Role of local self-governments in control of COVID-19 in Kerala: an exploratory study

INTRODUCTION

The focus of this research is the role of LSG bodies and their response to the COVID-19 pandemic in the Indian state of Kerala. As a prerequisite, there is a need to understand the local self-government structure in the state and their connection with the public health delivery system.

As per the 73^rd Constitutional Amendment Act, a third tier of government system was to be established under the state governments. Referred to as Panchayati raj, this led to the establishment of LSG bodies called panchayats in villages and municipalities and municipal corporations in sub-urban and urban areas respectively. The establishment of this decentralized system meant that some of the powers and responsibilities of the state government in some subject areas will now devolve to the panchayats and other LSGs. 29 such subjects; most of them related to social and human development, were included in the newly introduced 11^th schedule of the Constitution including health and sanitation that were to include hospitals, primary health centres (PHC) and dispensaries.

Kerala is one among the very few states that have successfully implemented the Panchayati raj system. The state was the first in the country to achieve 100% literacy rate in 1991 as well as the first state to achieve the United Nation’s SDG target for infant mortality rate reduction set at eight (per 1,000 live births) for 2020.¹ It established a three tier Panchayati raj system by introducing the gram panchayat (village level), block panchayat (block level), and zila parishad (district level) under the Kerala Panchayat Raj 1994 and the functions of each tier has been clearly demarcated. Each panchayat is further divided into wards that have a standard number of households under them. As far as health is concerned, Kerala is frequently quoted as an example of the successful use of LSGs in health care system. With respect to public health institutions (PHIs), all primary and secondary healthcare institutions (all institutions except medical colleges and regional hospitals) are under the control of LSGs. Although the state government has control over the appointment and regulation of employees at PHIs, it is the various LSGs and PHI officials that have to take several joint responsibilities and function in tandem for a good public health system.

Several studies conducted in the state have spoken of the role and efficiency of LSGs in the development of a robust public health system. A study conducted using secondary data from 1991-2011 period and primary data from 2011-2012 period concluded that wherever there was a good relationship between elected representatives of LSGs and health personnel, the system of dual controls and responsibilities yielded good results and in most districts, the relationship was cordial and productive.² Another study revealed that LSGs have succeeded to a great extent in creating adequate infrastructure for PHIs under them as a significant amount of funding was spent in rebuilding PHCs and sub-centres. It also showed that LSGs were successful in their attempts to create a healthy environment for the local population.³ Some studies also revealed that LSGs have played a major role in making heath personnel accountable to public and in increasing community participation in public health initiatives.⁴

At the onset of COVID-19 pandemic, Kerala was the first state affected in India and was slated to be the most affected given the high NRI (non-resident Indian) population. However, the state government swung into action with the LSGs leading the charge and two months later, widespread reports were circulated celebrating Kerala’s strategy to fight the viral infection.⁵ Even as of today, Kerala is considered to have the highest recovery rate and lowest death rate in the country.⁶ In addition to the long established panchayat-friendly fiscal system, several panchayat led public health initiatives such as the ‘Ashraya programme’ and ‘BUDS school’ provided Kerala with an upper hand in COVID-19 management.⁷ While the experience of dealing with Nipah virus epidemic helped the government formulate plans, it was truly the structural advantage of having a strong decentralized governance architecture that should be credited with success of the state in COVID-19 management.^8,9 The quick mobilization of local committees that consisted of panchayat representatives, local officials, self-help groups, educational institutions and local NGOs was yet another significant part of these efforts.¹⁰ This study was planned to understand the role of LSGs in COVID-19 management directly from the primary actors, i.e. the head of LSG bodies.

The main objective of this study is to understand the role of LSGs in COVID-19 management during the initial phase of the pandemic in Kerala.

METHODS

This is a qualitative study conducted on the basis of direct interaction with the heads of five different panchayats and municipalities near the Government Medical College Kannur, located in the central part of the northern district of Kannur in Kerala; a south Indian state. The selection of the panchayats was done by snow ball technique. Initially we, which is familiar to us as part of the routine field activity of the Community Medicine department. Other panchayats and municipality were selected as per information obtained from the preceding panchayat. Method of data collection followed was in-depth interview. Interviews were conducted with the head of the panchayats (presidents) and municipality (chairperson). Interview guide was prepared with relevant questions. But the respondents were allowed to speak freely, which could bring more information. The interview guide broadly covered areas like responsibilities, community participation, funding of the various initiatives, inter-sectoral participation of PHIs and other authorities etc.

