Public Health Action

VOL 13 no s1 PUBLISHED MARCH 2023

KERALA SUPPLEMENT

Combatting emerging infectious diseases from Nipah to

COVID-19 in Kerala, India
K. C. Prajitha,1 V. Babu,2 A. Rahul,3 M. J. Valamparampil,4 P. R. Sreelakshmi,5 S. Nair,6 R. P. Varma7

http://dx.doi.org/10.5588/pha.22.0024
Kerala had contributed to possible service delivery im- AFFILIATIONS
BACKGROUND: The state of Kerala, India, has experi- provements during these growing public health con-
1 Department of
Community Medicine,
enced several unprecedented events in the past few cerns. However, although the decentralisation of the Government Medical
years. The current study was an attempt to explore per- public health system in Kerala is often cited as a suc-
College,
Thiruvananthapuram,
ceptions of stakeholders on how the decentralised system cess, it has not yet attained its full potential.7 In a situ- 2 Comprehensive Stroke
helped during the Nipah virus (NiV) outbreaks and ation where it is speculated that more emerging zoo- Care Programme,
Department of Neurology,
COVID-19 pandemic in Kerala. notic infections, including NiV, might spread in Sree Chitra Tirunal
METHODS: This study used a qualitative descriptive ap- pandemic proportions in the near future,8 this study Institute for Medical
Sciences and Technology
proach built on the advocacy paradigm. The stakeholders aims to understand the perceptions of stakeholders on (SCTIMST),
who were involved in decision-making and the represen- how the decentralised system helped during the NiV Thiruvananthapuram,
3 Indian Council of Medical
tatives of local self-government who had real-time experi- outbreaks and COVID-19 pandemic in the state of Research Vector Control
ence and had handled the challenges were identified us- Kerala. Research Centre,
ing purposive sampling. Seven key informant interviews Puducherry,
4 State Consultant for
(KIIs) and nine in-depth interviews (IDIs) were conducted. Health and Wellness
RESULTS: Findings indicate that decentralisation had METHODOLOGY Centres, National Health
Mission,
enabled the state to effectively deal with the outbreaks Thiruvananthapuram,
and the pandemic. The survey revealed four major Setting and context 5 SUT Academy of Medical
Sciences,
themes: decision-making, engagement level, people-cen- The 2018 NiV outbreak occurred in two northern dis-
Thiruvananthapuram,
tric action, and difficulties. Two to four categories have tricts of Kerala and the index case was reported from 6 Department of Respiratory
Changroth village in Quilandy Taluk of Kozhikode Medicine, Government
emerged for each theme. Medical College, Thrissur,
CONCLUSION: The study results highlight the impor- District.9 One year later, in 2019, the second NiV out- 7 Achutha Menon Centre for
tance of human resources and service delivery as balanc- break in Kerala was reported from the Vadakekara Pan- Health Science Studies,
SCTIMST,
ing factors during public health emergencies in any de- chayat (the ‘panchayat’ is the lowest level of gover- Thiruvananthapuram,
veloping nation with limited resources. Given that very nance and administration unit in India) in Ernakulam India

few nations have the healthcare infrastructure and re- District.3 The first COVID-19 case was reported from CORRESPONDENCE
sources necessary to cater to the healthcare needs of the the Trissur District of Kerala, and within months, Correspondence to: Mathew
J Valamparampil, Health and
whole population, decentralisation should be reinforced. COVID-19 cases were reported from all other districts. Wellness Centres, National
A qualitative exploration was required to understand Health Mission,
Thiruvananthapuram, Kerala,
the degree of improvisation in surveillance mecha- India. Email:

K
nisms and the close collaborative activities between mathewjvalamparampil@
erala, the southernmost state of India has experi- gmail.com
the local government and the health system during
enced several unprecedented events in the past
the NiV outbreak, and how the previous experience KEY WORDS
few years, from raging floods to outbreaks of viral dis- Kerala; local government;
with two NiV outbreaks facilitated a prompt prepared-
eases. When the Nipah virus (NiV) outbreak was re- public health threats;
ness in the state during the COVID-19 pandemic. decentralisation; COVID-19
ported for the first time in May 2018, the health sys- pandemic
tem of the state was able to contain the outbreak by Research procedure and participants
mid-June with the involvement of the local govern- A qualitative descriptive approach using in-depth
ment. The outbreak was limited to 18 laboratory-con- (IDIs) and key informant interviews (KIIs) built on the
firmed cases by focussing on the prevention of infec- paradigm of advocacy was used to explore the objec-
tion based on isolating patients, contact tracing and tives. For a comprehensive understanding of the re-
other measures.1,2 During the second NiV outbreak in- search question, the researchers have used document
fection in June 2019, the whole public health system review along with qualitative exploration. The search
provided a swift response to contain to the index case terms used were Nipah AND Kerala, Nipah AND de-
and the number of deaths.3,4 The experience with the centralisation in Kerala, COVID AND Kerala local gov-
NiV outbreak instilled confidence and enhanced the ernance, COVID AND decentralisation in Kerala. A to-
skills in surveillance mechanisms at the grassroot tal of 26 peer-reviewed full-text articles available in
level. This enabled the health system of the state, PubMed Central were reviewed for the study. The
Received 1 May 2022
along with the local government, to be prepared for study was conducted from December 2020 to April Accepted 20 September 2022
the first COVID-19 case in India in January 2020.5,6 2021. The stakeholders who were involved in deci-
In light of this, it was deemed necessary to compre- sion-making and the representatives of the local PHA 2023; 13(s1): 32–36
hend how the decentralised public health system in self-government, who had real-time experience and e-ISSN 2220-8372
 Public Health Action Decentralisation and emerging infectious diseases 33

had dealt with the challenges, were identified using the codes and categories. The codes and findings were ACKNOWLEDGMENTS
The authors thank the local
purposive sampling; data collection was continued un- presented to this mixed group. The final report with self-government of the
til saturation. Seven KIIs and nine IDIs were conducted the themes was also circulated among the investigators Government of Kerala for
granting permission to
(Table 1). for peer scrutiny and among public health experts to undertake the study; all our
The investigators who had received training in ensure credibility and test its reliability. Investigator participants, who
co-operated with us amidst
qualitative research contacted the participants over the triangulation with the involvement of multiple re- the pandemic; R S
phone and to ask about their willingness to participate searchers brought different perspectives to the data Gopakumar, Health Officer of
in IDIs. After obtaining verbal consent, an appoint- and helped to reduce bias and individual subjectivity Kozhikode Corporation, for
helping in the process of
ment was made with the local government representa- during the interpretation. data collection; HSTP (Health
tives at a time and place of their convenience. Due to Systems Transformation
Ethics statement Platform) for supporting this
geographical dispersion of the interviewees and the re- research; and Sir Ratan Tata
Ethics committee clearance for the study was obtained
strictions on movement due to the pandemic, online Trust for the financial
from the Institutional Ethics Committee, Health Ac- contribution which made
platforms were utilised for conducting interviews and this research possible. The
tion by People (HAP), Thiruvananthapuram, Kerala,
informed consent was emailed. Of the 14 interviews, funders had no role in data
India (EC2/P1/Sep/2020/HAP). Permission was ob- collection and analysis or
11 were conducted using online platforms. Three di- preparation of the
tained from the local self-government for conducting
rect interviews were conducted at the office of the in- manuscript.
the study. All interviews were conducted after obtain- The manuscript was
terviewee maintaining all COVID-19-related precau-
ing informed consent and confidentiality was main- prepared from one of the
tions. The KIIs and IDIs lasted for 45 min–1 h and sub-themes of the project,
tained throughout the study. Separate permission was Local Government and
1–1.5 h, respectively. The interviews were conducted
obtained for audio-recording of the direct interviews, Health in Kerala,
using an interview guide and were participant-led. implemented by Health
and for audio, as well as video, recording of interviews Action by People,
Standards for Reporting Qualitative Research (SRQR)
conducted using the online platform to ensure the Thiruvananthapuram, Kerala.
guidelines were used to report the study results.
quality of the transcripts. All participants were given
Qualitative analysis the freedom to refuse or withdraw from the study at
During each session, the interviewer made notes and any time.
on termination, summarised the information collected
for the interviewee to determine accuracy. Recordings
were in the native language and were transcribed and RESULTS
translated to English. Thematic analysis using a deduc-
The data resulted in the emergence of 40 codes and
tive coding process was conducted. A document review
four main themes (Table 2).
was used in developing codes; pre-existing constructs
based on the existing literature was used in theme gen- Decision making
eration. The transcripts were compared with the notes Strong foundation
made during the sessions; quotes and extracts thus ob- All of the KII participants were homogenous in their
tained have been directly quoted here. The transcripts view of the legacy of the strong public health system
were read several times and coded manually by the of Kerala and the public health activities with people’s
first and second authors. The codes were rigorously re- participation in the state even before the introduction
viewed by all of the investigators and were categorised of decentralisation. The process of decentralisation by
after several discussions. Meetings were conducted endowing the local government with all development
with public health experts and persons experienced in functions has helped in tapping the existing capabili-
administration decentralisation to test the reliability of ties and skillsets at the grassroots level. This resulted in

