and/or epidemics. The word “unprecedented” drives the picture home. Ebola, a “Public Health Emergency of International Concern,”was felt exceedingly fleetingly around the world as it predominantly made its effects felt in West Africa. Similarly, the Zika fever, another epidemic as recent as 2015, originated in Brazil and spread to only parts of South and North America.4,5However, with both these outbreaks, and others in modern history, our societies have not witnessed the implementation of such lockdown-adjacent policies. Therefore, comparing these epidemics to COVID-19 would not yield any foresight into the behaviour of political economies, foreign relations or prospects of foreign aid.
Charity v/s Policy:
Foreign Aid Relevance
While foreign aid is altruistic and compassionate at face value, it has a deep-rooted history in “hard-headed diplomatic realism” and domestic economic considerations. In diplomacy, foreign aid is an archetypal tool for “soft-power” building.6 Economically speaking, the push for foreign aid began due to the belief that the key to triggering economic growth worldwide was to pump money into factories, public and market infrastructure.
During health crises such as COVID-19, however, foreign aid
takes on an additional short-term objective, i.e. providing ‘worse-off’
countries with immediate funds to bolster their public health capacity and
efficiency of state response. The word ‘additional’ here is of value to our
analysis, this addition is an insurance investment against a probable global
spill-over of mishandling in systems of Low- and Middle-Income Countries
Therefore, it is prudent to study the trajectory of foreign
aid movement as it has a legitimate impact on the LMICs’ capacities to mitigate
crises. A close study of TB-aid highlights how a disease that is largely
curable persists to this day in the LMICs. In the face of COVID-19’s disastrous
uncertainty, this analysis becomes increasingly relevant. The following figure
maps a brief history of noteworthy and aid adjacent events in modern TB
A Brief Analysis of
the Long History of TB-Aid: Establishing Context
Figure 1: Recent Trajectory of Foreign Aid Activities Against the TB Pandemic7
As depicted in Figure 1, despite TB’s long history, it was only declared a health emergency by the WHO in 1993. Notably, it was the first infectious disease to be declared so. TB began its journey in the HICs, ravaging politically significant locations such as New York before tapering out of public discourse in the mid-1990s.8 During that time, the HICs formulated strong initial global and domestic health policy pushes to combat TB. As these policies showed favourable and successful domestic results, the acceleration in case detection moved to the LMICs – primarily driven by India in 2000 and China in 2002. Regardless, only 7 out of 22 High-Burden Countries or HBCs, (countries with the relatively highest absolute values for total estimated TB cases), met their target of 70% reduction by 2005. Simultaneously, the estimated TB case peak, the global reported death burden was still high at 1.6 million people.9 However, notably, the HICSs reported a trend shift in infected persons from nationals to immigrants, or primarily “foreign-born or foreign citizens.”10 As the HICs’ death toll started declining (to a significantly reduced figure of 515 deaths in 2017 in the United States), and 95% of all TB cases shifted to the LMICs, the global political commitment from the HICs fell too. This is particularly alarming because, in our global economies, the pattern of foreign over national infection is a national security threat to the HICs too.
TB’s disease burden shift in the early
2000s, prompted international organisations and co-operations of the LMICs to
improve their TB response and reduce the dependency on aid, technology and
healthcare innovation from the HICs. Seeing how large HIC donors to TB relief,
such as the US or Canada, had rapidly started scaling back on overseas aid
during this time, this was a timely yet prefatory shift in global order. In
particular, the association of Brazil, Russia, India, China and South Africa
(BRICS) started stepping into spaces of research and domestic aid investment.
They accounted for 53% of the available funding in 2019, and 95% of their
funding came from domestic sources.
We must note that it has been established that TB is intricately linked to poor health conditions such as malnutrition, alcoholism, HIV and diabetes – these are afflictions more pervasive in the LMICs than the HICs.11 So, even though the aforementioned global paradigm shift provided the LMICs an opportunity to invest in themselves. Their disease burden is still significantly high and public health capacity is still significantly low. For instance, according to the 2019 Global Tuberculosis Report, India has the highest number of Multi-Drug Resistant TB (MDR-TB).12 This is also evidenced by the fact that by 2009, Asian and African regions constituted 86% of TB cases globally. However, apart from a few emerging economies, such as India or China, international donor funding remains crucial for the other LMICs.13 Therefore, even though focus has been placed on reach and research, quality of treatment remains to be a significant threat.
Despite increased global urgency for TB eradication, between 2015 and 2018, the aggregate reduction in cases was only 11% against the target of 35%.14 Here, it has been accounted that this figure of 11% does not cover unreported cases. What is of immediate consequence to public health in 2020 is the increasing lack of measures to quantify the threat from unexamined deaths during COVID-19.
