What the Tuberculosis Foreign Aid Trajectory Tells Us about COVID-19: An Analysis

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.4,5 However, 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 (LMICs).

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 history.

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.

Works Cited:

[1] Saleem, Amer, and Mohammed Azher. “Https://Www.bjmp.org/Content/next-Pandemic-Tuberculosis-Oldest-Disease-Mankind-Rising-One-More-Time.” British Journal of Medical Practioners 6, no. 2 (June 2013). https://www.bjmp.org/files/2013-6-2/bjmp-2013-6-2-a615.pdf.

[2] “Tuberculosis (TB).” World Health Organization. World Health Organization, March 24, 2020. https://www.who.int/news-room/fact-sheets/detail/tuberculosis.

[3] “Coronavirus Death Toll.” Worldometer. Accessed May 28, 2020. https://www.worldometers.info/coronavirus/coronavirus-death-toll/.

[4] Van-Tam, Jonathan; Sellwood, Chloe (2010). Introduction to Pandemic Influenza. Wallingford, Oxford: CABI. ISBN 978-1-84593-625-9. Accessed May 26, 2020.

[5] “Zika Map – Virus & Contagious Disease Surveillance”. HealthMap. Archived from the original on August 21, 2016. Accessed 26 May, 2020.

[6] Dan Banik, Nikolai Hegertun. “Analysis | Why Do Nations Invest in International Aid? Ask Norway. And China.” The Washington Post. WP Company, October 27, 2017. https://www.washingtonpost.com/news/monkey-cage/wp/2017/10/27/why-do-nations-invest-in-international-aid-ask-norway-and-china/.

[7] Collective Figure References:
“Tuberculosis (TB).” World Health Organization. World Health Organization, March 24, 2020. https://www.who.int/news-room/fact-sheets/detail/tuberculosis.

Worland, Justin. “5 Scariest Health Issues In 1900.” Time. Time, August 8, 2014. https://time.com/3086432/scariest-health-issues-1900/.

“Ending TB in India: U.S.-India Partnership: Fact Sheet: India.” U.S. Agency for International Development, November 18, 2015. https://www.usaid.gov/india/fact-sheets/ending-tb-india-us-india-partnership.

“Ending TB in India: U.S.-India Partnership – U.S. Agency …,” June 27, 2019. https://www.usaid.gov/india/fact-sheets/ending-tb-india-us-india-partnership.

Edwards, Sophie. “Ukraine’s Fight against TB Is at Risk from USAID Cuts.” Devex. Devex, June 6, 2017. https://www.devex.com/news/ukraine-s-fight-against-tb-is-at-risk-from-usaid-cuts-90425.

Igoe, Michael, and Adva Saldinger. “What Trump’s Budget Request Says about US Aid.” Devex. Devex, May 23, 2017. https://www.devex.com/news/what-trump-s-budget-request-says-about-us-aid-90342.

WHO Global Tuberculosis Report Executive Summary 2020.” World Health Organization. Accessed May 16, 2020. https://www.who.int/tb/publications/global_report/tb19_Exec_Sum_12Nov2019.pdf.

Schocken, Celina. “Overview of the Global Fund to Fight AIDS, Tuberculosis and Malaria.” Center For Global Development. Accessed May 16, 2020. https://www.cgdev.org/page/overview-global-fund-fight-aids-tuberculosis-and-malaria.

“Tuberculosis Mortality Nearly Halved since 1990.” World Health Organization. World Health Organization, October 28, 2015. https://www.who.int/news-room/detail/28-10-2015-tuberculosis-mortality-nearly-halved-since-1990.

Pai, Madhukar. “Time for High-Burden Countries to Lead the Tuberculosis Research Agenda.” PLOS Medicine. Public Library of Science, March 23, 2018. https://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1002544.

[8] 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, 2020. https://doi.org/10.1183/13993003.00650-2020.

[9] Watt, Catherine J, S Mehran Hosseini, Knut Lonnroth, Brian G Williams, and Christopher Dye. “The Global Epidemiology of Tuberculosis.” ResearchGate, December 2019. https://doi.org/10.1016/B978-1-4160-3988-4.00003-2.

[10] Ibid.

