Kadambari Shah and Prakhar Misra
On March 22, at 5 pm, following Prime Minister Narendra Modi’s request, millions of Indians flocked to their windows and balconies to express their gratitude towards healthcare professionals, police and other essential services providers who are working tirelessly to keep the rest of us safe during the COVID-19 pandemic. Their daily challenge is now their biggest strength: the need to constantly adapt to shifting ground, work in contingencies in the absence of protocols, and develop redress mechanisms along the way. However, they need support from policymakers to help them further leverage their strengths.
Political scientist Michael Lipsky termed frontline workers — doctors, nurses, school teachers, police officers and so on — as ‘street-level bureaucracy’. Described as “public service workers who interact directly with citizens in the course of their jobs, and who have substantial discretion in the execution of their work”, this line of bureaucracy liaises between policymakers and the general public to implement policy objectives.
The defining feature of their jobs is that they are tasked with drawing conclusions and making on-the-spot choices without complete information. In the ethos of the COVID-19 pandemic, there is no time to waste. Data, best practices, and processes are unavailable or non-existent; they are created and change in real-time as the situation evolves. This only exacerbates uncertainties and the need for quick decisions.
Across the globe, street-level bureaucracy is getting creative. In Bhutan, testing has become aggressive. A suspected COVID-19 case was quarantined and tested four times over 14 days. The first three times, the test came back negative, but doctors persisted. On the 14th day — the last day of quarantine — the patient tested positive. In Italy, where resources are stretched thin, doctors are turning to war-time strategies — triaging to help those who are most likely to survive.
These street-level bureaucracy initiatives are complemented by those from policymakers and other authorities.
In Spain, the government has nationalised all private hospitals to ramp up delivery of health services. In the United States, states are calling on retired medical personnel and students to increase the capacity of hospitals to serve a sharply growing number of infected patients.
India spends less than 2 percent of its GDP on healthcare. The WHO states that the ideal doctor to population ratio should be 1:1000. According to the National Health Profile 2019, India has a doctor-population ratio of 1:1457. For those living in rural areas, this ratio plummets to 1:10926. Further, as the Centre for Policy Research’s Yamini Aiyar pointed out on 22 March “doctors in rural primary health centres see barely eight to 10 patients a day.” With the number of active COVID-19 cases in India growing rapidly, the pressure that this is going to put on an already understaffed system is unprecedented.
All this goes to say that innovation by street-level bureaucrats is key to fighting this pandemic. The Hyderabad Police demonstrated ways in which people should wash their hands and sneeze properly, while Chennai had its police wearing helmets that resembled the coronavirus, in an effort to raise awareness. In Kerala, the police collaborated with actors to create videos on hand-sanitizers and self-quarantine, while local health workers took it upon themselves to stop a wedding after knowing that the groom had returned from China.
Policymakers have stepped in to support street-level bureaucrats in different forms.
To start with, the threat of these frontline workers catching the virus is being addressed. The government has contracted three firms to produce medical equipment at a rate of 20,000 pieces per week. Second, other public facilities are used to treat patients. In Kerala, like in the US, medical colleges and hostels are turning themselves into hospitals to reach a wider number of patients and assist with more number of beds. In Mumbai too, several private hospitals have been converted into quarantine centres.
Additionally, experts are pivotal in crafting solutions to issues ranging from direct medical-related effects to indirect effects on the economy and society. The PMO has set up 11 empowered group committees to discuss and inform policy to accompany on-ground functioning, such as through quarantine facilities and public grievance mechanisms.
There are still a few measures that could be undertaken to help street-level bureaucrats. First, ensure and stockpile hazmat suits for delivery boys/girls to protect them. China did this in Wuhan where couriers are being relied on for food delivery and medical supplies. It is important for India to ensure that supply chains are running, with those running them safe. Second, South Korea has set-up drive-through screening clinics where people can undergo testing within 10 minutes, processing up to 15,000 diagnostic tests a day. India should do something similar and reduce contact between frontline workers and patients. This is important given the low testing rate per capita that India has at the moment. Third, quick policies need to have foresight. Several states have taken the call to cut salaries of their employees and dependents, including teachers and pensioners. Such moves, in the long-run, could hurt the street-level bureaucracy immensely.
The only way to fight COVID-19 with low personnel numbers is to plan several steps ahead. The government is doing this in several domains, but it also needs to focus on assisting its street-level bureaucrats to contain this virus.
Kadambari Shah and Prakhar Misra are senior associates at IDFC Institute, a Mumbai-based think tank. Views are personal.
