The explosion of Covid-19 cases in China towards the end of 2022 and early 2023 reminded us, once again, that pandemics have a way of lingering and forcing themselves to the forefront of our consciousness. As public health policy experts have been saying for years, it is not a question of “if” but “when” the next pandemic (or a new and highly virulent variant of Covid-19) arrives. Since a future pandemic seems inevitable, we argue that the questions we should be asking are will we be able to respond effectively when the pandemic arrives and does effective response depend on non-state actors?

This latter question arises from a theory made popular by the World Health Organization (WHO) and Western schools of public health that argue that the ideal means of managing public health emergencies is through cooperation between state and non-state actors – collaborative governance. This theory makes the case that governments, alone, lack the capacity and resources to effectively manage a major pandemic (or crisis in general) and that only by collaborating with non-state actors can a successful response be realised. 

Insights from field study

Dr. Srinivas Raju and I conducted a field study in Bengaluru, Karnataka, over an eight-month period in 2022, seeking to address the questions of how well the state responded to Covid-19 and how well prepared it is for the next pandemic. Our research involved site visits and extensive in-person interviews with over 80 individuals, including representatives from civil society organisations, government, and for-profit health care providers, as well as ASHA (accredited social health activists), ANM (auxiliary nurse midwives) workers, and PHC (primary health centre) physicians. 

We sought to understand from the interviewees, including representatives from NGOs such as Janaagraha and Sama foundation, as well as from the state Covid-19 Technical Advisory Committee (TAC), their activities and responsibilities during Covid-19, the extent of state-society collaboration, their satisfaction with the overall Covid-19 response in Karnataka, and their views on how prepared the state’s public health system is for a future pandemic.

As was clear from a January 2023 Indian Institute for Public Administration roundtable session, assessing Karnataka’s Covid-19 response, government officials are overall quite satisfied with their pandemic response effectiveness and confident of their readiness for future pandemics. Regardless of one’s opinion of the government’s response, we acknowledge that no country has been completely successful in their Covid-19 responses. Even pandemic-fighting “stars” like Taiwan, New Zealand (and until recently, China) have eventually been forced to face rising case numbers and fatality rates. 

The Karnataka government did not act alone when responding to Covid-19. Many residents of the state either participated in or know someone involved in the pandemic response. This might have been as part of a government organised initiative, such as Booth Level Officers going house-to-house to check up on citizen health, or as part of an effort led by newly established or long existing civil society organisations (among others). Examples like Mercy Mission, SWAN (Stranded Workers Action Network), the Rotary Club, the Bangalore Apartments’ Federation, and others exemplify community initiatives by groups with often no public health experience, that identify gaps in services provided by the state and BBMP during the pandemic, and step in to fill those gaps. 

Read more: Govt took some action during COVID, but failed to address larger structural issues in healthcare

These organisations, often growing organically in an ad hoc manner, depended on deeply committed individuals willing to donate time and/or money and risk their lives in the field to help vulnerable communities. In some cases, these organisations coordinated closely with government agencies in order to achieve shared goals. However, quite often these organisations sought to minimise contact with the government, perceiving it as more of an obstacle to fulfilling their Covid-19 related initiatives.

Contribution of non-state actors

Interestingly, government agencies, which traditionally distrust non-state actors, grew increasingly reliant on the services the non-state sector provided. Among their many roles, non-state actors helped to educate, feed, vaccinate, test, and transport vulnerable populations while also training government officials in the work of pandemic response. These were critical services that an understaffed, under-resourced and over-worked government sector could not manage alone.

For example, Mercy Angels – a group of volunteers who stepped into a gap in funeral, cremation, and burial services – provided end-of-life services to those who passed away during the Covid-19 lockdowns. This critical service was left to Mercy Angels because government officials were often reluctant, fearful, or simply too overwhelmed to fulfil this need. There exist countless additional examples of community groups stepping into the gap, playing a key role, often alongside government agencies, and as in this example, often independently.

Shortcomings in providing long-term solutions 

We should all feel deep gratitude towards those who took on these roles, both in government and in the non-state sector. And yet, our interviews with both state and non-state actors highlight the fact that rarely were non-state actors perceived as capable of providing long-term and large-scale solutions to the many pandemic response challenges facing state and local governments. This is true for several reasons. 

For example, in many cases, non-state actors received temporary permission from their funding agencies to redirect funds from their original missions to Covid-19 response. But eventually, these NGOs were expected to return to their original missions. In other cases, community groups and citizen volunteers simply stopped their work as fatigue, employment, and family responsibilities, and even fear increased.

As was explained to us by several NGO interviewees, they never considered themselves replacements for government actors. Rather, they envisioned themselves as providing services supplementary to government initiatives while also perhaps providing models of best practices to then be adopted and implemented by the government. 

Furthermore, some interviewees expressed concern that should non-state actors take on many of the pandemic-related tasks, traditionally the responsibility of government, government actors might take the non-state actors for granted and abdicate their own responsibilities. 

In essence, our research of the Covid-19 response in Karnataka leads us to view non-state actors as lacking the ability or interest to take on the role envisioned in collaborative governance. 

Perhaps it is the case that collaborative governance can provide solutions to future crises, such as pandemics, but it seems more likely that this will be the case in wealthy countries that have high-capacity governments and deeply entrenched and extensive civil society networks. It seems unlikely that we can make the same assumptions elsewhere.

As Covid-19 continues to wax and wane and new pandemics (such as the  MPox outbreak) develop, it would be unwise to remain complacent or overly reliant on ad hoc community engagement. Will the countless NGOs, community groups, individual volunteers and for-profit organisations be able and willing to step into the breach? In other words, should we rely on non-state actors for the next pandemic? 

The importance of addressing public health infrastructure

We argue that a wiser step would be for the state government and BBMP to build, nurture and strengthen the public health system, in particular PHCs, ASHA and ANM workers. It should also foster long-term relationships with non-state actors, building trust through engagement, ongoing communication and cooperation, but without taking community participation for granted. These steps can result in improvement over past performance. Failing to acknowledge and address the weaknesses in Karnataka’s public health infrastructure and in its ties with non-state actors would constitute a grave error and should be a source of concern for us all.

Also read:

• What Bengaluru’s TB control programme tells us about efficiency of health systems for migrants
• The hazards of occupational cancer among informal workers
• Migrant workers — unaware and unable to access state healthcare schemes