India suffers from a problem of inadequate state capacity

If you are lucky enough to be healthy in covid-haunted Delhi, life feels strangely disconnected. Offline, there’s an undeclared lockdown. The normally noisy city is silent except for the sound of birds. Social media, on the other hand, is an unfolding tapestry of tragedy. People beg for help finding hospital beds and life-saving medicines. Friends and acquaintances call and text asking if you know where they can get an oxygen concentrator. In one way or another, everyone is battling the virus.

Everyone, it seems, except the Indian state. Once again, ordinary citizens feel as if we’ve been abandoned by our government. State and federal officials seem more interested in point-scoring and blame-shifting than in cooperation.

Denialism about the scale of the problem seems like official policy. Ministers, bureaucrats and even government lawyers insist that there is no shortage of oxygen or hospital beds, although everyone can plainly see that there is.

Things are even worse in places such as Uttar Pradesh (UP), India’s largest state. There we might not know the scale of the humanitarian disaster for months, if ever: Few deaths are being recorded and the state’s administration has warned those spreading online ‘rumours’—including about family members gasping for oxygen—that they might be prosecuted under draconian national-security laws.

Perhaps we shouldn’t be surprised. Perhaps we shouldn’t have expected more of the notoriously fragile Indian state. There’s no escaping the fundamental contradiction of 21st century India: It is one of the world’s largest economies, ambitious and aspirational, and its government has vast resources. But it is also, still, a poor country, with a per capita income one-fifth China’s. The state’s capabilities are spread truly thinly across India’s billion-plus people.

Government spending on health has always been shockingly low. In the villages of UP, the needs of hundreds of thousands of people might be filled by just five health centres—and no qualified doctor.

And citizens need more than the basics. In Delhi, the local government often talks up its expenditure on primary health centres, which are indeed vital. But that hasn’t made up for the lack of tertiary care, which is what most covid patients need. Delhi has only 5,000 usable ICU beds for its roughly 20 million citizens; less than a dozen were free on 30 April, by the official dashboard.

For years, many Indians believed the private sector could make up for the government’s shortcomings. Indians mostly pay in advance and in cash when a calamity hits and hospitalization is needed. We run down our savings, or we look to personal networks for help: As much as 60% of healthcare spending in India is out-of-pocket expenditure by households. That’s where Indians have turned in this crisis as well—to friends, family and Facebook.

But the pandemic is a reminder of why even a dynamic private sector needs a state that can support its efforts. That’s true in the best of times; in the worst, such as these, there is no replacement for a government that can coordinate private efforts and supplement them where needed. Instead, authorities can’t supply enough oxygen or even tell us which hospital has the fewest ambulances lined up outside its gates.

Underfunded and understaffed governments such as India’s simply have no spare capacity to serve their citizens when disaster strikes. You can’t hope for the private sector to do so; only the state can afford to carry this vital excess capacity or build it up at short notice.

It does not have to be this way. India’s southern states of Kerala and Tamil Nadu have, for decades, been better run than their northern counterparts. In recent weeks, they’ve set up elaborate systems of online triage to sort out covid cases and minimize the burden on hospitals.

Even the country’s financial capital Mumbai, epicentre of the latest variant, has established war rooms in each municipal ward, manned by public-school teachers, to triage patients and tell them where to go and what to do. While it took too long to increase the number of hospital beds, at least the local government is allotting those beds to the neediest.

Perhaps residents of Mumbai feel less abandoned; certainly, that city seems to have turned a corner in the past fortnight. In Delhi, by contrast, whether you and your loved ones live or die still largely depends on who’s in your phone book.

This is unfair to all of us, but particularly to those who are from historically excluded religions, castes and classes. A functional state would be impartial between these categories. A flawed government might not be impartial, but would at least pretend. Instead, in the anarchy that appears to rule here today, parts of India are reverting to their stratified worst.

Mihir Sharmais a Bloomberg Opinion columnist and a senior fellow at the Observer Research Foundation in New Delhi

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