[11] 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, and cancer.”
“WHO Consolidated 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

[12] Yadavar, Swagata. “More Than Half Of India’s Drug-Resistant TB Cases Remain Undetected.” IndiaSpend, October 23, 2019. https://www.indiaspend.com/more-than-half-of-indias-drug-resistant-tb-cases-remain-undetected/.

[13] Note: The spread of reduction % was primarily a measure of rates in WHO adopted regions of Europe and Africa.
“WHO Global Tuberculosis Report Executive Summary 2020.” World Health Organization. Accessed May 16, 2020. https://www.who.int/tb/publications/global_report/tb19_Exec_Sum_12Nov2019.pdf.

[14] Ibid.

[15] Dutta, Sumi Sukanya. “TB Case Detection in India down by 75 per Cent during Lockdown, Could Lead to Major Spike: WHO.” The New Indian Express. The New Indian Express, May 5, 2020. https://www.newindianexpress.com/nation/2020/may/05/tb-case-detection-in-india-down-by-75-per-cent-during-lockdown-could-lead-to-major-spike-who-2139577.html.

[16] “Photos: South America Is the New COVID-19 Epicentre; Brazil Worst Hit.” Hindustan Times, May 26, 2020. https://www.hindustantimes.com/photos/world-news/photos-south-america-is-the-new-covid-19-epicentre-brazil-worst-hit/photo-IoILzieL00XXxTHbGbMBuJ.html.

[17] Tondo, Lorenzo. “Italian Hospitals Short of Beds as Coronavirus Death Toll Jumps.” The Guardian. Guardian News and Media, March 9, 2020. https://www.theguardian.com/world/2020/mar/09/italian-hospitals-short-beds-coronavirus-death-toll-jumps.

[18] “Coronavirus: New York Warns of Major Medical Shortages in 10 Days.” BBC News. BBC, March 23, 2020. https://www.bbc.com/news/world-us-canada-51998429.

[19] “Coronavirus: Mumbai Hospitals Face Bed, Medical Personnel Shortage as Cases Rise.” Business Today, May 6, 2020. https://www.businesstoday.in/current/economy-politics/coronavirus-mumbai-hospitals-face-bed-medical-personnel-shortage-as-cases-rise/story/403016.html.

[20] “Coronavirus: U.S. Commits over $775 Million to Help Other Countries Fight Virus: U.S. State Dept.” The Hindu. The Hindu, May 2, 2020. https://www.thehindu.com/news/international/coronavirus-us-commits-over-usd-775-million-to-help-other-countries-fight-virus-us-state-dept/article31489355.ece.

[21] “COVID-19: UN and Partners Launch $6.7 Billion Appeal for Vulnerable Countries.” The Economic Times. Economic Times, May 8, 2020. https://economictimes.indiatimes.com/news/international/business/covid-19-un-and-partners-launch-6-7-billion-appeal-for-vulnerable-countries/articleshow/75618414.cms?from=mdr.

[22] Ankel, Sophia. “At Least 5 Countries – Including a Poor Caribbean Island – Are Accusing the US of Blocking or Taking Medical Equipment They Need to Fight the Coronavirus.” Business Insider India, April 7, 2020. Accessed May 15, 2020. https://www.businessinsider.in/politics/news/at-least-5-countries-including-a-poor-caribbean-island-are-accusing-the-us-of-blocking-or-taking-medical-equipment-they-need-to-fight-the-coronavirus/articleshow/75027113.cms

[23] “COVID-19: Rapid Test Kits from China Meant for Tamil Nadu Diverted to US.” The New Indian Express, April 12, 2020. Accessed May 12, 2020. https://www.newindianexpress.com/states/tamil-nadu/2020/apr/12/covid-19-rapid-test-kits-from-china-meant-for-tamil-nadu-diverted-to-us-2128949.html.

[24] Al Jazeera. “World Reacts to Trump Withdrawing WHO Funding.” USA News | Al Jazeera. Al Jazeera, April 15, 2020. Accessed May 17, 2020. https://www.aljazeera.com/news/2020/04/world-reacts-trump-withdrawing-funding-200415061612025.html.

[25] Desk, India Today Web. “PM Modi Leads SAARC Meet, Member Nations Start Work on Regional Strategy to Tackle Coronavirus: 10 Takeaways.” India Today, March 15, 2020. Accessed May 27, 2020. https://www.indiatoday.in/india/story/pm-modi-leads-saarc-meet-member-nations-start-work-on-regional-strategy-to-tackle-coronavirus-10-takeaways-1655837-2020-03-16.