As global systems prepare their COVID-19 economies, they have begun acknowledging that “post” COVID-19 is a far-off time. Currently, there is no way to assess and factor future COVID-19 treatment, vaccination and immunity failures and accessibility. What is also of immense policy concern to public health officials and civil society members is the rapidly changing status of TB. The threats of increased, unreported and mutated TB cases, and potential loss of progress of decades of investment in TB eradication, during the various COVID-19 “lockdowns,” are increasing. WHO has already estimated a 75% decrease in weekly detection of TB cases in India, the country with the largest global TB burden today.15 While this estimation has alarming conclusions of its own, it massively complicates and weakens India’s domestic COVID-19 mitigation capacities.
The Long Future of
COVID-19: Integrating What we Know
At present, with COVID-19 we see a similar “area of spread” trajectory, origin in Wuhan province spread first to the economically “well-off” countries such as Italy, Spain, Germany, the United States. Currently, the global epicentre has moved to the “worse off” South American region, specifically Brazil, Peru and Chile.16 Its progression to the LMICs has been gradual and has had some degree of forewarning. Both diseases’ propensity to overwhelm national health systems has been analogous: By March 2020, the news had broken that due to coronavirus, Italy had run out of beds in intensive care units in the most hard-hit regions.17 Similar shortages of Personal Protective Equipment (PPE), masks, medicine, ventilators and more were reported all the way from New York to Mumbai.18,19 Likewise, TB at its peaks, hit minority groups with higher incidence and record cases in clusters. It has become evident that low-income areas, even in HICs, have stressed public health systems which follows that during a TB spike, these systems came under more duress.
Evidently, the impact of foreign aid
has alleviated the burden of TB on global public health systems. As we have
just analysed, the HICs rallied together since the 1990s to invest billions in
fighting TB around the world. However, to better understand the future of
COVID-19 relief aid for the LMICs, it is important that we do not misconstrue
systemic efforts and participation of the HICs as solely altruistic in nature.
Patterns of increased global mobility made it imperative for the HICs to view
TB in its global context. COVID-19’s “unknown” vulnerability presents the same
problem to the HICs.
Initial Aid v/s
Sustained Aid: A Problem of Misinterpretations and Predictions
Foreign aid in health is unique when compared to other aid investments as its sole purpose is to associate a better image of the giver countries for the recipient countries. We have repeatedly established that the changing nature of foreign aid activity is a direct consequence of the shift in TB’s disease burden from the HICs to the LMICs. With COVID-19 too, there cannot be a zero-sum debate between investing money locally versus sending aid to foreign countries. This, we can conclude, has been one of the driving forces for why the Trump administration, an administration Figure 1 shows to have significantly tightened its foreign aid purse-strings in 2016, is currently pledging $5.9 million to India; $18 million of Afghanistan; $15 million to Pakistan; and an overall $775 million in emergency health, humanitarian and second wave economic assistance that will assist over 120 countries in combating COVID-19.20
The generosity in foreign aid may also be a reflection of a better understanding of the nature of global pandemics among the HICs – to treat it domestically, they will have to address it internationally. The UN has already warned developed nations that COVID-19 will “circle back around the world” in its second wave if they fail to equip poorer nations in managing the pandemic.21 Multilateral agencies are collectively agreeing that the unstable environments of LMICs are generating higher collateral and human costs. Therefore, in terms of prioritisation, a considerable portion of the aforementioned aid is routed to LMICs. The UK is another HIC leading this effort by allocating nearly $200 million aid solely to developing countries, of a total of $744 million aid given worldwide. The UK is currently one of the biggest donors to combat the global pandemic.
As forecasted by Figure 1, fissures in HICs commitments to foreign aid for COVID-19 mitigation are expected. However, we are noticing a quicker movement toward ‘self-preservation first’ from states like the US. Multiple countries, France, Canada, Brazil, Germany and Barbados, have accused the US of diverting medical supplies to itself by price-gouging.22 The United States has similarly strong-armed India into procurement of experimental medication to treat COVID-19 and then diverted medical supplies en route to India a short week after.23 This instinct for “America First,” that the Trump administration is showing, is symptomatic of the general foreign policy stance this government has taken since 2016. In sharp contrast, previous US administrations were considered leaders in the global relief efforts to combat TB. Apart from monetary foreign aid, the US had extended foreign aid in kind too – the US supported the Government of India’s national TB program by leveraging local experts and extending technical resources as well. It is ironic to note that the official USAID website highlighting said bilateral relationship is titled “Championing a TB-Free India.” The USA’s decision to temporarily withdraw 15% funding from the WHO has also come across as a shock to member countries and is again evidence of the nationalistic and self-serving attitude the United States has taken to combat a global struggle.24 This might also hinder the formation of effective multilateral efforts (such as the Global Fund) which were instrumental in procuring aid and sanctioning projects to curb TB.
