RESPONSE TO

C VID -19S E R I E S – 6

R E P O R T I

NAVIGATING TO NORMALA RESPONSIVE LOCKDOWN EXIT STRATEGY

T. M. PRANATHI | SHRUTI PRASAD

SCHOOL OF PUBLIC POLICY AND GOVERNANCE

TATA INSTITUTE OF SOCIAL SCIENCES

HYDERABAD

FACULTY MENTOR: ASEEM PRAKASH

About the Series:

The School of Public Policy & Governance, TISS Hyderabad, is

collaborating and supporting the initiative undertaken by its alumnus to

document the response of Union and State Governments to address the

Health, Livelihood and other Welfare concerns posed by COVID-19. The

initiative documents the response from Union and State Governments, Civil

Society, and Business Houses/Leaders.

Note: As we understand, this documentation is a dynamic exercise and will

require constant up-gradation. We will attempt to update it as required and

disseminate it widely.

Sources: The authors have taken due diligence to ensure the accuracy of the

information presented in this document. Any inadvertent omissions/lapses

are deeply regretted. Please inform of any such omissions at

sppg.secretariat@tiss.edu. Immediate measures will be taken to correct the

information.

In the sixth part of the series, an attempt has been made to provide a

more dynamic and comprehensive lockdown exit strategy. The policy

document lays out a staggered approach, taking into consideration the key

concepts of a) uncertain outcomes attributed to early relaxation, b)

infection trajectory and institutional preparedness, c) responsive and

flexible phasing.

About the Authors:

T.M. Pranathi, alumnus of the batch 2016-18, is an aspiring Civil Servant. She was the silver-medalist for

2016-18 batch.

Shruti Prasad, alumnus of the batch 2015-17, was a Chief Minister’s Fellow at the Government of

Maharashtra (2018-19). She was the silver-medalist for the 2015-17 batch.

Faculty Member:

Aseem Prakash, Professor & Chairperson, School of Public Policy and Governance, Tata Institute of Social

Sciences, Hyderabad.

All views expressed in this document are personal and has no relation to any affiliated institution.

CONTENTS

Abbreviations and Terminology 1

Introduction 2

Covid-19 Trajectory: India 3

Phase 1: Rising and Peak Infections 5

Goals 5

Action Points 5

Baseline Conditions 10

Phase 2: Falling Infections 11

Goals 11

Action Points 11

Baseline Conditions 13

Phase 3: Low/ No Infections 14

Goals 14

Action Points 14

Baseline Conditions 15

Post Covid Institutional Resilience 15

References 16

Goals, Action Points and Baseline Conditions:

The report has been structured into 3 Phases, each of these are further sectioned into Goals, Action

Points and Baseline conditions

The Goals summarize broad objectives of each phase.

The Action Points under each of the phases will detail the institutional and operational

interventions, which have already been implemented or need to be put in place before the

subsequent phase.

The baseline conditions are trigger points which bring the next phase into action, or conversely,

push the States back into the previous phase.

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TERMINOLOGY

ABBREVIATIONS

COVID-19 Coronavirus Disease 2019

TPM Tests Per Million

PPE Personal Protective Equipment

CDDEP The Center for Disease Dynamics, Economics and Policy

ICMR Indian Council of Medical Research

MoHFW Ministry of Health and Family Welfare

NDMA National Disaster Management Authority

MHA Ministry of Home Affairs

MeitY Ministry of Electronics and Information Technology

WHO World Health Organisation

CSO Civil Society Organisation

NULM National Urban Livelihoods Mission

The wide-spread and incomparably huge attempt at a lockdown period certainly proved to be effective in

holding down the spread of covid-19 pandemic, given the sheer scale of population in India. The

economic costs of this move have been experienced globally, with countries being put in a Catch-22

situation to choose between saving the economy or saving lives. With the national lockdown coming to a

close on May 3rd, 2020, it is a crucial juncture to examine the policy pathway and come up with a viable

lockdown exit strategy. While a number of states have put forth ideas on phasing out the lockdown, this

report has been authored with the premise that a more dynamic and comprehensive exit strategy is

required, taking into account real progress and preparedness.

This report incorporates three key concepts in the exit strategy framework:

Introduction

Early relaxation - uncertain outcomes: International experience, such as the

Singapore case, shows us that even countries with a robust healthcare system, rule following

populace and prior experience with pandemics are not completely safe from unexpected rising

infections. This points to the potential risk of a second-wave, especially if the lockdown is eased

before the infection peak has passed and in the context of weak institutional infrastructure.