The study adopted an inductive approach, where data is first collected, then documented, analysed, and developed to themes. There was no set target for the number of interviews, since it followed inductive approach and based grounded theory. Interviews were repeated until there was consistent pattern that could be observed from the information obtained. Therefore, the sample was based on redundancy.

Once the interviews were completed, they were transcribed into interview texts. The data from these were analysed and developed into condensation units, codes, and categories leading up to broader themes in order to arrive at the following findings and conclusions.

The selection criteria adopted in the study was mainly based on the LSGs that fall in the catchment area of the Government Medical College Kannur. Additionally, it was ensured that there was representation from both urban and rural areas and that there was geographical diversity in the LSGs selected.

These interviews were conducted in May-June months of 2020.

RESULTS

Findings

The major findings of this qualitative study can be divided into the following themes:

Organization of COVID-19 related activities in LSGs

Structural organization: Each and every COVID-19 response task was managed by various committees constituted at either panchayat/municipality level or ward level or at both. These include a monitoring committee that monitors all work related to COVID-19, an observation committee for observing quarantine rules and regulations, a safety team and an evaluation committee that looks after necessary facilities and awareness required to undergo quarantine at home, an emergency response team as well as rapid response team that mainly had health officials responding to immediate needs. Various Jagrata samitis were constituted at both panchayat and ward level and had workers from all sectors involved. A COVID-19 management committee was also common in most LSGs that included political representatives from both elected and opposition parties, government officials from panchayat as well as revenue office, public health officials as well as volunteers.

Resource mobilisation: All panchayats and municipalities interviewed for the study noted with thanks that a major part of their efforts was financed by generous contributions of sponsors and donors. Sponsorships were provided by various welfare organizations, orphanages, NGOs and other persons within the panchayat/municipality. Donations were in both money and kind; local farmers contributed to the community kitchen, government schools contributed the material meant from mid-day meal programs in schools, etc. The LSG’s own fund had to be used to a very small extent in most institutions interviewed. However, they were prepared to overcome any financial challenges as the state government had instructed all LSGs had put a stop to programs that were not urgently required so that funds could be diverted to COVID-19 relief work.

Facilities used: As widespread lockdowns and restrictions forced officials to work from home, most of the work was done through mobile phone/telephone communication and other internet platforms such as WhatsApp. Most committees had a WhatsApp group that enabled sharing of reports and discussion on ongoing work on a daily basis. Outside these institutions, information was made available on the online website of some LSGs to enable procurement of e-passes or home delivery process. A pre-existing broadcasting system involving the mobiles/telephones of all the households was also used to disseminate information and awareness by one municipality. Telemedicine and counselling services were also provided through telephone. Some mobile apps were also used by panchayats that would track the movement of quarantined persons beyond a set limit to prevent violation of quarantine guidelines and further spread of the infection.

Beneficiary groups

Several COVID-19 management efforts were specific to certain groups that would be considered vulnerable to and most affected by the viral infection; like the elderly population, children, migrant labourers from other states, destitute, etc. Early efforts started with the management of migrant labourers who were suddenly unemployed when lockdown was declared causing a complete halt in economic activities.

Most LSGs had prepared a list of all migrant labourers within their area of control and identified their addresses, employers, etc. In the initial phases, a few migrant labourers who were managed by a particular contractor were taken care of by the contractor himself. With the continuation of lockdown, when the contractors could not afford taking care of the labourers, most LSGs stepped in and provided them with food from the community kitchen and supplied other essential items through Kits. Some LSGs even arranged for medical camps for the migrant labourers to ensure that there was no spread of the infection within the community. In April when the central government allowed resumption of construction activities as long as labourers were accommodated on-site, some of these migrant labourers could return to work. In some panchayats, as migrant labourers demanded that they wanted to travel back home, LSGs made prompt attempts to complete a registration process for all such labourers and arranged trains to their home states with the help of IRCTC (Indian Railway Catering and Tourism Corporation) and state government.