TABLE 1 List of key informant and in-depth interviews

KIIs KII 1 An administrative officer working in the local government department of Kerala
KII 2 State planning board member
KII 3 State-level Public Health Officer #1, Directorate of Health Services
KII 4 Director, Kerala Institute of Local Administration, Thrissur, Kerala, India
KII 5 National level consultant in Panchayati Raj and local-level planning
KII 6 State-level Public Health Officer #2, Directorate of Health Services
KII 7 Public health activist and consultant in state-level public health projects
IDIs ID1 1 Local government representative #1, Changroth grama panchayat
IDI 2 Local government people’s representative #2, the Kozhikode Corporation
IDI 3 Health system representative from the Kozhikode Corporation
IDI 4 Local government people’s representative #3, Vadakekara grama panchayat
IDI 5 Local government people’s representative #4 from the municipality area of the northern district where clustering of COVID-19 was
reported
IDI 6 Local government people’s representative #5 from grama panchayat area of the northern district where healthcare facilities and
resources are limited
IDI 7 Health supervisor from the southern district where community transmission of COVID-19 was reported
IDI 8 District mission coordinator of Kudumbashree (women self-help group of Kerala)
IDI 9 Junior health inspector working in the district medical office of a northern district with a high COVID-19 case burden
KII = key informant interview; IDI = in-depth interviews.
 Public Health Action Decentralisation and emerging infectious diseases 34