Not just “when” but also “what”: Cautious phasing out requires a comprehensive

approach, where administrative units shift out of lockdown based on two criteria: (a) when the

infections are predicted to peak or fall and (b) what are the institutional and operational capacities

that should be in place. The staggered exit should be taken as an opportunity for strengthening

administrative systems, triggering medium-long term institutional changes, moving towards a more

responsive pandemic control strategy and perhaps creating more resilient futures.

Responsive Lockdown & Exit strategy: Considering the possibility of spike in

infections despite an extended lockdown, the report proposes a flexible approach to a phased exit.

Moderate or strict restrictions can be activated or removed in an adaptive manner, depending on

evidence of infection rates and institutional preparedness.

2

Covid-19 Trajectory: India

Source: Prasad, T.M., @ SPPG, TISS-Hyd data collected from MoHFW and ICMR Created with Datawrapper

3

..Figure A

The above graph depicts the trajectory of confirmed cases and milestone responses in India since

the pandemic was declared a notified disaster by Government of India.

Graph and data sourced from the Center for Disease Dynamics, Economics and Policy (CDDEP)

Current trajectory of confirmed cases in India (Refer figure A)

points to the fact that the lockdown has been effective in

delaying the steep rise in infections.

However, as the projected infections of the post 21-day

lockdown (Refer figure B) show - there is a high possibility of

India experiencing the peak of infections in the coming days.

In addition to this, the Basic Reproduction Number, R0 is

reduced to 2 during the lockdown period, and increases to 2.4

after the lockdown is lifted.*

With the above context, the authors of this report propose a 3-

phase responsive lockdown & exit strategy , where any guided

relaxation of restrictions should be considered only after

the predicted peak period has passed.*

The R0 or Basic Reproduction

Number, is the expected number

of cases generated by one

infection case, in a susceptible

population.

Higher R0 Implies exponential

spread of the disease.

For a real-time measure of such

cases, the authors recommends

using R, or Effective

Reproduction Number, which

proves more useful for decision

making and tracking.

* The report considers the

predicted peak resulting from the

“moderate lockdown” period in

the CDDEP projections (refer

figure b).

Using this model, 3 phases are proposed:

• Phase 1 : Rising and Peak infections

• Phase 2 : Falling infections

• Phase 3 : Few or no infections

Projected total infections (asymptomatic, symptomatic and hospitalised) in India

Figure B

4

i. Mass testing and quarantining

The current strategy for covid-19 testing in

India by and large covers all probable contacts

and dimensions. However, with growing

apprehensions about ‘community transmission’

/ ‘local transmission at a community level’ as

well as rising cases of asymptomatic

individuals testing positive, it is indispensable

to administer vigorous testing mechanisms,

preferably at an exponential rate.

Recent statistics reveal inadequate testing

numbers where approximately 0.27 are being

tested per thousand people, i.e., 270 people

per million population (source:

ourworldindata.org; data as of 18-04-2020).

Further, tests conducted across states are

highly uneven and reflect a disproportionate

screening drill with respect to the population

density.

Phase I

Goals

A. Slowing the transmission of novel coronavirus with adequate focus on ‘flattening the curve’

B. Augmenting the existing infrastructure and developing temporary healthcare capacities

(infra/medicine/equipment)

C. Creating widespread awareness (physical distancing/ hygiene) across people

Action Points

Tests Per Million w.r.t. Population Densities in Indian States

Source: Prasad, T.M., data sourced from Census of India,

2011; The Hindu – as of 18h April, 2020

West Bengal with a higher population density of

1029 person/sqkm has a TPM of 46.9, where as

Rajasthan with a density of only 201 person

/sqkm has a TPM of 516.

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Quarantining: Shelters and beyond

States should, therefore, strengthen the testing capacities to cover wider sections of populations. To

this effect, private players should be adequately incentivised by the government to provide affordable

testing. In addition, robust data collection and documentation of disease outbreaks can strengthen

and streamline covid-19 testing protocols.

ii. Contact tracing and surveillance

Incidence of positive covid-19 cases in highly congested areas, particularly, slums have highlighted

the need for rapid testing and comprehensive contact tracing mechanisms. At the local level, district

officials and community medical workers should play an important role in closely monitoring these

contacts to prevent further transmission in the following ways:

Enabling local health workers to undertake home-site visits in order to trace new chains of

transmission, if any

Vigorous testing needs to be continued in identified core pandemic zones (Covid-19

hotspots)

Risk assessments of doctors and nurses involved directly in covid-19 cases should be

carried out on a regular basis and consequent remedial measures, if any, must be suggested

Adequate emphasis should be placed on essential social and infrastructural amenities.

