Prasad V //
One among the States in India where the government has approached somewhat seriously the management of Covid-19 pandemic is Kerala. This attempt has given hitherto broadly good results also. While preparing this write up, the number of infected people in Kerala are increasing at a rapid pace. But that is due to the coming back of non-resident Keralites from affected areas which is after a conscious decision. Control of covid-19 pandemic in the state of Kerala has become a debate not only all over the country but also abroad. The state government got worldwide appreciation and acknowledgement for its effective handling of the pandemic. In this backdrop it will be worthwhile to examine the reasons behind that including the often narrated “Kerala model”.
The Achievements Of The State
Kerala’s Health Care delivery system is distinctly different not only from rest of India but also from that of Europe. It is traditionally less costly and built up by giving more emphasis on preventive aspects. Kerala doesn’t have equipment at par with developed West. Still ‘Kerala model’ is able to withstand the pandemic.
Corona virus control in the State has the following key elements.
- A stronger Public Health Care System
- Aggressive contact tracing
- Implementing strict home quarantine rules
- A popular campaign of ‘break the chain’
- Attempt to ensure Comparatively better supplies including food
- Comparatively better preparedness for a potential second wave
Kerala State had a previous experience in fighting with Nipah virus in May 2018 when an outbreak happened in Kozhikode and Malappuram districts. The Nipah infection has an extremely high death rate. During that occasion, the government system created for combating that worked well. That outbreak was successfully managed. Coordination structures and mechanisms that were instituted by the state was rated with high ranking by WHO and other agencies. This was based on assessment of control of transmission. This is true in the case of other support structures of non-technical nature also. The experience gained from managing Nipah virus has helped the State Government very much in starting the coordination center much early as well as in coordinating different departments of the government reasonably well against Covid-19. The net result was that the mechanism of contact tracing has worked reasonably well. In many of the districts this was aggressive also.
‘Break The Chain’ Campaign And Its Relative Success
One of the campaigns that has become victorious in the State is the ‘break the chain campaign’. Different governments tried to propagate the same message more or less in every state. But for such a campaign to be victorious needs a relative degree of higher literacy and scientific temperament of the population. Kerala is the most literate state in India. More than that it has a long history of renaissance and left movement. The educational movement in Kerala is inseparable from that. The campaigns like the temple entry movement, the library movement, the film society movement, co-operative movement, etc. were also part of that.
That is why the ‘Break the Chain’ campaign has become victorious in Kerala. The state has successfully slowed the spread of infection by promoting physical distancing, sanitary precautionary measures, and by providing better protection for health care staff, by learning lessons from its earlier implementation of Nipah prevention activities.
The State where the influence of the renaissance was deep and the Left has been in power for many years since 1950s has invested comparatively better in public education and universal health care. Kerala has the highest literacy rate and benefits from the best-performing public health care system in the country. It tops India’s rankings on neonatal mortality, birth immunizations, life expectancy and many other health indicators. Along with the system of hospitals, the availability of specialists at primary-care facilities is better compared with other states. Further it is to be added here with emphasis that without the higher literacy rate and system of universal education that is existing in this state, the achievements in the healthcare system were not possible.
The strength of its health-care system allowed it to follow the WHO’s recommendations on aggressive testing, even as central agencies maintained that mass testing was not feasible in a country like India. Through the first week of April, Kerala had conducted more than 15,000 tests. By comparison, Andhra Pradesh, a much more populous state with a similar number of cases, had carried out nearly 8,000 tests, while Tamil Nadu, with more than double the number of cases, had done more than 12,700 tests. But in the later part the number of tests done has become much lesser and even below many other States is another fact to be counterposed here.
Another important factor to be mentioned here is the fact that a significant number of the doctors and other health staff working today in Kerala are hugely influenced by the left movement in the 70s and 80s of last century during which time the campuses were politically very vibrant. That resulted in better social consciousness and pro-people attitude from them.
The Other Side
But attributing the entire credit of the success to the present government is with narrow political motive. Let us examine the other side of the story.