[26] The Wire Staff. “SCO Meet on COVID-19: Russia, China Raise US ‘Bullying’, India Flags Terrorism.” The Wire, May 14, 2020. Accessed May 24, 2020. https://thewire.in/diplomacy/sco-meet-covid-19-india-russia-china.

[27] Le, Sang Minh. “Containing the Coronavirus (COVID-19): Lessons from Vietnam.” World Bank Blogs (blog). World Bank Group, April 30, 2020. Accessed May 10, 2020. https://blogs.worldbank.org/health/containing-coronavirus-covid-19-lessons-vietnam.

[28] 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.

Download White Paper

Inline Feedbacks
View all comments
Related Articles


​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.


  1. 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.
  1. United Nations Population Fund (2017) ‘Caring for Our Elders: Early Responses’ – India Ageing Report – 2017. UNFPA, New Delhi, India
  1. Rajan, S.I. and Mishra, U.S., (2020) Senior citizens of India: Emerging challenges and concerns. Springer Nature.
  1. Lillypet, Santham.( 2011). 8324324521 Operational Guidelines NPHCE final. Directorate General of Health Services Ministry of Health & Family Welfare Government of India
  1. Mahapatro, S., Singh, P., & Acharya, A. (2020). The health of India’s older population: do living arrangements matter? | Emerald Insight. Retrieved 1 December 2020, from  https://www.emerald.com/insight/content/doi/10.1108/WWOP-10-2016-0031/full/html
  1. Sathyanarayana, K.M., Kumar, S. and James, K.S., (2014). Living arrangements of elderly in India: policy and programmatic implications. Population Ageing in India, 14(74).
  1. Census (2011), Primary Census Abstracts, Registrar General of India, Ministry of Home Affairs, Government of India, Available at: http://www.censusindia.gov. in/2011census/PCA/pca_highlights/pe_data.
  1. Ministry of Law and Justice (2017). The Maintenance and Welfare of Parents and Senior Citizens Act. Government of India. 
  1. World Development Indicators (WDI)(2013) Data Catalog. World Bank.org. from https://datacatalog.worldbank.org/dataset/world-development-indicators.
  1. 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.
  1. 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.
  1. Dutta, S. (2020). Inderscience Publishers – linking academia, business and industry through research. Retrieved 1 December 2020, from http://www.inderscience.com/offer.php?id=106936
  1. Sarukhan, A. (2017). The Epidemiological Transition (or What We Died, Die and Will Die From) – Blog. ISGlobal., from https://www.isglobal.org/en/healthisglobal/-/custom-blog-portlet/la-transicion-epidemiologica-o-de-que-moriamos-morimos-y-moriremos-/3098670/0.
  1. 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). 
  1. World Health Organization. (‎2020)‎. Global spending on health 2020: weathering the storm. World Health Organization. https://apps.who.int/iris/handle/10665/337859. License: CC BY-NC-SA 3.0 IGO
  1. 25 30 Rajan, I.S. and Mishra, U.S., (2011) The national policy for older persons: Critical issues in implementation. New Delhi.
  1. Srivastava A., Mohanty A. ( 2012) Poverty Among Elderly in India, Social Indicators Research 109(3) December 2012 DOI: 10.1007/s11205-011-9913-7
  1. Garroway  C.,(2013) ’How much do small old age pensions and widow’s pensions help the poor in India?’Year: 2013 Published by: UNESCAP
  1. Sinha, S.R. and Batniji, R., (2010). Protecting health: thinking small. Bulletin of the World Health Organization, 88, pp.713-715.
  1. MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT (1999)’National Policy for Older Persons’ Year 1999 GOVERNMENT OF INDIA http://socialjustice.nic.in/writereaddata/UploadFile/National%20Policy%20for%20Older%20Persons%20Year%201999.pdf
  1. 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.
  1. 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.
  1. 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.
  1. Ministry of Health and Family Welfare (MOHFW), Government of India. (2009). National Health Accounts India 2004–05.
  1. 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.
  1. Seth, S. M., & Mishra, R. (2011). Comparative analysis of encryption algorithms for data communication 1. chapter 5, p.136
  1. 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.
  1. 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.
  1. National Programme for Health Care of the Elderly (NPHCE) (2020). | National Health Portal Of India. https://www.nhp.gov.in/national-program-of-health-care-for-the-elderly-
  1. Mader, P., (2013). Rise and fall of microfinance in India: The Andhra Pradesh crisis in perspective. Strategic Change, 22(1-2), pp.47-66.
  1. Dutt, N. (2010, November 9). India’s loan arrangers hit by crisis. BBC. https://www.bbc.com/news/business-11711617
  1. Malegam Y.H.,Birla K.M, Chakrabarty K C.,Rajagopalan S., Rao U., Sharma V., (2011). Report of the Sub-Committee of the Central Board of Directors of Reserve Bank of India to Study Issues and Concerns in the MFI Sector. Mumbai: RESERVE BANK OF INDIA January 2011. Retrieved from https://rbidocs.rbi.org.in/rdocs/PublicationReport/Pdfs/YHMR190111.pdf
  1. 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.