MoHFW has issued interim guidelines on the functioning of state quarantine facilities, however

there is a pressing need to ensure its ground level implementation.

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Source: Prasad, T.M.

India: ‘Aarogya Setu’ mobile app developed

by MeitY uses bluetooth and location-

generated social graph to alert people who

may have come in contact with covid-19 +ve

patient

Tamil Nadu: JioVio healthcare startup

developed ‘MadhuraiKavalan’ app which

enables GPS tracking to monitor those in

mandated quarantine

Maharashtra: Drone based mapping of

city areas in Nagpur to identify unusual

activity and control crowds

Karnataka: Shivamogga Smart City

Limited (SSCL) has used its Digital

Virtual Library application to send alert

messages

Deficiencies in medicine, protective gear

equipment, critical-care infrastructure will

inevitably result in sub-optimal healthcare

delivery and expose front-line care workers to

greater risks.

The “National Preparedness Survey on

COVID-19” highlights the need for

strengthening health-care capacities at both

district and sub-district levels.

However, mere reliance on importing will not

be sufficient and the government in

partnership with several private firms, public

sector units, and other non-state actors should

further vigorously extend possible alternatives.

iii. Alternate arrangements to enhance infrastructure capacities

Source: The Economic Times

7

In the case of 6-day doubling of covid-19 cases, it is estimated that the

states will run out of hospital beds by the end of May, i.e. a shortage of

about 7 lakh hospital beds (Source: livemint.com).

Various production facilities and PPPs should be engaged to drastically

scale up the production of hospital beds.

Indigenous production capacities can adopt innovative approaches to scale up the

manufacturing of PPEs.

Government tenders incentivising the same must be fast-tracked in order to meet

the growing requirements.

Chhattisgarh: Raipur’s NULM women workers and several SHGs were involved

in the production of around 5000 masks

Telangana: Prisoners in Greater Warangal city jail prepared around 3000 masksIIT-M 3D prints face shields to

counter PPE shortage

Ho

spit

al B

ed

sP

PE

s

Building (Walk-in Sample Kiosk), a South Korean model of mobile cubicle with a

sealed glass front and extended gloves that enables medical practitioners to collect

samples in huge numbers.

This drastically reduces the need for additional PPE kits and enhances testing

mechanisms.

Kerala: About six such WISKs have been built in Ernakulam district.

Source: livemint

Source: The Quint

WIS

Ks

•Up-gradation and refurbishment of existing infrastructural facilities (sports complexes,

railway coaches and hospitals, mobile vehicles, PHCs, panchayat bhavans etc.) will

ensure increased attendance to covid-19 suspect cases

Karnataka: South Western Railway has converted Divisional Railway Hospitals into

dedicated covid-19 operational units.

Tamil Nadu: In Thanjavur, hostels of some educational institutions have been

converted into temporary quarantine rooms

Source: The Week

Train coaches converted into isolation

units

Isola

tion

ward

s an

d

ICU

s

Source: NDTV

Critical Infrastructure

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iv. Sanitising Public Spaces and Safe Disposal Protocols for Bio-Medical Wastes

Bio-medical waste generated during the course of treatment and diagnosis of covid-19 patients should

be segregated and disposed of immediately in a scientific manner. Temporary treatment facilities and

storage rooms can be established to ensure effective containment of waste.

In this regard., adequate measures must be taken to implement the guidelines issued by the WHO and

Central Control Pollution Board of India.

MoHFW recently issued an

advisory against spraying of

disinfectant on people for covid-

19 management. Such

mechanisms of sanitation have

no scientific evidence to support

them. Moreover, they underplay

the emphasis on hand-washing

and physical distancing

measures.

