Indian Journal of Social Psychiatry

: 2020  |  Volume : 36  |  Issue : 5  |  Page : 89--90

Utilization of primary health-care infrastructure in tackling COVID-19

Roy Abraham Kallivayalil1, Arun Enara2,  
1 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, India
2 National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Correspondence Address:
Prof. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla - 689 101, Kerala

How to cite this article:
Kallivayalil RA, Enara A. Utilization of primary health-care infrastructure in tackling COVID-19.Indian J Soc Psychiatry 2020;36:89-90

How to cite this URL:
Kallivayalil RA, Enara A. Utilization of primary health-care infrastructure in tackling COVID-19. Indian J Soc Psychiatry [serial online] 2020 [cited 2023 Feb 6 ];36:89-90
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Full Text

There is a wide discrepancy in India on how the various states have responded to the threat posed by COVID-19. The response strategy and its success varied from State to State and the strength of the primary health care has been an important determinant.[1] This pandemic has tested the health-care delivery systems across the world. Even the developed nations, who were regarded to have well-established health-care delivery system in place, struggled to cope with the challenges that the pandemic posed.[2] Kerala has been in the limelight for its effective strategies in tackling the COVID-19. The success of the state's strategies is attributed to a multitude of factors. A firm rooting on evidence-based public health, the high rate of literacy among its population, investment in universal health care, the unique sociocultural and political fabric, and the strict but humane approach of the bureaucrats and civilians alike are some of the factors that played a key role. The first case in India was detected in Kerala on January 30, 2020, in a student returning from Wuhan, China. Learning from its own lessons in successfully tackling the Nipah virus outbreak in 2018,[3] Kerala quickly implemented effective test, track, and trace strategies by leveraging the existing primary health infrastructure that they have strengthened over the years. This was in stark contrast to the strategies based on herd immunity, which was reflected in the policies of many developed countries. The fundamentals were solid and the State relied on testing aggressively with excellent contact-tracing strategies.

The success of the Kerala model did not happen overnight. It is a reflection of the consistent efforts of the State in diverting significant resources every year toward building public health infrastructure, trusting village-level bodies with autonomy and funds, and promoting shared values that encourage social cooperation.[4] Kerala became a separate state in 1956. Much before this, the region saw many ground-breaking public health interventions. In 1879, the then rulers of the princely state of Travancore (which forms the south and part of central Kerala now) made a decision to make vaccination compulsory for public servants, prisoners, and students. In 1928, a parasite survey, done in association with the Rockefeller Foundation, led to the control of hookworm and filariasis. Added to this was the State's focus on literacy and women's education, which helped it attain near 100% vaccination levels and also in developing a culture of personal hygiene. When the State began the “Break the Chain” campaign during the COVID-19 outbreak – to promote handwashing and use of sanitizers – the masses were already attuned to the importance of these measures.[5]

The public health system in Kerala focuses on its population having access to primary health care, at the first level of contact. In June 2019, Kerala was on the top of the list among all the states in India, on the NITI Aayog's annual health index with an overall score of 74.01.[6] The preexisting effective local health systems and efficient health workers (accredited social health activist) made possible, the effective implementation of the WHO-recommended “test, trace, and contain” strategy. This effective strategy reflects on the significant lower number of COVID cases in the State. More than 100,000 people were traced and placed under quarantine by March 26, 2020, a day before the nationwide lockdown.

Among the other significant initiatives, the leaderships also focused on the mental health of its population. Various projects such as the District Mental Health Programme, “DISHA,” a 24 × 7 tele-health helpline under the Department of Health and Family welfare were brought together to strategize and implement mental health initiatives. The multidisciplinary teams provided counseling and psychosocial support for people in isolation and quarantine. The focus was also on tackling the stigma surrounding the virus, and this was evident when the State requested the members of the public not to stigmatize COVID infections because this would potentially lead to underreporting, misinformation, and lack of cooperation. This facilitated an open approach in clarifying queries and also in sharing concerns. These teams of health counselors, across all the districts, checked in on the people in quarantine with calls to reassure them and also to get an idea of their mental state. If they need additional mental health assistance, they are given a district helpline number on which their queries and issues were dealt with by qualified clinical psychologists and psychiatrists every day.

Added to these strategies, rooted on the existing well-oiled public and primary health delivery system, was a leadership that focused on the basics. The State leadership formed a volunteer group, the members of which grew to 250,000 in a week to run community kitchens that fed lakhs of isolated people. The migrant workers in the State from various parts of the country were identified as a vulnerable group and were rechristened as the “guest workers.” The State prioritized the care of this special group and placed their security and well-being at the forefront of its initiatives. This involved making brochures and short videos in the “guest workers'” native language and also redeploying members of the staff who could converse in these regional languages to improve engagement with these particular groups. The “guest workers” were also offered free food and shelter.

The success story of Kerala is a testament to “good health at low cost,” and this is possible because of the years of work around policies that focused on strengthening the primary health-care systems and also a political will, that saw this as crucial. Through this pandemic, the Kerala model sheds light on the need for well-established primary health-care services across the world. It also offers a case as to why mental health should be part of the primary health care.

At the same time, Kerala is facing a major challenge in the form of thousands of its natives coming back home, especially from the gulf countries and other States of India, a large number of them testing positive for COVID-19 within few days after arrival. This is a serious situation, but Kerala with its strong public health infrastructure and willingness for collaboration with other stakeholders, can be expected to ride over this storm too!

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Conflicts of interest

There are no conflicts of interest.


1Khandelwal SK. Debating the process, impact and handling of social and health determinants of the COVID-19 Pandemic. Ind J Soc Psych 2020;36 (Suppl):S64-S83.
2Dalglish SL. COVID-19 gives the lie to global health expertise. Lancet 2020;395:1189.
3Ajith Kumar AK, Anoop Kumar AS. Deadly Nipah outbreak in Kerala: Lessons learned for the future. Indian J Crit Care Med 2018;22:475-6.
4Nidheesh MK. Stories from Kerala's Spirited Virus Fight. Livemint; 2020. Available from: [Last accessed on 2020 May 12].
5Behind Containment in Kerala: Robust Healthcare System, Effective Strategies. The Indian Express; 2020. Available from: [Last accessed on 2020 Jun 4].
6Kerala Number 1 in Overall Health Index: NITI Aayog. India Today. Available from: tops-1556163-2019-06-26. [Last accessed on 2020 Jun 4].