Sound public health policy need of hour
BEST BET The government needs to invest in public health to reopen the economy safely
KARTHIK MURALIDHARAN
C ovid-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 governmentenforced arguably the strict est lock down in the world. This has slowed the spread and saved lives -- but has come at a heavy human and economic cost.
These costs have now polarized 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 counter productive 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.
THE NEED FOR PUBLIC HEALTH-DRIVEN PLAN
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, and so those infected 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.
If done well, such an approach could lead to sequestering 1-3% of the population at a time, but allow the rest to prudently resume economic activity with precautions such as 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 not knowing who 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.
COST-EFFECTIVE INVESTMENT
The deepening economic distress has led to widespread demands for a government rescue “package”. Some, like the Confederation of Indian Industry (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 superspreaders before they spread the virus. Doing so would allow us to cover 5% of the population (70 million tests/year) at a cost of ~17,500 crore (at ~ 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 {accredited social health activist} workers on a oneyear contract. The average cost of an ASHA worker is around ~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 ~10,000 crore/year.
Safe and dignified quarantine: A key reason for why quarantines in India may fail is that the poor cannot afford to be without income. Ensuring high-quality quarantine, through a daily wage to compensate the poor, will also not be expensive. Even if 2.5% of India’s population (or 35 million people) are put in a 14-day quarantine during the year, they can be compensated at the National Rural Employment Guarantee Act daily wage (~200/day) for 14 days, at a total cost of ~10,000 crore/year.
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 ~10,000 crore (at ~35 per mask).
Put together, these investments would cost around ~50,000 crore a year and will allow us to implement a Kerala or Tamil Nadu model across the country. Since each week of the lockdown costs ~200,000 crore, these investments will pay off many times over even as they enable lifting the lockdown 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 can 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.