The idea of disinfectant tunnels

in this case should be

reconsidered and replaced with

better researched alternatives.

v. Strict sectoral restrictions

Sectoral lockdown and restriction has been one of the accepted solutions to stem the spread of the

virus. The degree of lockdown in crucial sectors and some examples of preparedness is detailed below:

Education: Strict Lockdown

•Digital Classrooms including alternatives

such as local TV News Channels and radio

stations

•Doorstep delivery of Mid-day Meals: Kerala

was one of the early implementers followed

by Karnataka, Odisha, etc;

Transport: Strict Lockdown

•Ban on passenger transport, excepting

emergency cases and transportation of

freight

•Some states have implemented the E-Pass

system to allow and monitor the movement

of certain vehicles

Government Departments and State

Institutions: Moderate Lockdown

•Switch over to online mode of

functioning has begun but needs to be

more widespread

•Courts proceedings conducted through

video-conferencing

Others: Strict Lockdown

•Unique operational interventions such as

token systems and age-brackets to reduce

crowding at retail outlets in some districts

•Tele-medicine and portability of

entitlements

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vii. Immediate relief measures for hard-hit sectors and vulnerable populations

• Cash transfers which match at least minimum wages and in-kind provisions for informal sector

workers who depend on wages for survival.

• Input subsidies for the agriculture sector, allowing farmers to sell directly to bulk buyers and

retailers, buying perishables which are potentially going to waste and distributing it among the

needy.

• Strengthening a collaborative effort between the government and NGOs, across States to ensure

that the needs of the various social groups unhoused, destitute, migrants and transgender.

Baseline Conditions

Pre-requisites to move from Phase 1 to Phase 2, based on the premise that the peak phase has

passed. India (as on 20-04-20) is yet to pass the peak phase. Any move to ease strict restrictions prior

to passing the peak may have uncertain outcomes and greater risks.

vi. Public Awareness:

It is crucial for an emphasis on hand-washing, hygiene practices and social distancing through large

scale public awareness programs as these are some of the critical mechanisms to prevent spread of

infections. District Administrations should play a pivotal role in taking up the challenge of relaying

verified information.

The strict restrictions must apply in accordance to clear-cut guidelines, exemptions and alternatives.

However, it is crucial to ensure that the restrictions do not lead to a disruption in supply chains. This

requires more coordinated on-ground enforcement and information symmetry among

administrators.

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*Decline in average growth factor i.e. doubling of cases does not necessarily imply that the testing efforts should be reduced, especially in phase 1

i. Sustaining efforts towards slowing the spread of infections

Phase IIGoalsA. Continuing and sustaining efforts towards slowing the spread

B. Initiate efforts towards ‘raising the line’

C. Ease strict regulations on lockdown

D. Sustained behavioural changes in the population to build adaptability

Action Points

Rapid antibody testing* can primarily be used to test vulnerable clusters of the population - a)

migrant workers, b) front-line health personnel, c) municipal workers, d) slum dwellers, e)

individuals in quarantine shelters, f) patients discharged and recovered from the virus, etc. as well

as those in Red Zones. For instance, the Brihanmumbai Municipal Corporation (BMC) has planned the

execution of anti-body tests for several of its healthcare personnel and municipal workers.

Robust surveillance mechanisms: Recently, China and South Korea reported recurrences of

virus in cases of recovered covid-19 persons. India should consider this as an early warning

system and continue to implement robust contact tracing and monitoring mechanisms. Existing

tracking apps should incorporate better UI and privacy in order to increase usage by citizens. e.g.:

Singapore’s ‘TraceTogether’ app has instilled confidence among its users with minimal invasion of

privacy.

Real time monitoring of transmission can be done through tracking the ‘Effective Reproduction

Number, R’. This will aid in informed timely decision making as well as district level plans for

containment and recovery.

ii. Adaptive Social distancing:

Social distancing rules can be relaxed in areas with few infections and adaptive social distancing can be

operationalized. This would mean that administrative units or zones can announce social distancing

rules whenever infections spike up in particular regions, avoiding the need to go into complete

lockdown.

*Emerging methods of testing are subject to further research and validation. Rapid Antibody Testing is included in Phase 2, primarily because it has been presented as a supplementary tool for surveillance and tracking and not for early disease detection (ICMR)

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iv. Moderate Restrictions on some sectors, while continuing strict lockdown in

others:

Limited intra-state transport lines including buses, trains and private transport can be allowed to function

with very strict passenger caps and continued monitoring. However, containment zones or hotspots with

high case loads must continue to observe strict restrictions.

Schools and non-essential industries should preferably stay under lockdown.

Micro enterprises, especially home based productions can re-start operations by phase 2. These

manufacturing units can be directed to produce basic medical equipment.

v. Continued State support for markets and socio-economic provisioning:

States need to look into the granularity of inter-state supply chains and establish robust market

networks. This necessitates the need to develop a National Transportation Grid (forthcoming).

