Every day for nearly three weeks, roughly 50,000 to 60,000 new cases of Covid-19 have occurred around the world, of which about 1,500 cases have been reported in India. Historically, pandemics were underpinned by poverty, inequality and discord. Not so with Covid-19, which was carried by jet-setters in their respiratory tracts.
Given the rapid spread and devastating effect of the infection, the world experimented with a combination of strategies: social distancing, lockdowns (complete, partial, only in hotspots), testing (voluntary, compulsory, focussing on risk groups) and cocktails of different prophylactic measures.
At the same time, scientists and advisors have sometimes pushed unproven prevention methods and therapeutic strategies, while modellers have used permutations of assumptions to inform policymakers and the public of the shape of things to come. The intention of these strategies was to stop or slow the epidemic, reduce the pressure on health workers and tertiary care systems, and plan for unprecedented contingencies.
In the face of the coronavirus crisis, the government of India and state governments resorted to a standard practice – that of setting up committees. Though some states labelled these as taskforces, empowered groups, coordination teams and war rooms, most function like committees. With its origins in British-style decision-making, the framework of such committees and the inclusion (and exclusion) of members hinges crucially on the existence of bureaucratic and political loyalties.
But setting up committees during a crisis seems a bit paradoxical. After all, the word “crisis” has its roots in the medical world. It is derived from a late Middle English word that denotes “the turning point of a disease”, and it originates from Latin for krisis or “decide”. The policy that India seems to have followed could be stated thus: when in doubt, set up a committee
Based on government orders and government resolutions and on information on websites and in the media, we reviewed the committees appointed by the Central government and 17 states and Union Territories. The majority were formed to prevent and control the outbreak, monitor and take measures against the spread of Covid-19.
In our assessment of the states that we reviewed, only Kerala and Tamil Nadu stand out as the ones that had the right mix of experts and implementers. Other states had current and retired bureaucrats, eminent clinicians, some scientists and generalists.
Clearly, sufficient thought had not been put into how the committees have been set up, who its members should be, what their roles should be and how these committees would be accountable to the people.
In terms of composition, most committees lacked experienced epidemiologists or specialists like virologists, pulmonologists and modellers who could predict the trajectory of the transmission of Covid-19. The majority of the doctors in the committees were either clinicians or from community medicine departments, most of whom have very little experience in handling outbreaks.
Further, the minutes and proceedings were rarely shared with the public even on websites, other than through press statements. Nearly all member of committees were drawn from their capital cities. The Centre also has not sought representation from states. Expect for one bureaucrat from Kerala on the Indian Council for Medical Research high-level technical committee, state representation to a large extent was absent in Central committees.
Despite the World Health Organisation declaring a pandemic on March 11, it took the Indian government a week to get its act together. It wasn’t until March 18 that the Indian Council for Media Research established a 21-member high-level technical committee to deal with situation, under the chairmanship of Dr VK Paul, a member of the government’s NITI Aayog think tank. Although it consisted of eminent doctors, few members have handled disease outbreaks.
Even though there was little understanding of where the trajectory of the epidemic might head, a decision to impose a lockdown was announced by Prime Minister Narendra Modi on March 24. It was only on March 29 that the Ministry of Home Affairs appointed 11 Empowered Action Groups consisting of 79 officers, most of them Indian Administrative Service officers, with representation from the cabinet secretariat and Prime Minister’s Office.
The Indian Council for Medical Research and the Empowered Action Groups now had to work with the chaos of lockdown and support states on rolling out diagnostics, case management, treatment, procurement and coordination. Despite directions from the highest office and committees in place, no standard operating principles were proposed. These got added gradually, only after states began to demand them.
At the state level, the Delhi government on March 3 constituted a state-level task force comprising 34 members under Chief Minister Arvind Kejriwal, which in turn recommended the establishment of 11 District Task forces headed by District Magistrates.
Kerala set up its first committee to fight Covid-19 on March 19, under the chairmanship of Dr B Ekbal, a member of the Kerala Planning Board, which set its course ahead of the curve. Kerala was better prepared for Covid-19 more so by default than design, thanks to the two Nipah outbreaks, and the early influx of Covid-19 symptomatic patients. It was able to get the right people into the committees who put interventions like contact tracing in place.
