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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 318-321

A study on COVID-19 management strategies of two Indian states

1 Department of Physics, TKM College of Engineering, Kollam, Kerala, India
2 Travancore Medical College, Kollam, Kerala, India
3 Sree Gokulam Medical College and Research Foundation, Trivandrum, Kerala, India
4 Department of Environmental Science, Savitribai Phule Pune University, Pune, Maharashtra, India

Date of Submission27-Aug-2020
Date of Decision20-Nov-2020
Date of Acceptance23-Nov-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. S S Shemim
Department of Physics, TKM College of Engineering, Kollam - 691 005, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_229_20

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Ever since the outbreak of COVID-19 disease in December 2019, the World Health Organization (WHO) has been keeping a constant vigil over its spread and progress. The WHO first declared COVID-19 as a public health emergency of international concern on January 30 and subsequently upgraded it as a pandemic on March 11, 2020. The first objective of this study was to identify two states of India; one which has been successful to a large extent in combating COVID-19 spread and another state which has largely been unsuccessful so far in the similar effort. The other objective of the study was to identify the shortcomings of the existing system to deal with the current COVID-19 crisis. The most important statistic that has caught our attention is the death rate per million population. As of now, India's fatality rate stands at 19/million which is significantly below than that of the global average of 76/million. The fatality rate in Kerala is 1.15 per million which is lower than nearly 170 countries in the world. In sharp contrast to Kerala, Delhi's fatality rate is at an alarming 189.5 per million population. Kerala's approach to tackle COVID-19 could be implemented in any state for medical emergencies. Kerala model has highlighted the advantages of a strong and vibrant local self-government system, which is further strengthened in association with volunteer groups.

Keywords: COVID-19, fatality rate, Kerala model, public healthcare

How to cite this article:
Shemim S S, Shaju SS, Sooraj S, Soyam PS. A study on COVID-19 management strategies of two Indian states. Arch Med Health Sci 2020;8:318-21

How to cite this URL:
Shemim S S, Shaju SS, Sooraj S, Soyam PS. A study on COVID-19 management strategies of two Indian states. Arch Med Health Sci [serial online] 2020 [cited 2021 Oct 23];8:318-21. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/318/304719

  Introduction Top

COVID-19 pandemic that has plunged the whole world into an unimaginable and unprecedented crisis since the beginning of the year was reportedly first detected in the Wuhan Province of China. The severity of the disease caused by severe acute respiratory syndrome coronavirus-2 forced the World Health Organization (WHO) to declare it as a pandemic by the 2nd week of March 2020. As of recent reports, the total number of infected patients has crossed 14 million with over 604,000 deaths globally[1] affecting 215 countries. The countries with the maximum number of COVID-19 cases include US, Brazil, India, Russia, Peru, Chile, Mexico, South Africa, Spain, and UK.

After the first COVID-19 case was reported on January 20, it has been on the increase in India, with our medical facilities and health forces being tested to the brink. Being home to over one billion people, our motherland is facing its most severe health crisis in the last 100 years. In spite of all the efforts by our central government led by the Prime Minister Narendra Modi and the various state governments, cases are on the rise with each passing day. The total number of infected cases has crossed a million with nearly 27,000[1] deaths across India. The state of Kerala was the first state in India which reported the first COVID-19 patient as early as January.

  Case Study Top

The state of Kerala where the first COVID-19 case was reported in the country as early as January has been fighting the spread of this pandemic in a remarkable manner so far. The Ministry of Health and Family Welfare (MOHFW) has been tasked to develop the protocols to counter the ever-changing situations of COVID-19 pandemic across various states in India. The complexities associated with the ground-level situations in states vary and the MOHFW has successfully incorporated them in its response protocol tailored to each state.

Various states have evolved their customized response strategy to COVID-19 on the basis of the guidelines and protocols set by the MOHFW. This study aims to identify two states; one which has been successful to a large extent in combating COVID-19 spread and another state which has largely been unsuccessful so far in the similar effort.

In spite of best efforts by the central government and various state governments, the total number of cases is still on the increase in India which is a matter of serious concern. The total number of fatalities in the country has crossed 27,000[1] and is on the rise. The performance of various states has been mixed with some performing fairly well but many others falling short of expectations.