Continued socio-economic provisioning for hard-hit and vulnerable sectors while also taking into

consideration the needs of industries and agriculturalists for the next financial year.

Credit-lines and soft-loans for MSMEs to cover immediate liquidity requirements - especially wage

payment of workers.

iii. Raising the line

‘Raising the line’ is critical to go beyond attempts at just ‘flattening the curve’, implying the need to

fill in the institutional and infrastructural shortages.

Increasing the local production of health equipment to address rising demands

Encouraging the setting up of drug and Active Pharmaceutical Manufacturing (API) plants.

Focus on augmenting the existing laboratories with required medical equipment and creating

newer ones, especially at the district level.

Disinfecting and sanitising public spaces should be effectively exercised to ensure a safer

environment.

Enhanced training of frontline healthcare workers

Ensuring adequate deployment of medical staff in districts and sub-districts by way of

involving community health workers and ASHA personnel. It is important to equip these

health workers with necessary protective gear and hand-sanitizers

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Baseline Conditions

13

Pre-requisites to

a) Move from phase 2 to phase 3

b) Revert to phase 1

Phase III

GoalsA. Prevent further infections

B. Continued surveillance to enable early detection and treatment

C. Lift all restrictions across sectors

D. Ensure sustained efforts towards ‘raising the line’

E. Work towards long term institutional interventions and resilience

Action Points

i. Monthly Pool Testing should be carried out at Community-level, especially across vulnerable clusters

of population - elderly, slum dwellers, migrant workers, etc.

ii. Ensuring widespread and long-term usage of dedicated pandemic related SMS tracker systems and

applications

iii. Maintain citizen awareness on hygiene and create a mindset of adaptability by keeping public

memory fresh

iv. Lifting all sectoral restrictions:

This has to be accompanied with continued enforcement of sanitation of workplaces and

ensuring the availability of healthcare for workers

v. Raising the line: Medium-term to long term

Strengthening public health expenditure

Enhancement and building of robust healthcare infrastructural facilities

Establishing robust Public Health Emergency Preparedness system

Sustained in-house production of medical supplies

Regulating and enforcing health & hygiene protocols in workplaces

Mitigating the problem of understaffing

Capacity building of community health workers at ground level

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Baseline Conditions

Post Covid Institutional Resilience Strengthen public health expenditure and build robust health infrastructure.

Establishing Medical Emergency Response Teams, consisting of Health personnel, Police, and

NDMA.

Institutionalising robust social security model.

A pressing need exists to ensure portability of entitlements, especially, for migrant workers and

the vulnerable.

Building capacities to operationalize nutritional security of informal workers.

Institutionalising civic solidarity for a more proactive and far-reaching response to any crisis.

Need for robust, functional and real time disaggregated data at district level for informed and

quick decision making.

An expert committee with sectoral experts on board should be constituted to provide short term

solutions as well as a long-term economic roadmap, particularly in light of this pandemic.

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* In order to exit the suppression loop and beyond Phase 3, there need to be continued

efforts towards pandemic control at the micro, meso and macro levels

Pre-requisites to move from phase 3 to phase 2

References

16

Center for Disease Dynamics, Economics & Policy (CDDEP). (2020, March 22). Modeling the spread

and prevention of COVID-19. Retrieved April 21, 2020, from https://cddep.org/covid-19/

Department of Administrative Reforms and Public Grievances. (2020). National Preparedness Survey

on Covid-19. Government of India. https://darpg.gov.in/sites/default/files/COVID-

19%20Impact%20Feedback%20Report.pdf

M.K., N. (2020, March 13). Coronavirus: Mid-day meals at homes in Kerala, children spread awareness.

Livemint. Retrieved April 2, 2020, from https://www.livemint.com/news/india/coronavirus-mid-

day-meals-at-homes-in-kerala-children-spread-awareness-11584083644665.html

Ministry of Health and Family Welfare. (2020). Advisory against the spraying of disinfectants on people for

Covid-19. Government of India.

https://www.mohfw.gov.in/pdf/AdvisoryagainstsprayingofdisinfectantonpeopleforCOVID19man

agementFinal.pdf

The Times of India. (2020, April 3). Could we see a second COVID-19 wave? Retrieved April 21, 2020,

from https://timesofindia.indiatimes.com/india/could-we-see-a-second-covid-19-

wave/articleshow/74961712.cms

SCHOOL OF PUBLIC POLICY AND GOVERNANCE

TATA INSTITUTE OF SOCIAL SCIENCES

HYDERABAD