May 13, 2020
Are the Indian regulations and legislative frameworks equipped to combat the COVID-19 crisis? This article locates the responsive measures to COVID-19 in India in its two central legislations and analyses the gaps in regulations that renders the response to the pandemic non-democratic and inadequate. Alok Arunam proposes to drive a shift in the notion and understanding of security from a macro to a micro perspective, rooted in the security of individuals and communities


Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down or our heads from a blue sky.” 

– Albert Camus (The Plague, 1948)

The world today is grappling with global COVID-19 public health emergency and its social, economic and political ramifications.   There have been 33.86 lakh confirmed cases and 2.4 lakh fatalities in 187 countries/regions till today.1 The world has never before seen a pandemic sparked by the coronavirus.2 These are hard times that necessitate ‘urgent and aggressive action’ on part of individuals, communities, organizations and governments to prevent and limit the spread of infection and control the epidemic. Several countries including India have implemented stringent measures like travel restrictions, self-quarantines, closing schools/colleges, lockdowns to prevent the transmission at the community level. Essentially, they have adopted what is called the “Social Distancing measures” as a way to reduce the spread of the virus. Social Distancing- physical distancing- measures, as argued by experts, are essentially to ‘flatten the curve’– a term used to describe the strategy aimed at spreading the damages caused by the virus over time so that health systems do not get overwhelmed.3 However, social distancing measures have other second order effects such as income loss, shortage of goods/services, malnourishment, social anxiety, violence against women and human rights abuses, amongst other effects, which impact the well-being of the population at large. Hence, there is a need to strike a fine balance in COVID-19 response and relief strategy between protecting lives and safeguarding livelihoods while minimizing social disruption and respecting human rights.

The global pandemic response has exposed the under-preparedness in spite of warnings and previous local epidemic outbreaks like Ebola, SARS. This article locates the COVID-19 measures in India in its two central legislations and analyzes the lacunae or gaps in regulations that renders COVID-19 response strategy non-democratic, inadequate and not in sync with constitutional values. This article, going forward, proposes to drive a shift in the notion and understanding of security from macro to micro perspective, that’s rooted in the security of individuals and communities. The lessons from Ebola outbreak and recently successful Kerala model in COVID-19 response highlight an approach rooted in local community leadership and oversight coupled with strong and effective public systems.

Figure 1: Total confirmed cases worldwide and social distancing measures to flatten the curve

Government Intervention- Rationale and Toolkit

The foremost question is – does the pandemic fall into a class of problems that legitimises the role of the State? What is the market failure that the state intervention seeks to address here? The state’s coercive power- the capacity to coerce to change or modify individual actions/behaviors and the capacity to inflict violence upon individuals- has legitimate grounding only when the ‘freedom doesn’t work well’.4  Externalities are such situations where ‘persons impact upon each other in ways that are not intermediated through voluntary agreements’.5

Epidemics have large externalities because it may impact multiple sectors and spill across borders.  The spread of infection through local or community transmission is a negative externality because it imposes cost on others who have no control over this spread. Hence, individual behaviors may be regulated to contain the spread because high social cost outweighs low private cost.  This regulation or modification of behaviors may be achieved through stringent penalties and/or better risk awareness. Pandemic also results into shortage of food supplies due to supply-side disruption or collectively irrational consumer behaviors such as panic buying. The government’s coercive action, therefore, will be necessary to curb market power in order to ensure regular supply of essential goods and services through producing or financing. Additionally, the outbreak may aggravate living conditions of those living in the margins such as migrant labor, urban poor, self-employed etc because the social distancing and lockdown measures may force them to give up their livelihoods.  Thus the government intervention in pandemic scenario emanates from the urgency due to a combination of factors like ‘low risk awareness, diffuse accountability, multisectorality, externalities’.6