The death rate statistic with respect to the population for the various states was compared, and the two states that stood out were Kerala and New Delhi. As of now, India's fatality rate stands at 19/million which is much below the global average of 76/million.[1] The fatality rate in Kerala is 1.15 per million which is lower than nearly 170[1] countries in the world. This has caught international attention toward Kerala's fight against COVID-19 which is discussed in detail in the subsequent sections. In sharp contrast to Kerala, Delhi's fatality rate is at an alarming rate of 189.5 per million[2] population. Delhi's fatality rate is comparable with that of the top 261 worst affected countries in the world when this index is taken into consideration. With one of the worst fatality rates, the total number of cases in Delhi has crossed 1,180,002. [Table 1] represents the comparison of fatality rates for the states of Kerala and New Delhi.[3] Based on this assessment, it was decided to assess the factors behind their performance and to suggest the measures to improve the existing scenario.
Table 1: Comparison of fatality rates for the states of Kerala and New Delhi

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  Discussion Top

Delhi government in the 1st week of April presented the model of “5Ts”[3] as its strategy to combat the menace of COVID-19 pandemic.[4],[5] These are testing, tracing, treatment, teamwork, and tracking. Delhi government felt that by following the South Korean model of massive testing, the infected will be identified at an early stage itself by this aggressive strategy. Tracing refers to identifying the individuals who came into contact with an infected person and quarantining them to effectively break the chain. Treatment implies treating people with varying levels of infection that necessitates setting up of COVID-19 testing centers, COVID care centers, COVID health centers, and COVID hospitals, plus the procurement of personal protective equipment, ventilators and oxygen beds. The government's strategy included setting up of 30,000 beds (8000 beds at hospitals, 12,000 hotel rooms, and around 10,000 beds in banquet halls). It was decided that patients with serious medical conditions and those above 50 years will be kept in hospitals and others in hotels and other similar facilities. Teamwork of all key stakeholders including central and state governments, opposition parties, and nongovernmental organizations are critical for the success of reigning in on this deadly virus. The fifth aspect, tracking, refers to keeping strict monitoring on the first 4T's on how successfully they are being implemented.

Delhi government started a taskforce to prepare the various administrative arms of the government in this massive task. The various government agencies were entrusted with the task of appraising the various sections of the society about COVID-19 and spreading advisory on the do's and don'ts. After the nationwide lockdown was announced, the state government declared relief measures for the needy which included (i) setting up of temporary relief centers and hunger relief centers and (ii) provision of temporary ration cards.

To educate and to prevent people from panicking and to ensure timely response, it is necessary to keep the public updated about the status of the spread of the disease and various government decisions in this regard. The measures taken include setting up of an exclusive WhatsApp COVID-19 helpline number and a COVID app. However, such measures have so far not been successful in reducing the fatality rate and the spread of disease in New Delhi.

There are a multitude of reasons why Delhi has recorded a high number of positive cases in the country. The highly dense and urban nature of the country's capital must have contributed to the fast spread of the virus. Delhi, being the national capital and one of the major arrival destinations for people traveling to India, received a sizable number of coronavirus-positive people who returned home from abroad.

A total number of 20,000 beds provided by the state government for a population of nearly 19 million have been found to be inadequate. The standard operating procedure laid down to control the spread of the disease was not followed vigorously. The limited number of beds, shortage of medical workforce, and high number of patients forced the government to slow the testing rate as well as limiting healthcare only to Delhi residents which was later revoked. Lack of proper coordination between the Union health ministry, Delhi government, and Municipal Corporation of Delhi that controls various hospitals in Delhi compounded the matter to a great extent. Multiple orders from the Lieutenant Governor (LG's) office and Delhi government clearly indicate lack of coordination between them to fight COVID-19. The most critical factor impacting the collective fight against COVID-19 is the national capital's long-neglected tertiary healthcare system. Allocations in the health sector were limited to the primary healthcare facility expansion, and initiatives such as free medicines, and critical patient surgeries among others.

Delhi, one of the country's four metro cities, being the national capital city, has the distinct advantage of mobilizing medical equipment easier than many of the other affected areas. However, the community-based approach to counter the spread of the disease does not work in metro cities due to the lack of effective public participation in the local tier government institutions.

The strategy adopted by Kerala in its exceptional fight against the virus, which at one time by May had flattened the infection curve, was investigated. The state began its preparation as early as the outbreak of the disease in Wuhan, China, based on the lessons learned from the Nipa epidemic, which was a more localized outbreak. On the detection of the first case, the entire state machinery led by the health department sprang up into action and initiated contact tracing in association with the public. The state went into a lockdown even before the declaration of the national one closing down schools, workplaces, banning gatherings, etc.

The effective surveillance system that was deployed at the four airports to screen passengers bound from outside India was extended to the community level with the monitoring of the health department and assistance from elected members of local self-governments, local self-help group named Kudumbashree, and the public. The government started to plan for the worst from the beginning by seeking cooperation from private hospitals to safely quarantine people. Even empty houses were identified for the process in the worst-case scenario which resulted in identifying around 100,000 hospital beds[4] which could increase up to 200,000. Local self-help groups were tasked to manufacture face masks, sanitizers, etc., to prevent its shortage.