LSGs also ensured that the destitute in the area were provided food under the community kitchen program and some of them even arranged facilities for their stay in lodges and centres under the Social Security Mission. It was ensured that pension funds were disbursed for widows and senior citizens and funds were allocated to offer loan facilities to members of self-help groups such as Kudumbashree (women self-help groups) and Ayalkkoottam (neighbourhood groups). Patients with severe ailments were also taken care of by some LSGs. For example, free and regular transportation was offered to some dialysis patients by a municipality. Another category that LSGs paid attention to was returnees from other countries and states, for whom quarantine facilities was arranged by their respective panchayat/municipality.

The senior citizens were given priority in efforts to prevent exposure to the virus. There were existing schemes and systems where doctors from the concerned PHC would regularly visit the elderly population for regular health check-ups and follow-ups. As the lockdown hindered this and also since they could be at risk due to exposed doctors, these schemes were stopped. However, it was ensured that there was regular delivery of required medicines at their doorstep. Senior citizens could also access doctors through telemedicine system that was set up. They even supplied them with ayurvedic and homeopathic immunity building medicines. If the need was felt, delivery of meals from the community kitchen was also ensured. In the early phases, if there were relatives returning from abroad, some of the elderly people were even provided with separate accommodation in unoccupied houses within the locality.

Services

Welfare services: These services ranged from free meals provided through the community kitchen set up in early March to kits that were distributed through the public distribution system or directly from the LSG office. All panchayats/municipalities had one or more Community Kitchen that was later converted to a Janakiya hotel that would provide meals at a subsidized cost (20 INR per meal). While kits containing essential food, item were distributed by the state government, several LSGs followed the lead to distribute more kits with additional essential items. Several LSGs even ensured the supply of sanitisers, masks, special kits on festivals such as Vishu, etc. Financial support was facilitated through loans provided by self-help groups. Other major service offered was through the help desk/call centre/online portal/WhatsApp facility set up by all LSGs that facilitated delivery of necessary items from shops and other pharmaceuticals.

Quarantine services: Arranging quarantine and isolation facilities was one of the mammoth tasks that fell upon LSGs during COVID-19 pandemic. Quarantine facilities were arranged at educational institutions’ building such as engineering colleges or BUDS school or at building provided by welfare organizations such as Ignatian Retreat Centre in Pariyaram panchayat. These facilities were referred to as COVID Care Centres and the arrangement was overseen by the COVID management committee. Volunteers and sanitation workers posted at these centres were given special training for serving there. Food for the centres was arranged through the community kitchen and some municipalities even arranged for a special waste management system for these centres.

Addressing psychological problems: There was a lot of stigma and myths related to COVID-19 infection among the population causing fear and panic about returnees from other countries and states. In order to deal with such misconceptions, some panchayats/municipalities conducted awareness classes to spread the right information. It was observed through some telemedicine facilities that several middle-aged women were facing sleep problems and anxiety due to fear of COVID-19. Therefore, arrangements were also made for counselling sessions through telephonic means.

Networking

Various activities of LSGs had an inter-sectoral nature requiring coordination and cooperation with other institutions including PHIs, police authorities, etc. The theme of networking deals with several aspects of such inter-sectoral activities.

Primary health centres (PHCs): Officials from PHIs, mainly the PHC (every panchayat/municipality has one or more PHC, with one of them often functioning as a family health centre [FMC]) were involved in most activities of the LSGs. This means that several public health officials such as Medical Officer, Health Inspector, Public Health Nurse, etc were part of the various committees constituted by the LSGs, evaluating and monitoring the situation at the ground level and preparing daily assessment reports. They were a part of the teams that participated in health check-up activities as well as the telemedicine facility. They were also tasked with the duty of admitting and discharging persons at the various quarantine facilities.

Police: The police authorities coordinated with LSGs to make sure that the restrictions imposed by the state government were followed. This included preventing large social gatherings, checking up on persons under quarantine on a daily basis as well as imposing fines and taking legal actions wherever required. Higher ranking police officers such as the circle inspector of police were a part of LSG committees and often gave reports on the various surveillance activities. In one panchayat however, the police activities were reported to be harsh and unnecessary.