Therefore, current geo-politics seem to
predict that the future trajectory of global efforts in combating COVID-19
might indeed observe brief collaboration, akin to what the TB crisis observed
for decades. However, despite the need of the hour, polities might soon devolve
into self-serving interests. While one may want to argue that ‘every country
for themselves’ is a reasonable foreign policy stance to take during an ‘unprecedented’
global pandemic. It is indisputable that much like TB, the second, third, or
even a wavering fourth wave of COVID-19 will impact the entire world (HICs
alike). Furthermore, the manner in which COVID-19 will leave its residual
externalities in the HICs has already started surfacing; global lockdowns of
our interdependent economies have threatened globalisation. Therefore, for an
HIC to justify its spirit of ‘self-preservation’ by measures such as decreasing
foreign aid, is a fundamentally skewed argument. It must be reiterated that a
foreign-aid package is not to be categorised as only an altruistic handout to
the LMICs, it is as much for an HIC’s political interests, economic
interdependence and mitigation of public health crises. Public health crises
are not just a problem of today. How well the HICs include the LMICSs in their
foreign aid packages will directly affect years of established global supply
chains and the current achieved level of free movement of labour in the world.
COVID-19 is Atypical
We must revisit the word
“unprecedented” at this juncture in our analysis. As comparable global reaction
to TB has been to COVID-19, we have never witnessed such a state of global
arrest and lockdown. Therefore, any speculation is incomplete without that factoring.
Contrasting to TB though, the geopolitical situation of the world is
unquestionably different than the late 90s and early 2000s. Therefore, the US’s
populist and self-serving stance may hinder global unity in combating COVID-19.
Although, multilateral blocs (that came into action much later during the TB
epidemic) have been quicker to engage and collaborate during COVID-19.
With the LMICs learning from the outlined historic foreign aid trajectory, their resistance to the US’s global withdrawal has been better. The South Asian Association for Regional Cooperation (SAARC) member nations met in the early-stages of COVID-19 to formulate a joint-strategy to mitigate the effects of coronavirus in the region.25 The group formed an emergency corpus where almost all member countries pledged millions, agreed to share rapid-response teams during critical moments and initiated open-channels of communication on technical and medical resources. The Shanghai Cooperation Organisation (SCO) is another important regional bloc where India, Russia and China consolidated the region’s efforts for a collective fight against the virus. There was also some outcry on the US’s “bullying” role which reiterates our argued paradigm shift in geopolitics.26 Here, it is imperative that we note that this is not to say all HICs are allowing their foreign policies to adopt an ‘escapist’ and ‘self-serving’ strategy. One may argue that the current shift partly owes itself to global economic deficits. However, it also owes itself to the manner in which countries are responding to the Eastern ‘origin’ of the disease. This behavioural assessment has weakened the credibility of multilateral organisations that played a significant role in facilitating TB aid, namely the WHO.
Lastly, we have also been able to observe that individual economies of the BRICS countries are managing COVID-19 significantly better than they handled TB. Their initiatives are amplified and backed by more robust economies and medical infrastructure. Vietnam, an LMIC and a country considered highly vulnerable to the pandemic due to its border with China, has been commended by the World Bank on its efforts against COVID-19.27 It is too soon to say whether this is a product of limited dependence on the HICs or a consequence of Western and Eastern ‘political split.’ However, it can be said with surety that the LMICs will need more inclusionary packages of foreign aid for sustained mitigation.
We have iterated that the extension of foreign aid by the HICs to the LMICs leads to an increase in independence of domestic control and global eradication. The former’s economies cannot discount the role of the latter’s labour, capital and market contributions. What our system can hope to learn from the drawn TB trajectory is an increased understanding of global communities. Additionally, especially for the LMICs, domestic development sectors must use this time to address trust-deficits and consequently maximise their impact. As the world acknowledges that increasing MDR-TB cases coupled with the uncertainty around COVID-19 is one of our most pressing ‘wicked problems,’ our response cannot be temporally or spatially delimited.28 Collaboration has always been a preferred conclusion in public policy discourse and literature.
 Alagna, Riccardo, Giorgio Besozzi, Luigi Ruffo Codecasa, Andrea Gori,
Giovanni Battista Migliori, Mario Raviglione, and Daniela Maria Cirillo.
“Celebrating TB Day at the Time of COVID-19.” European Respiratory Journal,
 Note: Strong evidence for control of and progression to active TB from “clinical
trials is lacking particularly for indigenous populations and people under the
following circumstances: diabetes, harmful use of alcohol, tobacco smoking,
underweight, silica exposure, on steroid treatment, rheumatological diseases,
Guidelines on Tuberculosis: Tuberculosis Preventive Treatment.” World Health
Organization. Accessed May 16, 2020. https://apps.who.int/iris/bitstream/handle/10665/331170/9789240001503-eng.pdf
 Note: “A
wicked problem is a social or cultural problem that is difficult or impossible
to solve for as many as four reasons: incomplete or contradictory knowledge,
the number of people and opinions involved, the large economic burden, and the
interconnected nature of these problems with other problems.”
Kolko, Jon. “Wicked Problems: Problems Worth Solving
(SSIR).” by Jon Kolko, March 6, 2012. https://ssir.org/books/excerpts/entry/wicked_problems_problems_worth_solving.