They took charge of the treatment of all COVID-19 patients as their responsibility. It needs to be highlighted that the treatment of the government health system could successfully cure a 93-year-old man and two 80-year-old patients from COVID-19. The state which had one testing facility at the onset of the pandemic quickly increased it to 14 within a month's time.[6] Similarly, COVID-19 wards and exclusive COVID-19 hospitals were set up in quick time.

The state gave high importance to social security measures starting with Rs. 2000 crore relief package.[6] The measures included disbursement of social welfare pensions, interest-free loans to self-help groups, and free ration to all cardholders. Extensive arrangements (approximately 20,000 units) were undertaken to provide cooked food or food materials for the 2.5 million strong in-migrant community in Kerala. In addition to these, free meals were also provided to the needy with the help of Kudumbashree volunteers.

The community-based approach followed by the state was led by the effective three-tier local panchayat system, and they successfully mobilized volunteer support for the mission. Special teams at the ward levels were constituted under the leadership of the elected members, and this gave necessary support and comfort for the public who found solace in them. Clear demarcation of responsibilities and directions to all medical institutions from the level of the primary health center to the various medical colleges in the state was made. The field-level staff including Accredited Social Health Activists workers functioned as teams with definite protocols and instructions. The grass-root-level elected members and Kudumbashree members were given adequate training. District-level officials led by District collectors, District Medical officers, and District Police Chiefs coordinated the entire process.

The high-level war room functions under the directions of the Chief Minister (CM) who communicated with the public directly through his daily briefing established an effective awareness program to allay any apprehensions of the general public. The communication strategy is focused on transparency in sharing accurate information on COVID-19, to explain all problems and dangers – providing confidence to the public. The CM explains in detail the measures taken till date and what they propose to undertake in the coming days to tackle specific issues related to controlling the pandemic.

Kerala's approach to tackle COVID-19 could be implemented in any state for medical emergencies. To implement such a model, the concerned state should turn its attention on empathy and welfare. A national strategy should be designed to strengthen the public healthcare systems for all states in line with Kerala model. Private healthcare facilities or market-driven health insurance schemes cannot replace the state's involvement in public healthcare which has been one of the biggest lessons from this pandemic. The Kerala model has highlighted the advantages of a strong and vibrant local self-government system, which is further strengthened in association with self-help groups. Such a change can be easily implemented in India which is home to more than 250,000 local panchayats and 3 million plus elected members. It is estimated that around 40% of them are women.[6]

The biggest advantage possessed by Kerala in countering the COVID-19 spread is the grass-root-level public involvement in the government's effort to curb the spread of the virus. The high literacy level among the residents also has helped the government in cascading information related to controlling the spread to each household in an effective manner. However, the state lacks enough financial resources to increase the health infrastructure to counter the pandemic.


We thank Dr. Rajani Panchang, Assistant Professor, Department of Environmental Sciences, SPP University, Pune, who provided her insight and expertise that greatly assisted this research work. We would also like to show our gratitude to Mr. Sameer Muneer, Former Faculty Member of TKM College of Engineering, Kollam, for sharing his pearl of wisdom with us during this research and for his valuable comments that greatly improved the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

www.worldometers.info. India. Available from: https://www.worldometers.info/coronavirus/. [last accessed on 2020 Jun 09].  Back to cited text no. 1
Mohf.gov.in. India. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Jul 18].  Back to cited text no. 2
Ghani AC, Donnelly CA, Cox DR, Griffin JT, Fraser C, Lam TH, et al. Methods for estimating the case fatality ratio for a novel, emerging infectious disease. Am J Epidemiol 2005;162:479-86.  Back to cited text no. 3
Chatterjee C, Jain R. Is COVID-19 Equally Deadly across All States; 2020. Available from: https://www.ideasforindia.in/topics/macroeconomics/is-covid-19-equally-deadly-across-all-states-a-preliminary-examination.html. [Last accessed on 2020 May 01].  Back to cited text no. 4
Goswami B. An Exploration into Delhi's COVID-19 Response Model. New Delhi; May, 2020. Available from https://practiceconnect.azimpremjiuniversity.edu.in/an-exploration-into-delhis-covid19-response-model/. [Last accessed on 2020 Jul 01].  Back to cited text no. 5
Vijayanand SM. Kerala's management of COVID-19: Key Learnings. Government of Kerala; 02 May, 2020. Available from: https://www.ideasforindia.in/topics/governance/kerala-s-management-of-covid-19key-learnings.html. [Last accessed on 2020 Jul 01].  Back to cited text no. 6


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