Sound public health policy need of hour | Opinion
Best bet: The government needs to invest in public health to reopen the economy safely.
The coronavirus disease (Covid-19) is an unprecedented global challenge for both health and economic well-being. As seen in Italy and New York City, the exponential growth of Covid-19 infections can quickly overwhelm health systems and lead to tens of thousands of deaths. Wary of the risk of a fast-spreading pandemic, the Indian government enforced arguably the strictest lockdown in the world. This has slowed the spread and saved lives – but at a heavy human and economic cost.
These costs have now polarised the policy debate around the government’s next steps (and similar debates are playing out around the world). Some argue that lockdowns are excessive, hurting us more than the disease itself. Others claim that lockdowns are the only realistic option to prevent a catastrophic increase in cases and deaths. However, framing the debate around lives versus livelihoods is counterproductive because it distracts attention from the most urgent actions we need to take. Specifically, we need a strategy focused on making the public health investments required to reopen the economy safely as soon as possible.
Why we need a public health-driven strategy
India needs a strategy grounded in public health because, at its core, this is a public health crisis. What makes Covid-19 so dangerous is that it takes time for those who are infected to show symptoms, so they remain unaware and active – spreading the virus at scale. This is why governments around the world have resorted to lockdowns as the only option to contain virus spread in a setting where anyone could be a carrier and transmitter.
But a lockdown only slows the spread of the virus. A worrying misconception is that the lockdown will eliminate the coronavirus problem and enable a safe reopening. Yet simply lifting the lockdown after a few weeks will likely lead to a resurgence in the number of cases. Even in green zones with zero active current cases, Covid-19 can reappear and spread rapidly through the community, as seen recently in Singapore and South Korea.
Thus, a lockdown on its own does not “solve” the problem of the virus. Rather, it needs to be seen as the first step in a long-term “Hammer and Dance” strategy for a battle expected to last at least 12-18 months (which is the earliest that a vaccine may be available). The hammer (lockdown) phase aims to slow down the spread of the virus enough to buy us time to prepare for the “dance” phase, when a substantial amount of economic activity can resume but under modified guidelines and under a much stronger surveillance system – based on testing, tracing, and quarantine – to limit the health costs of reopening the economy.
By ramping up testing among both symptomatic cases and in populations who are at high-risk of contracting and spreading Covid-19 (like frontline workers), we will be able to catch cases early and isolate potential spreaders. Ideally all high-risk individuals should be tested. However, given testing capacity constraints, it makes sense to test random samples of high-risk individuals – even if they show no symptoms. This testing needs to be followed up with diligent contact tracing (up to at least two degrees of contacts) and strict quarantine.
Done well, such an approach could lead to sequestering 1-3% of the population, but allow the rest to prudently resume economic activity with precautions like mandatory mask wearing and social distancing in public places, frequent handwashing with soap, a continued ban on large gatherings, and modified protocols for public transport. This is clearly a much better outcome than a blanket lockdown driven by the fear that anyone may be a carrier. Thus, the main value of increased testing is in allowing us to identify and isolate only those at risk as opposed to the entire population.
Across the world and in India, this comprehensive system of testing, tracing, and quarantining is the only approach that has worked to gain the confidence needed to safely lift a lockdown. For instance, Vietnam, which has a comparable GDP/capita to India and had early exposure to the virus, has had zero Covid-19 deaths largely because of a combination of aggressive testing, five degrees of contact tracing, and strict quarantine compliance. This success is now allowing Vietnam to safely open up its economy. Closer to home, Kerala has been a global role model in managing Covid-19 with a largely similar approach.
Investing in a public-health strategy is highly cost-effective
The deepening economic distress has led to widespread demands for a government rescue package. Some, like CII, have suggested this package be worth 15 lakh crore or 7.5% of GDP. But any economic “recovery” package will only make sense after one is able to open up the economy itself. Thus, just like the best foreign policy for India is an economic policy that delivers consistent 8% or greater growth for multiple decades, the best and most cost-effective economic policy right now is a sound public health policy. Consider the cost of scaling up four key components of the health strategy:
Testing: India’s testing rate is a long way from global leaders, but even ramping it up to test at the rate of Tamil Nadu (which is conducting over 10,000 tests/day) would substantially increase our ability to identify potential super-spreaders before they spread the virus. Doing so would allow us to cover 5% of the population (70 million tests/year) at a cost of Rs 17,500 crore (at Rs 2,500/test).