Laws and Regulations: Existing Framework

When two alternative tools yield the same outcome, we should prefer the one which uses the least coercion.’                                                             -Occam’s razor of public policy

Policy interventions like epidemic mitigation are always imperfect and have unintended consequences.7 The right way to minimize unintended consequences is by ensuring all coercions by the state are codified into laws and regulations that again are grounded in the principles of Rule of Law, Separation of Powers.  

The question becomes: What are those laws that give governments authority to draft regulations during pandemics? Are there sufficient checks and balances to limit arbitrariness and concentration of power? Does the law comprehensively control executive discretion?

Figure 2: Daily number of confirmed cases and series of government interventions to contain the spread

Indian government’s efforts to tackle COVID-19 pandemic is centered in following legislations-

  • The Epidemic Diseases Act (EDA), 1897:

This colonial era legislation, enacted to control Bombay bubonic plague in late 19th century, empowers central and state governments to take special measures and prescribe regulations.

  • It empowers central government to inspect ships or vessels leaving or arriving at any port in India and detain people if necessary (Section-2A).
    • It empowers state governments to take any necessary measures and prescribe regulations to prevent the spread of infections (Section 2). 
    • It enforces by making any non-compliance as criminal offence (Section 3) and provides protection to officials/persons acting under this law (Section 4).

As evident, the powers granted under EDA to the centre is very limited and it’s ultimately left to the individual states to frame appropriate regulations and enforce its advisories. Various states, therefore, invoked this law to pass orders and guidelines on social distancing measures, closure of establishments and limitation on group activity for example – Maharashtra COVID-19 Regulations 2020 listed down the notifications. Though used to control epidemics like cholera recently in Gujarat, EDA lacks teeth because it doesn’t authorize the government to enforce a lockdown or even screening of passengers at the airports.

  • Disaster Management Act (DMA), 2005.
    DMA covers all natural or man-made disasters which ‘results in substantial loss of life or human suffering’ and are ‘beyond the coping capacity of the community’.  National Executive Committee, under DMA, delegated power to Union Health Secretary to enhance the preparedness and containment of COVID-19, retrospectively from Jan 17.
    • Section-2(d) empowers National Disaster Management Authority (NDMA) to classify as notified disaster under DMA. It empowers the central government ‘to declare the entire country or part of it as affected by a disaster and to make plans for mitigation to reduce risks, impacts and effects of the disaster’.
    • Section-6(2),-38,-72 enshrines a duty on states to follow the directions of NDMA so as to ensure consistent implementation of measures across the country.
    • It empowers the centre and state officials to quickly mobilize financial resources under National Disaster Response Fund (NDRF) or State Disaster Response Fund (SDRF) and to provide cash relief and compensation.

Prime Minister’s three-week nationwide central lockdown measure starting March 25 derived its power from DMA. This Act also empowers district level committees to take coordinated measures.  

  • International Health Regulations (IHR, 2005)

India is signatory to World Health Organization (WHO) International Health Regulations 2005 (IHR) and therefore, obligated to strengthen prevention, detection, protection and control of public health events of international significance (PHEIC). WHO  declared COVID-19 outbreak as ’Public Health Emergency of International Concern (PHEIC)’ on Jan 30, 2020 and this declaration allowed signatory countries to respond through a series of trade and travel restrictions such as travel ban, cancellation of almost all visas, sealed border.

Besides the regulations involved in containing the spread of the disease, there are several others laws and regulations like Essential Services Act, Indian Medical Council Act that are at the forefront to inform COVID19 response in ensuring healthcare preparedness and supply of essential services.

Figure 3: Timeline of Indian government interventions in response to COVID19

Analysis of regulatory frameworks and some examples-

The question worth asking is: Do public healthcare laws fall short of meeting the needs of pandemic situation?