TABLE 2 Themes and categories emerged in the study Extent of engagement

Data analysis revealed that during the NiV outbreak in 2018, and
Sl no: Themes Categories later in 2019 (a single confirmed case), the role of the local gov-
1 Decision-making • Strong foundation ernment was limited. However, the very nature of the COVID-19
• Evidence-based decisions pandemic necessitated its management in a decentralised manner,
• Inclusive communication as needs arising at the local level demanding a prompt response.
2 Extent of engagement • Decentralised enforcement mechanisms
• Grassroot-level network Decentralised enforcement mechanisms
• Community participation Enforcement of protocols mandating mask-wearing and social
• Repurposing of resources
distancing was thought to be the most important step with regard
3 People-centric action • Identifying gaps
to controlling the COVID-19 transmission. The same was
• Emphasis on local action plans
achieved to an extent with the concerted action of police person-
4 Challenges • Institutional shortsightedness
• Exercising power in decentralisation nel, teachers, local government and several other Government
departments. This was largely made possible by taking the people
into confidence by improving awareness at the local level under
strengthening the local government and ensured the involve- the leadership of the local government.
ment of the local government in healthcare activities at the grass-
Loudspeakers were tied on all the roads in the five parishes, there
roots level. were around a hundred loudspeakers. Through that our medical
Perhaps the reason why Kerala looked at the constitutional amend- officer and other staff were giving notices from time to time. We
ments as an opportunity, was because of its legacy of strong public also tried to convey our message on COVD-19 preventive strate-
action. (Administrative Officer working in local government de- gies through the church. (HS 7)
partment of Kerala, KII1)
Grassroot-level network
Most of the key informants felt that 25 years of decentralised The strong grassroot level network of women’s self-help groups
governance had paved the way for a strong public health system (locally termed “kudumbashree”), Anganwadi workers (outreach
in Kerala that has encouraged social behaviour that is conducive workers from the Integrated Child Development Service Scheme),
to the prevention of water-borne and other communicable dis- and Accredited Social Health Activists (ASHAs) (group of women
eases, and improved healthcare-seeking behaviour and the sur- recruited through the National Health Mission, Thiruvanantha-
veillance system in the state. It has also enhanced the deci- puram in Kerala played a significant role during the lockdown pe-
sion-making capability of policymakers at all strata by adopting riod. These networks participated in door-to-door symptom sur-
preventive strategies, which was reflected during the current veys and ensured the quarantine of suspect cases during the NiV
COVID-19 pandemic. outbreak and the COVID-19 pandemic. They were instrumental
in establishing the ‘community kitchen’, along with the public
Evidence-based decisions
distribution system, thereby ensuring an uninterrupted food sup-
All the study participants agreed that the process of decision-mak-
ply to quarantined people, the destitute and migrant labourers.
ing during any public health threats needs to be based on evi-
dence and scientific rigour for better penetration and acceptance We have a structured system established at the ground level and
at the community level. when rapid response team was formed even at ward level, we be-
came a major entity. This network enabled us to contribute well
An individual’s or family’s or society’s healthcare is vested with the during the COVID-19 pandemic, be it supplying food to ‘COVID
local government and it is their major responsibility. The general first-line treatment centres’ (CFLTC) or managing community
instructions and guidelines or advice will be provided from the kitchens, or manufacturing cloth masks and sanitizers at the local
state or national level owing to the expertise, but the implementa- level. (DMCK, IDI 8)
tion based on the evidence happen at ground level. (State Plan-
ning Board Member, KII 2) Community participation
During the Nipah outbreak, an area with 10 households was kept in
During the Nipah outbreak in 2018, regular fever surveys were isolation for about 15 days. Initially, it was fear all around, but see-
conducted in Changroth panchayat by the local government in ing the active involvement of local representatives, many youths of
collaboration with the health department, and in 2020 during the locality volunteered to arrange food and other needs of those
the COVID-19 pandemic, the local government was instrumental families. (Local government people’s representative 1, IDI 1)
in implementing several preventive strategies announced by the
state. The proactive action of local government in social mobilisation
was more evident during the COVID-19 pandemic. At the ward
Inclusive communication
level, committees, panchayat members, ASHA, Kudumbashree
Whenever there was an issue warranting immediate decision, a
meeting would be held with the representatives from all fields in- workers, community volunteers and youth organisations worked
cluding grass root level workers and volunteers at panchayat level together under the broad umbrella of the panchayat government.
or ward level and a decision will be sought through proper com- This synergism in activities resulted in the effective utilisation of
munication. Now during COVID-19 due to repeated meetings for resources and met the needs of the people promptly. The collabo-
every issue, we all became experts in online platforms. (Local gov- ration between grassroot networks and the people, along with the
ernment people’s representative 4, IDI 5) local government enabled the dissemination of information at dif-
ferent levels and countering of misinformation to a certain extent.
This focus on inclusiveness in transferring information and
obtaining feedback for implementation made the process easy During the pandemic, ASHA along with community volunteers
and swift. This helped build trust among the people and ensured gathered data that enabled tracing of almost all the contacts of the
the people’s adherence to the necessary precautions. positive patients in the initial wave, thereby preventing further
 Public Health Action Decentralisation and emerging infectious diseases 35