The Kerala government was one of the State Governments in India which has declared in the beginning itself an economic package of Rs. 20000 crore to alleviate the effects of Corona pandemic in March 3rd week itself. The government has claimed everywhere that this is due to the pro-people attitude of the left front government. But if one is looking into the facts connected with this, one can see the real picture.
Out of the Rs 20,000 crore, Rs 14,000 crore is the arrears to contractors, Rs 1,300 crore arrears of social welfare pensions, Rs 2,000 crore for the employment guarantee scheme which is entirely funded by the central government, and another Rs 2,000 crore kudumbasree loan for 9% interest from Banks. So, the real package is below Rs 500 crore. One can see that in essence, this is a fraud just like the Modi government has done with the central package. This is the typical Kerala finance minister Thomas Isaac style.
Looking at the migrant workers plight, Kerala has seen the protest of migrant workers in different districts. At the beginning of the lockdown the migrant workers protested in Kottayam and some other places demanding essentials. Government has heard to that. Community kitchens were opened in many places which were funded by the local governments mobilizing resources from various means including donations. But after some weeks the community kitchen for migrant workers were stopped in most of the places. The government has even asked the house owners to provide food to migrant workers where the contractors are not available. Large number of migrant workers are without any contractor. They are working individually in shops or even day-to-day work. They stay usually in rented accommodations in old houses where the rent is very cheap. The State government has made a directive that the house owner should provide the food and accommodation. But a large number of the house owners were also belonging to the lower middle-class sections. They were not in a position to provide food. They were also without any employment in lockdown. So, the mechanism has not worked. In the absence of food and other essentials, the migrant workers came to street in different places demanding that they should be sent back to their respective States. Demonstrations occurred in Trivandrum, Kozhikode, Kannur, etc. with this demand.
The Government employees were asked to donate one-month salary to the chief minister relief fund. In last year also due to the flood, the same thing happened. As the amount was collected in 6 monthly installments, the payment has completed only in February. Just after 1 month the government has proposed for the further cut off of one-month salary in next 6 months. The radical left groups in Kerala protested in that.
The protest was for two reasons. One is the neoliberal agenda behind the decision and the second is the trustworthiness of chief minister relief fund. During the beginning of the present left front ministry in Kerala, a particular economist has been appointed as advisor to the chief minister who later become the chief economist of international monetary fund, the IMF. She has become reputed among the monopoly houses for suggesting austerity measures in Greece and adjoining countries during the time of last economic crisis. Kerala chief minister welcomed her advice. This was the reason behind the continuous salary challenge imposed upon Kerala employees. But Kerala is a heavily unionized place. Some year back the government had to withdraw the salary challenge due to the employee’s protest. In order to combat with unions, the Kerala government has undertaken systematic propaganda work to divide the common people from the government employees. The government has created a narrative that, due to the high salary government employees are getting, the poor people are in their condition. This was an anticipatory move to divide the common people from government employees by such propagandas. Further this attempt was to de unionize and de politicalize the people.
After the floods happened in last year, a good sum has been collected from employees, the non-resident keralites and other sections of the population to the chief minister relief fund. But the amount has not been spent upon the flood victims. On the other hand, government utilized the money in order to manage their day to day expenses while the victims of flood got nothing. This approach put a question on the reliability of chief minister relief fund itself.
Further, Kerala was energetic in doing the Covid-19 tests in the beginning. The average number of tests done gone upwards then. But with some signs of control, the number of tests done is drastically reduced. The government intention was to save money as much as possible. The government has economic shortage is a fact. The central government is not giving the adequate fund to Kerala is also fact. The central government has not paid even the GST arrears. During last year floods, when some of the foreign countries came forward to help Kerala, the central government has blocked that. But at the same time, the Kerala government also failed to collect the sales tax arrears which is thousands of crores. On the other hand, they have moved to impose the employee’s salary challenge. When the Kerala government is charging the central government for inadequate payment of fund, a contrary fact also remains true. Kerala finance minister and CPM leader, Thomas Isaac, was actively supporting the GST before its implementation. Kerala was one among the first States which signed the GST agreement.