Most other states were unprepared and started notifying committees only in the last week of March or the first week of April (Andhra Pradesh, Assam, Goa, Haryana, Rajasthan, Tamil Nadu, West Bengal). The panic was apparent. Most state committees were headed by the chief ministers (Delhi, Goa, Madhya Pradesh, Uttar Pradesh, West Bengal, among others) or chief secretary (such as in Tamil Nadu, Assam). Most of the committees kept adding members and gave birth to more committees and sub-committees, leading to confusion.
The usual suspects
When Tamil Nadu on April 2 set up a 25-member committee headed by the chief secretary, it thankfully had more technical members than bureaucrats. The next day, another committee was set up to decide on treatment protocol consisting of 19 members. mainly clinicians from various medical colleges and corporate hospitals (though sadly without any women scientists).
Tamil Nadu is the only state to have included a representative from the Indian system of medicine and homeopathy. On April 9, nine more “coordination teams” comprising 29 IAS officers, with only one women officer among them, were established.
Not all jurisdictions have massive committees and further sub-committees. Assam had a committee under the chairmanship of the chief secretary consisting of 17 members, all of whom are IAS officers except for the Director General of Police. Chandigarh established a committee under the chairmanship of the governor, consisting of seven members, again all IAS officers.
Goa’s 11 members in the high-level committee have the chief minister as the chairman, the health minister, eight IAS officers and the head of the police. The state epidemiologist is authorised to give updates. In addition, Goa had notified another state level taskforce for information dissemination, surveillance and more. On the other extreme, Rajasthan set up an advisory committee of seven members, four of whom are former professors from medical colleges.
Uttar Pradesh Chief Minister Yogi Adityanath constituted 11 committees each headed by a senior bureaucrat. At the district level, 11-member committees chaired by district magistrate were responsible for Covid-19 control. Each committee reported to the chief minister’s office on a daily basis.
West Bengal announced a committee on March 26 consisting of global luminaries including the Nobel economics laurate Abhijit Banerjee.
The national high level technical committee set up by the Indian Council for Medical Research had 21 members, 15 were from Delhi and four were from the All India Institute for Medical Sciences, Delhi. In the Central government committees and in most states, committee members were nominated by name and their designation (Assam, Delhi, Andhra Pradesh, Rajasthan, Tamil Nadu, Kerala, Uttarakhand, Chandigarh, West Bengal, and Goa (except for the Chief Minister and Health Minister).
Sidelining of key actors
Except in four states (Delhi, West Bengal, Tamil Nadu and Uttarakhand), committees constituted by the Centre and state governments seemed to have side-lined the technical head of health – the Director of Health Services The Director of Health Services leads the team of doctors and allied health professionals in all government facilities and collectively have a rich expertise and experience in managing outbreaks. Excluding the office of the Director Health Service, governments have done a disservice and may be demotivating to personnel.
Further, there was under-representation of specialised agencies like the National Centre for Disease Control, the premier institution for outbreak investigation in India, and National Institute of Epidemiology. The director of the National Centre for Disease Control and the Director of the National Institute of Epidemiology are in the ICMR Committee but missing from other committees. Representatives of the Integrated Disease Surveillance Programme and the National Disaster Management Authority were nowhere in the picture.
Accountability is key
It is important to build on existing structures, rather than setting up parallel structures. There is a need for balancing the composition of the committees with a mix of experts with scientific knowledge to advise on technical aspects and those who are expected to lead the interventions.
The policy preferences that determine how India is fighting Covid-19 are the result of interactions of these committees, which uneasily straddle bureaucratic positions and political beliefs. None of this is evidence based, and therefore expert opinion has seldom been considered within committees.
As the Covid-19 curve continues to rise, the government is rustling up new committees. This of course does not deter the spread of virus. The ad-hoc manner in which committees and members were appointed, and the lack of transparency and accountability to the people does not bode well for India’s battle against the disease. The experience of committees in India shows that they are seldom accountable for their diagnosis and decisions, roles and responsibilities, outcomes, recommendations and corrective actions proposed. A review and audit of decisions made by Covid-related committees are in order.
Sunil Nandraj has been working in the public health sector for more than 30 years including with the World Health Organisation.
Dr N Devadasan is a public health expert with more than 30 years of experience, both at the grass-root as well as at the policy level. He teaches health financing at various universities.
PL Girish is a Delhi-based public health and development professional.
The views expressed in the article are personal.