spread of infection. Also, they helped in preparing the list of vul- breaks, surveillance and measures to control the spread of infec-
nerable people in the locality and played a pivotal role in ensuring tion were key in the management of the diseases, rather than
infection control practices. (Health Supervisor, 1D1 7) treatment. The lack of better public health capacities that would
provide long-term benefits was mostly replaced by knee-jerk reac-
Repurposing of resources tions, which posed a great challenge to local government during
Even before the COVID-19 pandemic, the disaster management these public health threats.
committee had identified volunteers from each ward and pro-
Exercising power in decentralisation
vided them with training. When the COVID-19 pandemic hit the
As elected representatives, who were the decision makers at grass-
state, these volunteers helped to overcome the lack of human re-
root levels, had varying educational background, public health
sources. The efficient handling of field expertise of ASHA and An-
personnel found it difficult to empower them in technical mat-
ganwadi workers strengthened the COVID-19 preventive and sur-
ters. This was true to some extent with regards to even profession-
veillance activities.
als in allied departments. There was reluctance and fear, at least
When the number of COVID-19 cases increased, unoccupied
among some officials regarding the financial liabilities related to
buildings and nearby schools were converted into quarantine and
the implementation of rapid decisions, resulting in slow-paced
treatment facilities by the local government, along with the disas-
and incomplete actions.
ter management authority.
When 83 out of 260 inmates of a psychosocial rehabilitation cen-
tre turned positive, we thought the situation will get out of hand DISCUSSION
as a majority of these inmates were either mentally challenged or
destitute of elderly age. Immediately, the local government con- Kerala is renowned for its governance capacity that evolved over
verted a nearby college institution to Covid-19 First Line Treat- time and its development model based on social determinants of
ment Centres and positive patients were transferred there, pre- health, which enabled to alleviate endemic deprivation and
venting further spread. (JHI, IDI 9) achieve a noteworthy health status despite inadequate re-
sources.10,11 The state is known for its high literacy rate, which
People-centric action has positively contributed to the administrative decentralisation
Identifying gaps of the state.12 The NiV outbreaks, as well as the COVID-19 pan-
During the Nipah outbreak in 2019, we had only one confirmed demic, have stretched its administrative capacity and exposed the
case with 25 people in quarantine in our panchayat. But that vulnerabilities of the state’s system of decentralised governance.
helped us to identify the gaps and enabled us to prepare well and During the NiV outbreaks, a top-down approach was adopted
respond swiftly when COVID-19 hit us with a large number of in decision-making, allocation of resources and designation of du-
cases. (Local government people’s representative 3, IDI 4)
ties.2 Lack of experience and fear caused by the fatal virus at the
grassroots level hindered the local government from exercising
Both local government members and public health personnel
administrative authority and relegated it to executing activities at
found that shortfalls at the panchayat level varied throughout
the grassroots level under the direct supervision of state and dis-
time and place. Inadequacies were initially observed in the avail-
trict level systems.13 However, the NiV outbreaks and the unex-
ability of trained human resources for the management of indi-
pected floods in the state had offered first-hand experience at the
viduals in quarantine and isolation, surveillance and disinfection.
grassroots level and trained the local administration in coordinat-
Numerous panchayats faced a lack of personal protection equip-
ing various sectors and mobilising available resources during a cri-
ment (PPE) and medical supplies for palliative patients. In certain
sis. This allowed the local administration to respond quickly
panchayats, the facility for transporting patients to higher-level
during the initial phase of COVID-19 by identifying the potential
medical facilities was disrupted.
of accumulated social capital, leveraging established networks,
Emphasis on local action plans and repurposing the available resources.6,10,14,15 Nevertheless,
The analysis of data from IDIs revealed that the process of decen- challenges in the implementation of preventive measures at the
tralisation had enabled the local government to implement proj- grassroot level highlighted the need for improved strategies.16
ects according to local needs, as well as to allocate funds even at Taking advantage of administrative, budgetary, and political de-
the ward level. During these public health emergencies, the funds centralisation, the local government was able to ensure superior
were used to a large extent for purchasing PPE kits, medicines and service delivery and become the state’s major community partici-
the management of Covid-19 First Line Treatment Centres. pation player.14,17,18
The eleven categories that emerged from the study are directly
When the number of patients increased beyond the capacity of
CFLTC in certain panchayat of our district, an immediate decision or indirectly linked to the six core components of the building
was home isolation with SPO2 monitoring. But the majority of block framework that contribute to the strengthening of the
poor people couldn’t afford to buy a pulse oximeter. Within three health system.19 Although all of the building blocks were found
days, all panchayats bought twenty pulse oximeters each from to be equally important, the majority of the categories that
their funds and handed them over to needy patients till the period emerged in the study were directly linked to human resources and
of isolation. (JHI, IDI 9) service delivery, which highlights the importance of these two
factors in handling any public health threat.
Challenges However, the uncertainty of the pandemic is taking a toll on
Institutional shortsightedness frontline workers and has disrupted the balance at the grassroot
Some of the participants were of the opinion that, for a long time, level, exposing vulnerabilities and shortcomings; this underlines
the local government had concentrated on building hospital in- the state’s failure to advance decentralisation to its full poten-
frastructure and in-patient wards rather than on capacity building tial,10 and demands rethinking and revisiting the strategies to-
and training individuals in preventive activities. During the out- wards as future public health threats appear to be inevitable. The
 Public Health Action Decentralisation and emerging infectious diseases 36

