The Indian state of Kerala has been widely held up as a model of efficiency and humanism for its successes over the past year in handling the Covid-19 pandemic. Kerala's ability to cope with India's ongoing second wave has sharply contrasted with the desperate shortages of oxygen and hospital beds across much of the rest of the country.
The face of this success has been KK Shailaja, who was the state's health minister until earlier this month. Mrs Shailaja was controversially replaced by the Left Democratic Front (LDF) government that she is a part of – even though the communist-led coalition won a historic re-election just days earlier. Her exit from the cabinet after five successful years has shocked many, and led to worries that the state government's efficient handling of the pandemic might suffer. However, even though any loss of public confidence during a crisis is unwelcome, the sources of Kerala's performance are far too deep to be overturned by the replacement of a single minister. Understanding why provides hope not only for the state, but for the country and the region at large.
Much of the praise for Kerala in the outbreak phase concentrated on its early and extensive pandemic preparation, and its effective use of contact-tracing to contain the disease. But as Covid-19 spread across India and lockdowns eased, transmission rates in Kerala were amongst the highest in the country. This is not surprising given that Kerala's density of population is the third-highest of any state in the union. But when we look at the ratio of deaths to infections, it has performed better than any other state in the country.
In other words, your chances of surviving Covid-19 in India – if you are unlucky enough to catch it – are better in Kerala than almost anywhere else in the country. This has everything to do with successive governments’ emphasis on expanding access to health care, which meant Kerala had significantly more doctors and patient beds per capita than the national average.
On top of that, the LDF government is engaged in an aggressive, data-driven push to expand the healthcare system’s capacity to cope with the pandemic’s growing demands. It has consciously modelled its approach on the internationally recognised Cuban system, minus that country’s crippling sanctions. The push for highly decentralised, "people friendly" healthcare delivery led the government to launch a major effort last year to upgrade hundreds of rural primary healthcare units to "family health centres", complete with modern lab facilities and extended operating hours.
The idea was to bring high-quality outpatient health care as close as possible to every resident, regardless of location or income. This kind of network has helped ensure that the disease surveillance has remained strong, and that patients aren’t on their own if their health care needs escalate.
This evidence-based approach to planning and delivering affordable public goods is what Indian citizens all across the country have been repeatedly promised; it is a core element of the pledge made to voters by New Delhi's ruling party – the Bharatiya Janata Party (BJP), which ignored scientific advice to hold large campaign rallies and religious events. But Kerala’s success in many ways also problematises the widespread assumption that the BJP’s shortcomings at the central government level are largely responsible for the tidal wave of sick and dying people.
Although there has been a major push towards ever-greater centralisation under the BJP's Prime Minister Narendra Modi, health remains a state subject. The worst-performing states include those run by the BJP, its allies and opponents alike; as do the best-performing ones. Centrally administered Union Territories have, in fact, experienced outcomes ranging from the best to middling. It is clear from the sheer range of conditions that differences cannot be explained solely by which party is currently in power.
However, the central government is still responsible for providing assistance to states during crises. The difficult relationship between the LDF and the BJP – the latter had hoped to make inroads into the state in the recent election – has undoubtedly played a role in the very limited resources offered to the state. This is despite devastating floods, the painful economic contraction caused by the pandemic (including more than a million expatriate workers returning from the Gulf alone), and major changes that have deprived states the ability to directly collect sales taxes.
Kerala’s success, for example, in expanding Covid-19-testing and oxygen production without much external assistance isn’t just a story of the state health ministry. It is also the story of adroit footwork by the state’s finance ministry, backed by political commitment from the cabinet. These policies are unlikely to change under the new, also female, health minister, Veena George. For her part, Mrs Shailaja has now been appointed her party's chief whip, a position of arguably even greater political power.
The aforementioned commitment of the state has built on decades of steady investment in the social infrastructure of the state; education, health care and housing, and a range of programmes intended to provide a safety net for the disadvantaged and the precarious. The strong public consensus for this approach has provided for consistency across a steady alternation of power, usually every five years, between the LDF and its primary opposition in the state, the Congress party-led United Democratic Front coalition.
The question is whether this public consensus can be exported elsewhere in the country and the region. While economic growth in the few states that have adopted the social democratic elements of the so-called "Kerala model" have been lower than the national average – such as West Bengal – poverty has steadily reduced while purchasing power has grown. It has also proved to be politically extremely successful, altering the grounds on which elections are fought.
The horrors of Covid-19 provide India, and its many individual laboratories of governance, a moment to frame their options outside the partisan BJP versus Congress arguments that play out endlessly across television studios and WhatsApp groups. The real choice is between growth-focused capitalism and justice-focused social democracy, between patronage and performance.
Kerala’s sure-footed and agile response to enormous simultaneous crises is something that stands out even on the global stage, and offers hope as complex emergencies such as climate change continue to unfold. Voters elsewhere in the country are unlikely to indefinitely ignore that.
Johann Chacko is a writer and South Asia analyst