History Of “Kerala Model”
The Kerala Government and CPM is trying to picturize a superior ‘Kerala model’. They are actively trying to market the same throughout the world. The term ‘Kerala model’ was first used by Malcolm Adiseshiah in his book, ‘Kerala Economy since Independence (1979)’. In 1990s Robin Jeffrey through his book ‘Politics, Women and Well-being (1992)’, popularized ‘Kerala model’ as a model in social development by achieving India’s lowest infant mortality, longest life expectancy and highest female literacy. Later, many articles by Amartya Sen and others stated that Kerala State has attained high social development at a relatively low level of income by comparison to the rest of world.
The existence of an available and accessible system of chain of hospitals and other centers throughout the state differentiate the ‘Kerala model’ from others in health care. This was not created overnight. This has nothing to do with the Corona pandemic either.
The historical roots of ‘Kerala model’ of social development has been well narrated by many researchers. It has a very complex and tortuous history. The socio-political movements in Kerala has a history of more than one century. The maharajas came under the influence of European Renaissance as well as Christian missionaries have contributed to that in the 19th century and beginning of the 20th century.
From the 19th century onwards there is active participation of Christian missionaries in Kerala’s educational and healthcare domains. Education to the marginalized sections like the Dalits and lower castes was favored by the Christian missionaries. Like that the female education was also favored. Creation of a large band of female nurses which is today rendering a world class service not only in Kerala but also throughout the world has its origins from the educational movement and subsequent health movement in which the Christian missionaries have also contributed immensely.
Vaccination was made compulsory to public servants, prisoners, and students through the royal proclamation of 1879. Epidemiological surveys were conducted in 1928 to investigate the presence of parasitic infections. Sanitation and drinking water distribution were started during the same time or before.
With the independence, Kerala has become the stronghold of left movement in India. Education and health care were promoted by the left governments. Even the right has to compromise with that owing to the political opinion mobilization in the state. Due to these factors, government spending in health and education was much higher compared with other states from independence onwards.
The Model At Present With Its Contradictions
Along with above said advantages, Kerala suffers from the worst type of unemployment situation among the major states in India. Even before the high unemployment because of current economic crisis, a number of indicators showed that. The labor force participation rate (LFPR) which is the measure of those employed within the 18 to 60 age group was 50.7% for Kerala when the national average was 53.8%. Like that the worker population ratio (WPR) which is the number of persons employed per thousand persons was 43.8% in Kerala while the national average was 47.5%. In both the cases the surrounding states of Kerala perform better.
In general welfare state measures and in particular, the European social democracy mitigated the unemployment problem to an extent by huge government investment to create new jobs. But in Kerala the government investment to create jobs is almost negligible. Even the existing smaller industrial units are in the path of collapse.
But at the same time, the village level disposable income is the highest in India. This is due to the large migrant population from Kerala with skilled labor to other parts of the world – from Middle East to Europe and America. Basically, this migration is for employment in professions like nursing, teaching, etc. The remittance from non-resident Keralites is the main source of the village level economy.
Later many researchers criticized the ‘Kerala model’ which could not mitigate the unemployment problem to the youth, welfare services financed by undue borrowing, unfettered land use that led to too much quarrying, environmental catastrophes and disappearance of food crops from the state’s farm lands, as an unsustainable model. This was for a pro-monopoly liberalization.
If we specifically look in the healthcare delivery system also, the following trends can be seen in recent years. Historically ‘Kerala model’ of health care has been known and evaluated to be as a low-cost model of healthcare with great success. But right now, the health expenditure from families as a share of the total income is increasing exponentially. The factors that contributed to this feature is the domination of the private sector hospitals in the post-liberalization period coupled with lifestyle diseases of an aging population and the return of many earlier prevented illnesses due to the compromise in sanitation and in many other fronts due to excessive urbanization and lack of government commitment leading to going back from fund allocation. Due to this attitude many of the diseases like Malaria, Typhoid, Cholera, etc. that have been eradicated from Kerala are fast coming back. Along with that incidence of lifestyle diseases like hypertension, cardiac problems, diabetes, immunological problems, kidney problems, etc. are on the rise as life expectancy in Kerala is higher.