COVD-19 pandemic has given an opportunity to the state to ex- 5 Sadanandan R. Kerala’s response to COVID-19. Indian J Public Health
tend decentralisation by focussing on elements of cohesiveness 2020;64(6):99–101.
6 Rahim AA, Chacko TV. Replicating the Kerala state’s successful COVID-19
and sustainability and investing more in the public health containment model: Insights on what worked. Indian J Community Med
system. 2020 J;45(3):261–265.
7 Nair MS, Naidu VN. Public health interventions by local governments in
kerala: an effectiveness analysis. BMJ Global Health 2016;1(1):OP-24.
CONCLUSION 8 Devnath P, Masud HM. Nipah virus: a potential pandemic agent in the con-
text of the current severe acute respiratory syndrome coronavirus 2 pan-
The lessons learnt from Kerala provide a balanced perspective of demic. New Microbes New Infect 2021;41:100873.
the evolution of a decentralised public health system and how it 9 Arunkumar G, et al. Outbreak investigation of Nipah virus disease in Kerala,
India, 2018. J Infect Dis 2019;219(12):1867–1878.
can be utilised during a threat to public health. The results high- 10 Chathukulam J, Tharamangalam J. The Kerala model in the time of
light the importance of human resources and service delivery as COVID19: rethinking state, society, and democracy. World Dev
balancing factors during public health threats in any developing 2021;137:105207.
11 Singh T. Trivandrum: poverty, unemployment and development policy : a
nation with limited resources. case study of selected issues with reference to Kerala. India Q
1979;35(1):138–140.
Limitations 12 Kannan KP, et al. Kerala: a unique model of development. Health Millions
The main aim of the study was to understand the perceptions of 1991;17(5):30–33.
stakeholders on the decentralised response to NiV outbreaks and 13 Rahim AA, et al. Evaluation of the Nipah epidemic containment and multi-
the COVID-19 pandemic; the challenges and lacunae that sectoral involvement in Kerala using an appropriate management frame-
work. Int J Community Med Public Health 2020;7(7):2813–2819.
emerged as a main theme based on the study findings were not 14 Prajitha KC, et al. Strategies and challenges in Kerala’s response to the initial
explored in detail. Every effort was made by the authors to reduce phase of COVID- 19 pandemic: a qualitative descriptive study. BMJ Open
the risk of potential bias in answers using appropriate questions 2021;11:e051410.
15 Radha D, Kumaran JA, Nair MT. Role of local self-governments in control of
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CONTEXTE : L’État du Kérala, Inde, a connu plusieurs évènements RÉSULTATS : Les résultats indiquent que la décentralisation a
sans précèdent au cours des dernières années. Cette étude a cherché permis à l’État de gérer les épidémies et la pandémie de manière
à analyser l’opinion des parties prenantes quant à l’aide apportée par efficace. L’enquête a mis en évidence quatre thèmes majeurs : prise
le système décentralisé pendant les épidémies de virus Nipah (NiV) et de décisions, niveau d’engagement, action centrée sur les personnes
la pandémie de COVID-19 au Kérala. et difficultés. Chaque thème a pu être divisé en deux à quatre
MÉTHODES : Cette étude a eu recours à une méthode descriptive catégories.
qualitative construite à partir du paradigme de mobilisation. Les CONCLUSION : Les résultats de l’étude soulignent l’importance des
parties prenantes impliquées dans la prise de décisions et les ressources humaines et de la fourniture de services en tant que
représentants des administrations locales autonomes, forts de leur facteurs d’équilibre en période d’urgence de santé publique dans
expérience en temps réel et de leur expérience de gestion des défis, tous les pays en développement dotés de ressources limitées. Puisque
ont été identifiés par échantillonnage dirigé. Sept entretiens avec des très peu de pays disposent des infrastructures de santé et des
informateurs clés (KII) et neuf entretiens approfondis (IDI) ont été ressources nécessaires pour répondre aux besoins sanitaires de
réalisés. l’ensemble de la population, la décentralisation devrait être renforcée.

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