The present legislative framework and its provisions lack in the following aspects: –

Enforcement and Coordination: EDA, 1897 lacks in consideration of national level policy, strategy and public messaging in order to facilitate a whole-of-nation approach. A consistent application and implementation of measures across the country is considered necessary to ensure maintenance of essential services and supplies in the times of outbreaks. The invocation of DMA, 2005 provisions have empowered a unified approach, however it impinges on federal structure as public health in the state subject as per Schedule 7. EDA, 1897 doesn’t provide administrative and governance arrangements to facilitate consultation process involving exchange of public health surveillance, healthcare system preparedness or coordinated public health messaging. An example is- Australian Health Protection Committee (AHPC), constituted as per National Health Security Act 2007, is the highest level emergency forum ‘tasked with high level cross jurisdictional collaboration in public health preparedness’.8  The federal aspects of public health emergency challenge has been addressed in Draft Public Health (Prevention, Control and Management of epidemics, bio-terrorism and disaster) bill 2017 (PHPCM) that empowers state governments ‘to amend the rules prescribed as appropriate to the circumstances of each state.’

Oversight: Regulations must be grounded in evidence to demonstrate expertise and reason.  It’s quite likely to exercise wide-ranging executive powers to tackle public health emergency. A good regulatory design shall ensure the measures are evidence-based, duration of lockdown measures is appropriate and the privacy infringement is proportional.   The present legislative framework guiding COVID-19 response doesn’t provide oversight over decision making that authorizes regulations and therefore, fails to limit the footprint of executive discretion. The coercive measures of the officials are implemented without ‘reasoned orders’ and neither are the orders are subjected to appeal. There is no Ombudsman. Draft PHPCM Bill 2017 provides for appeal against the orders before authority notified under the act.

Healthcare system capacity: Equipments and Personnel: As the number of COVID-19 cases rise in India, there is going to be a rapid and huge increase in demand for testing and treatment equipments/facilities. The capacity augmentation during such times is constrained by regulatory hurdles such as import tariffs that have limited expansion of in-house capacity in order to strengthen the supply chain of medical resources such as masks, gloves, ventilators.9 In absence of a comprehensive public health care law, these regulatory hurdles persist. Public health emergency situation also requires some flexibility or relaxations in government regulations to timely respond to crisis such as addressing shortage of healthcare staffs or protective equipment.10 The urgency of COVID19 has facilitated deregulations or regulatory certainty. Medical Council of India (MCI) regulations have been revised to engage nearly 100,000 doctors in COVID19 response In order to address the shortage of health professionals. Telemedicine Practice Guidelines 2020 have enabled e-adoption of healthcare services through platforms like DocsApp, mfine, Practo to allow patients to connect with doctors and schedule virtual consultations.11

Healthcare data privacy and security: There is a trade-off between the disclosure of patient’s medical information and public health. The aggressive surveillance measures to track individuals, a crucial pillar of track-test-treat strategy, require a balance with the data privacy and protection laws (Hao 2020).12 Aarogya Setu app sets up a mechanism to trace and track those who came in contact with an infected person in order to isolate and test quickly before it spreads. This App operates in regulatory vaccum and hence there are genuine concerns of disclosure, transfer or access of digital health data. Draft Personal Data Protection (PDP) Bill, 2019 and Draft Digital Information Security in Healthcare Bill (DISHA) 2018 categorizes health data as sensitive personal data and legitimizes its sharing even during public health emergency conditional on being demonstrated as ‘strictly necessary’. Several privacy designs principles like use limitation, data minimization and retention have been applied.13

Finances- Amidst looming uncertainty and growing apprehension that the COVID-19 threat may last longer, several countries have allocated substantial fiscal resources as credit guarantee plans, wage subsidies etc to safeguard livelihoods and provide income support. India, with substantial portion of small and medium enterprises and informal labors, lacks the legislative framework guiding COVID-19 response delineate methods and mechanisms to mobilize finances. The inter-governmental transfers become necessary during the emergency situations like COVID-19 because state governments alone cannot handle such situations on its own. The State Disaster Risk Fund (SDRF) have been mobilized now but a dedicated financial mechanism is required.  