Contact Tracing: The most effective way to scale up Covid-19 contact tracing and surveillance would be to hire and train additional ASHA workers on a one-year contract. The average cost of an ASHA worker is around Rs 60,000/year but even increasing this to Rs 1 lakh (to augment pay and include training costs) would allow us to double India’s ASHA workforce and hire an extra one million ASHA workers for Rs. 10,000 crore/year.
Safe and dignified quarantine: Studies suggest that a large fraction of Covid-19 transmission happens between family and friends, making high-quality public quarantine centres critical. These centres will be especially important for India, where most people live in packed high-density conditions and social distancing is nearly impossible. Further, the poor, whose families cannot afford the income loss, should be compensated for being put in quarantine in the public interest (for no fault of their own). Even if 2.5% of India’s population (35 million people) are put in a 14-day quarantine in a year, this would cost Rs. 35,000 crore/year (conservatively budgeting Rs. 500/day for public quarantine facilities, and Rs. 200/day for an NREGS equivalent wage payment, yields around Rs. 10,000/person for a 14-day quarantine).
Universal mask wearing: Evidence suggests that universal wearing of a layered cloth mask may be one of the most cost-effective options to significantly reduce the rate of transmission). Providing two high-quality washable and reusable cloth masks to the entire population of 1.4 billion people would cost Rs 10,000 crore (at Rs 35 per mask).
Put together, these investments would cost around Rs. 75,000 crore a year and will allow us to implement a Vietnam, Kerala, or Tamil Nadu model across the country. Since each week of the lockdown costs Rs 200,000 crores, these investments will pay off many times over even if they enable lifting the lockdown just a few weeks earlier. This list is not exhaustive and it would be cost effective to include other public health actions (like increased frequency of cleaning public toilets and spaces, and ensuring easy and reliable access to soap and water). But the key point is that all these investments are public goods that benefit the broader public (by reducing the risk of transmission) and not just the recipient of the benefit. Thus, they are excellent candidates for government provision, and will likely be underprovided otherwise.
More broadly, Indian health expenditure is skewed substantially towards curative spending (which is a private good that only benefits the recipient and immediate family) rather than preventive investments in public health (that benefit many more people, but are less visible). Making these investments may also improve the long-term quality of health expenditure in India by strengthening public health systems. For instance, the extra ASHA workers hired for Covid-19 related surveillance could be retained (based on performance) on longer contracts to improve community health.
Making it Happen
Successfully implementing this strategy requires clarity not just on what to do, but on roles and responsibilities across national, state, and local governments. Based on principles of fiscal federalism, the national government should focus on roles that benefit from economies of scale, and require coordination. These include financing, purchasing and procurement, global coordination (especially ensuring access to vaccines and treatments), and national coordination (such as policies on inter-state travel, and sharing best practices across states). Consider testing: the current low rate of testing is partly driven by low testing capacity, but if the Govt. of India were to use its scale and commit to procuring Rs. 17,500 crore worth of test kits in the coming year, it could dramatically increase supply, reduce costs, and allow us to expand testing to catch potential super spreaders early.
State governments should lead on operational matters such as doing the testing; hiring and training staff for health surveillance; contact tracing and quarantine; and transparent communication regarding public health guidelines and safety protocols. Local governments in partnership with civil society should lead in making the citizen experience as smooth as possible and securing community support for implementing national and state guidelines. Overall, the experiences of Vietnam and Kerala highlight the importance of cohesion among all parts of the government, combined with transparent communication, and community support for effectively implementing a public-health strategy.
While the lockdown seems excessive to many, it is important to remember that, historically, germs and pandemics have caused many times more deaths than wars. In India, the Spanish Flu of 1918-20 is estimated to have caused over 12 million deaths, which is 75 times more than the 160,000 Indian soldier deaths in World War I and II combined. The economic cost of the lockdown is very real, but there is no conflict between prioritizing health and the economy. The two are deeply interlinked and a public-health led strategy is likely to have both the highest return on public expenditure and provide the only sustainable way out of these challenging times. It is therefore essential that we use every single day to urgently make the public health investments that will allow a safe exit from the lockdown.
Karthik Muralidharan is the Tata Chancellor’s Professor of Economics at UC San Diego. Vishnu Padmanabhan contributed to this piece.