The shutting down of cities and public transport triggered a massive urban to rural migration in India after Prime Minister Narendra Modi announced a nationwide lockdown.
While the coronavirus outbreak has united India like never before, it has also revealed starkly deep social inequities in cities. India’s migrant workers are part of its urban poor undertaking low-paying, often hazardous informal market jobs. The 2017 Economic Survey of India estimates the total number of internal migrants in the country to be a staggering 139 million. It is estimated that 81 per cent of all employed persons in India make a living in the informal sector. And 52–98 million people live in urban slums, most of which (59 per cent) lack legal recognition by the government.
Several states initially caught on the back foot at the enormous human displacement that the coronavirus lockdown failed to anticipate, sprung to action amidst civic outcry. Most responses were ad-hoc, ranging from transportation for migrants, distribution of food, temporary shelters, with tremendous support from civil society. The Modi government has responded with a Rs 1.7 lakh crore relief package for the urban and rural poor that may still be inadequate.
So, what can the Covid-19 crisis teach us about shoring up health system preparedness and governance for vulnerable populations? Solutions need to be both immediate and long term.
Anticipate and prepare
The first solution is to anticipate, plan and coordinate. The Centre and states need to work together to anticipate the spread of the coronavirus amongst vulnerable groups. Slums and shanties must be prioritised and prepared for community transmission during this containment and mitigation phase.
Now, and during phased lifting of the lockdown, urban municipal governments should implement repeated targeted testing of those communities who have little provision for self- isolation or access to good sanitation. There have been recommendations to use a pooled-testing strategy, which could be applied to geographic clusters within urban shanties and to rapidly test groups of individuals within each cluster to pick up traces of the virus. Testing alone is ineffective without being able to isolate and contact trace. Indian cities need to simultaneously prepare for temporary quarantine facilities to isolate those who are positive or symptomatic.
Engage informal health workers
Two, engage informal economies in fighting the pandemic. Seventy per cent of urban primary health care is provided by the private health sector. This includes formally qualified general practitioners (GPs), nursing homes as well as informal (un-licenced) healthcare providers and small pharmacies, who are the first point of care for more than 80 per cent of slum populations (Priya R., Singh R. and Das S., Health Implications of Diverse Visions of Urban Spaces: Bridging the Formal-Informal Divide).
The COVID-19 outbreak presents an excellent opportunity to quickly engage and train these informal networks into a frontline workforce for screening, contact tracing and quarantining slum populations. Integrating informal health providers, pharmacies, private GPs and smaller nursing homes into municipal Covid response teams would enable prevention for communities on a much wider scale. Select urban primary health centres can be designated as pandemic preparedness centres for triage and training with private GPs.
Co-opt enterprises to help with Covid
Three, collaborate with industries that employ migrant labour for Covid-19 related response targeted at these populations. Shortage of protective gear, masks, sanitisers and water supply are already issues of concern. Taking a leaf from China and S. Korea, state and city governments can actively co-opt small-medium and larger enterprises in garments, chemicals and construction for manufacturing of masks, and protective gear and infrastructure for quarantines.
Bring in community networks
Four, prepare for the long haul and engage communities. The Centre must support states for a more coherent response or in providing relief to the urban working poor and migrant families. This is the time to take stock of numbers, grain reserves, distribution systems and to work with non-state actors and the community in ensuring food supply, essential care and shelter are provided until lockdowns are lifted.
Engaging local networks also has critical implications for ensuring food and water in congested slum communities. Regular water supply must be ensured and local representatives in slums should be co-opted in the delivery of food and other essentials to the poorest residents. States responses like those of Kerala, Delhi and Punjab around food rations, accepting portable IDs like Aadhaar for cash-transfers, appealing to landlords for rental subsidies and providing shelters for those displaced must be replicated. A portable civic identity is a long-term need of migrant-workers that would enable them to universally access public distribution systems, bank accounts and other entitlements from wherever they may work.
Strengthen health infrastructure
Finally, the current situation warrants a deep reconsideration of public investments in India for health systems capacity and provision of Universal Health Coverage (UHC). Covid-19 while revealing existing health system weaknesses is also a significant contributor to economic contraction of up to of 4-5 per cent GDP. (Annual GDP growth forecast was 6 per cent prior to the outbreak versus the currently projected 1.6 per cent). This makes strengthening of primary health services all the more crucial to ensure a healthy society. This is the time to consider recommendations of the 2011 High Level Expert Group report on UHC and increase health-spending for more frontline health workers, medical supplies, technology and good quality infrastructure for primary health. This has to be a central priority, and states who are already doing this should be further supported.
Crises like Covid-19 force societies to look beyond disease to the social determinants of health. Do we learn from them? Not always, whether it is floods caused by indiscriminate land use, urban droughts brought on by climate change or the ravages of urban air pollution on populations. Cities have shown resilience in overcoming even the toughest of challenges. Yet, resilience has not always resulted in improving urban governance, investing in health system capacity and improving the lives of the urban poor. We have been given the chance of a lifetime, time to start now.
Priya Balasubramaniam is a senior public health scientist at Public Health Foundation of India & Centre for Sustainable Health Innovation, Singapore. Meenakshi Gautham is a research fellow at London School of Hygiene and Tropical Medicine. K. Srinath Reddy is the president of Public Health Foundation of India. Views are personal.