Rights based framework: A good regulatory design influences individual and institutional actors through a structure of information and incentive.14 The present legislative framework guiding COVID-19 response puts too much focus on the ‘duties of the government in preventing and controlling epidemic and little on the rights of citizens.’15 Even the health and administrative risks of infection spread among healthcare personnel have not received adequate attention. The provision of high-quality PPE in sufficient quantity is likely to save approximately 4 Doctor Duty days per PPE.16

Conclusion: A new framework of regulations to fight pandemic

The management of public health emergency like COVID19 crisis requires a strong partnership of the government, the scientific community, the healthcare providers, the law enforcing bodies and others. There is need of a rights based comprehensive public healthcare framework rooted in following design principles-

  • A balance between a whole-of-nation approach and decentralized response.
  • Informed by evidence and Oversight over executive discretion.
  • Systems capacity augmentation through systemic collaboration across private players, governments and multilateral institutions.
  •  Dedicated mechanism to mobilize fiscal resources. 
  • A balance between data privacy and public health concerns.


[1] “COVID-19 Map,” Johns Hopkins Coronavirus Resource Center, accessed May 8, 2020, https://coronavirus.jhu.edu/map.html.

[2] WHO DG, 2020a. ‘Opening Remarks at the media briefing on COVID-19’, World Health Organization. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020

[3] “Social-Distancing Measures May Be Flattening the Curve,” Harvard Gazette (blog), April 9, 2020, https://news.harvard.edu/gazette/story/2020/04/social-distancing-measures-may-be-flattening-the-curve/.

[4] Kelkar, Vijay and Shah, Ajay. 2019. In Service of the Republic: The Art and Science of Economic Policy. Penguin Random House. New Delhi

[5] Ibid – 3

[6] Jonas, Olga. 2014. ‘Pandemic Risk’, Background paper, World Development Report 2014 ‘Risk and Opportunity: Managing Risks for Development’ https://www.worldbank.org/content/dam/Worldbank/document/HDN/Health/WDR14_bp_Pandemic_Risk_Jonas.pdf

[7] “India’s Lockdown Has Brought Unexpected Benefits,” The Economist, accessed May 8, 2020, https://www.economist.com/asia/2020/04/23/indias-lockdown-has-brought-unexpected-benefits.

[8] NatHealth, 2011. ‘National Health Emergency Response Arrangements’, Government of Australia. https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-response-arrangement-nov11-l

[9] Rajagopalan, S. and Tabarrok, A. 2020. ‘Pandemic Policy in Developing Countries: Recommendations for India’, COVID-19 Policy Brief Series, Mercatus Centre George Mason University. https://www.mercatus.org/publications/covid-19-policy-brief-series/pandemic-policy-developing-countries-recommendations-india

[10] Thaler, Richard and Mullainathan, Sendhil. 2020. ‘To Fight the Coronavirus, Cut the Red Tape’, Newyork Times. https://www.nytimes.com/2020/03/24/business/coronavirus-medical-supplies-regulations.html

[11] Sreenidhi Srinivasan, “Coronavirus Has Become the Booster Shot That Telemedicine Was Waiting for in India,” Quartz India, accessed May 8, 2020, https://qz.com/india/1833374/coronavirus-to-boost-telemedicine-apps-mfine-and-practo-in-india/.

[12] Hao, Karen. 2020. ‘Coronavirus is forcing a trade-off between privacy and public health’, MIT Technology Review. https://www.technologyreview.com/s/615396/coronavirus-is-forcing-a-trade-off-between-privacy-and-public-health/

[13] Matthan, Rahul. 2020. ‘The privacy features that are built into Aarogya Setu’, LiveMint.

[14] Roy, Shubho, Shah, Ajay, Srikrishna, BN and Sundaresan, Somasekhar, 2019.’Building State Capacity for Regulation’, In ed Regulation in India: Design, Capacity, Performance (Oxford: Hart Publishing, 2019)

[15] Yadavar, Swagata and Mandhani, Apoorva. 2020. ‘Modi govt is using two laws to tackle coronavirus spread. But one of them needs change.’ The Print. https://theprint.in/theprint-essential/modi-govt-is-using-two-laws-to-tackle-coronavirus-spread-but-one-of-them-needs-changes/386052/

[16] Behl, Rhytm. 2020. ‘Tackling COVID19: The need for effective capacity utilization of health professionals’, ISPP Policy Review. https://policyreview.in/tackling-covid-19-need-for-effective-capacity-utilisation-of-health-professionals/