Other participating groups: LSGs additionally required the cooperation of various other groups in COVID-19 management efforts. For example, they were aided by the usual group of health officers who facilitate public health activities such as the ASHA worker, Anganwadi worker, etc. These workers facilitated all initiatives throughout COVID-19 time as they went door to door collecting information about persons arriving from other countries or states, informing the community about steps being taken, etc. Since these workers have been involved in various activities before and are familiar to most community members, they act as a link between the LSG and the community. The role of volunteers was also immense in the COVID-19 response work. Volunteers were assembled early in the month of April and were mainly tasked with conducting home delivery services, posted at the help desk/call centers, posted at the quarantine facilities, etc. Volunteers were specially trained for their specific tasks and were provided with e-passes to permit traveling amidst the restrictions. The officers from respective revenue offices were part of committees in charge of various activities. Members of self-help groups functioning under LSGs such as Kudumbashree (women self-help groups) and Ayalkkoottam (neighbourhood groups) were involved in the production of masks and sanitizers locally and occasionally assisted in other monitoring activities. Fire Force officials were actively involved in the transport and delivery of medicines that had to be procured from other States and districts.

Organisations: Several voluntary organizations, welfare organization, resident’s association and banks were actively involved and contributed by providing quarantine facilities or donating in money or in kind. COVID-19 management activities saw cooperation from various other sectors and individuals such as faculties from educational institutions who guided in production of sanitisers locally, local shops and merchants that provided home delivery in association with LSGs, Ayurveda hospitals, government educational institutions, private auditoriums and lodges that provided quarantine facilities, etc.

Impact of the LSG activities

Due to the various efforts of LSGs, the COVID-19 infection has been significantly under control in the northern district of Kannur, in the initial phase. Once the community was made aware of the restrictions, people mostly acted on their own; diligently following social distancing and wearing masks. In some places, police intervention was required to disburse large gatherings and enforce distancing at shops but mostly the impact was positive. Some programs were also conducted by the community to appreciate public health officials and police officials for their efforts amidst the pandemic.

The response of the community to the various initiatives of LSGs was largely positive although not devoid of negative aspects. The communities were cooperative, taking part notwithstanding their political affiliations and contributing the best to their capacity. Although it took time for communities to adjust to lockdown restrictions, LSG efforts were positively received.

DISCUSSION

Kerala’s local self-government bodies functioned as epicentres of coronavirus control measures in the initial phase of the pandemic. They coordinated various preventive measures and developed a support system for the community. PHC, family health centres, police and various other organisations like self-help groups worked in harmony to identify the groups vulnerable to COVID-19 and support them. Migrant workers, elderly, widows, returnees from other countries were given priority in COVID-19 management work. Inter-sectoral coordination helped mobilisation of necessary and sufficient resources for proper conducting of these relief activities. Buildings suitable for acting as quarantine facilities were identified and occupied with the help of other agencies and volunteers. Community kitchens played a prominent and active role in taking care of people in need and other target groups. The basic necessities of people, including that of medical nature was handled and taken care of by the various committees formed at LSG level. There were also monitoring committees to ensure quarantine regulations to be observed by people. The committee members include members from health, self- help groups, social welfare organizations, volunteers and other agencies.

Community participation and response to the epidemic are evidenced through these LSGs and their initiatives. This helped in the control of pandemic by flattening the curve of disease incidences and reducing mortality in the state of Kerala. LSG’s leadership underscores the need of addressing welfare issues in controlling a pandemic situation. The potential of local level planning can be realized through training of more volunteers and social workers coupled with people’s participation in the upcoming stages of the pandemic that could potentially include a community transmission phase.

Limitations

This qualitative study does not represent or embody the functioning of LSGs throughout the state of Kerala. This is essentially because the panchayats and municipal corporations that have been studied are limited to the ones in central part of the northern district of Kannur. The existing social and political situations vary across the different districts in the state.

CONCLUSION

In the past, several studies have been conducted to understand the dynamics between LSGs and PHIs in the state of Kerala. Cooperation between these two sets of bodies have been identified to be a significant component of the well-functioning public health system in the state. With the emergence of novel coronavirus, the cooperation and interaction between these two bodies become even more crucial. By exploring the role played by LSGs in control of the pandemic, this study adds to the diverse perspectives on the existing public health system. Learnings from Kerala may be useful to other regions as well.

ACKNOWLEDGEMENTS

The authors would like to thank to Sasi Vattakkovval (Chairman, Payyanur municipality), P. K. Shyamala (Chairperson, Anthoor municipality), E. P. Balakrishnan (President, Kadannappally Panapuzha grama panchayat), A. Rajesh (President, Pariyaram grama panchayat), Santhosh V. P. (Secretary, Pariyaram grama panchayat) and Ramakrishnan K. V. (President, Kannapuram panchayat) for their time and contribution in making this research article possible.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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