We need a hospital policy; a human resource policy; transparent data on oxygen requirement, allocation and supply processes; war-rooms to help citizens find beds, oxygen, medicines and tele-consultation (PTI)
We need a hospital policy; a human resource policy; transparent data on oxygen requirement, allocation and supply processes; war-rooms to help citizens find beds, oxygen, medicines and tele-consultation (PTI)

The second wave and the Indian State

The Centre and states are at war, but India urgently needs a coordinated response. It’s not too late. But soon it will be
By Yamini Aiyar
UPDATED ON MAY 09, 2021 10:32 PM IST

In an influential paper published over a decade ago, the economist Lant Pritchett described India as a “flailing State” — in which the head, that is the elite institutions at the national level (and, in some cases, state level) remained sound and functional but was no longer reliably connected to its own limbs.

Pritchett turned to India’s public health system to illustrate his argument. When you talked to the top tiers of India’s government, he said, you get an elaborate story of facilities, human resources, health services and programmes. But travel to any part of India, particularly in the north, Pritchett noted, and it became clear that this description of India’s “health system” was, in fact, a complete fiction.

As the horror and suffering of the second wave of Covid-19 unfold, one thing is clear. In the short decade between when Pritchett first posited the idea of the flailing State and today, India has transitioned to a failed State. The “fiction” of India’s health system is now exposed. And as hapless citizens struggle to find oxygen, basic medicines, hospital beds, the once sound and functional “head”, or more specifically the national government, is no longer visible. Indeed, it has abdicated from all responsibility, from leadership and governance.

The flailing State, in Pritchett’s formulation, was capable of undertaking “thin”, logistical, tasks. Tasks where goals are clear, outputs visible and command-and-control actions could be deployed. After all, India managed to conduct large-scale elections, vaccination programmes (the irony is inescapable), even handled natural disaster relief with relative competence.

Yet, when it comes to Covid-19 management, the Centre has failed to perform even these logistical tasks — oxygen supply, availability and access to basic medicines, treatment protocols, data systems, vaccinations. The political leadership, from the prime minister (PM) downwards, is completely absent and the Indian Administrative Service (IAS) — whose “brain power”, as Pritchett saw it, could capably formulate excellent policies — is drafting botched-up and confused policy. It is extraordinary that oxygen supply chains and aid distribution cannot be streamlined weeks after hospitals and state governments sounded alarm bells. Of course, when all else fails, we are reminded that health is, after all, a state subject.

Ironically, it is the erstwhile uncontrollable limbs, now left to their own devices, that have proven far more resilient. We hear tales of leadership and innovation in the occasional district, of the Brihanmumbai Municipal Corporation’s war-room, of states and local governments with relatively better health infrastructure managing the pandemic with competence, and, most of all, of frontline workers who are battling the pandemic with remarkable courage despite personal risks. Yet, none of these sporadic tales adds up to a national plan or a coordinated response to a pandemic by the Centre and states. Instead, central and state governments have locked themselves in a bitter political war with Twitter as their battleground.

In the next few months, as Covid-19 travels through small towns and rural India, the country is likely to confront even greater suffering. There is still time — and, indeed, there is a moral obligation — for the Indian State to course correct. The prescriptions are well known. Even the Supreme Court seems to have greater clarity on the actions that the government needs to take.

We need a hospital policy; a human resource policy; transparent, publicly available, evidence-based data on oxygen requirement, allocation and supply processes; war-rooms at every level of administration to help citizens find beds, oxygen, medicines and tele-consultation (no one should have to go through the daily horrors experienced by the citizens of Delhi in their battle with Covid-19). We need to resource primary health centres and wellness centres with medicines, oxygen and capacity to triage patients to reduce stress on hospitals. We need enhanced surveillance capacity, transparent and accurate data on every aspect of the disease. But for all this to happen, there is one crucial missing piece that falls squarely within the domain of the central government — inter-state cooperation and coordination.

India’s Covid-19 response has failed because it ignored a fundamental first principle of good governance — the principle of subsidiarity, which means that the central authority performs only those functions that cannot be performed at the local level and no other. At the start of the pandemic, decision-making was overly centralised.

Now, when it comes to tasks where the Centre needs to play a role — procurement of vaccines, supply chain management and allocation of oxygen, human resource and treatment protocols, ensuring resources move to areas experiencing surges — states have been told health is a state subject. Rather than a coordinated response, states are at war with the Centre and each other.

Battling Covid-19 requires political maturity. This cannot be done in an institutional vacuum. One option is to set up an inter-state council within the National Disaster Management Authority, comprising the PM, chief ministers, senior ministers and bureaucrats from both states and the Centre. Institutionalised coordination will send the right signals to the limbs of the once flailing State. But this requires political leadership and trust. It’s not too late. But soon it will be.

Yamini Aiyar is president and chief executive, Centre for Policy Research

The views expressed are personal

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