Even though the public health centers and taluka level hospitals are remaining still intact, for the last two decades the governments are neglecting them with so much vacancies unfilled of all the professionals in order to help the private sector. Naturally, the utilization rate of these institutions remains comparatively low. The upper middle-class sections of the population and even the lower sections who have the capacity to pay in some way is absent in the main from the government institutions. One of the studies shows that among the patients in private hospitals, more than 25% of in-patients were borrowed money or went into debt. While 3.4% of them have sold or mortgaged their landed property to some banks for getting appropriate treatment. This is happened due to the conscious deterioration of the quality of the government institutions.
This shows that even though the Kerala health care delivery system is comparatively much better than many other states, it is in the process of neoliberal attack in last two decades. Recently the central government has planned for public-private partnerships in healthcare. The Niti Aayog has already came with the document which tells the way for takeover of District Hospitals by the private players. A model of public private partnership (PPP) is envisaged in which some percentage of the beds will be available to the ordinary people, but another section will go to sales. Kerala government has not declared its position regarding this issue.
In school education in Kerala the PPP model has not worked well. The government was favoring the private schools to establish further. In order to create a favorable condition for the growth of private schools in profitability, they are consciously trying to deteriorate the government system of schools while posing to be saving the government schools. It is likely that, in healthcare also such a type of system may come. The government may not go for the central government route of takeover of the district hospitals by the private in the foreseeable future. But they were already favoring the major private hospital chains by consciously depriving the government hospitals including the district and taluka hospitals with the shortage of doctors and nurses as well as other staff along with inadequate provision of fund.
The ‘Kerala model’ is the product of a powerful and deep-rooted social movement. Sometimes that social movement has taken massive proportions. Sometimes that has influenced even the rulers very deeply. But at present the forces of that social movement are very week in Kerala society. The renaissance movement that has influenced the kings as well as taken the shape of mass movements later in the early 20th century is no longer existing. This is due to the development of capitalism to monopoly capitalism and subsequent adoption of neo liberal policies in the backdrop of collapse of socialist system.
The main left parties are degenerated by the usurpation of leadership by a pro-neoliberal pro-capitalist cliques. Even though there are some radical left groups at present, they have gone below the required strength to influence the opinion mobilization in the society. In the absence of such social movements, the ‘Kerala model’ cannot sustain for long. Signs of disintegration of that were already visible. Since 1990 onwards there occurred huge investments in private hospital services. In order to serve the private hospitals, both the left and right governments have tried to discredit its own public health care delivery system. Even though there are so many large private hospitals in Kerala, the moment of calamity proved beyond doubt that none of them could do anything for people’s benefit. It is only the government system of hospitals and health staff that has taken up the challenge. Without such a system no government could function effectively in such calamities is the fact established.
Thus, the pandemic of Covid-19 has given a huge blow to the neo-liberal policies all over the world in public sentiment. Even though neoliberal policies were initiated in Kerala even in health, the earlier structures remained intact due to the organized nature of the society. The governments wanted to dismantle that. But it was not possible for them to do so. Now it has come to the fore that the existence of the institutions of health care delivery system intact has saved the Kerala society in the Corona pandemic. Now all the parties want to claim the credit of that. So, all parliamentary parties are now trying to champion as the defenders of ‘Kerala model’. So, we can say without much doubt that, more than the ‘Kerala model’ saved the Kerala population from Corona pandemic, the Covid-19 may save the ‘Kerala model’ for some more years from neoliberal disintegration. If in case, Kerala society is able to develop powerful and massive social and mass movements within that period, the ‘Kerala model’ could be defended.
Originally published in The Truth: Platform for Radical Voices of The Working Class (Issue 2/ June ’20)