Vol. XLIII No. 28 July 14, 2019

Kerala Marches Forward in Health

Dr B Ekbal

KERALA has once again topped in the latest health ranking NITI Aayog report, "Healthy States, Progressive India". The report ranks states and union territories on their year-on-year incremental change as well as overall performance with respect to 23 health indicators such as neonatal mortality rate, ‘under five’ mortality rate, percentage of low birth weight infants, sex ratio at birth etc., NITI Aayog had first come out with its state-wise health rankings  in February 2018   over financial year 2014-15 (base year) to 2015-16 (reference year). The current second round of health index report examined the period 2015-16 (base year) to 2017-18 (reference year). In both the reports Kerala ranks first and in overall performance far ahead of all other Indian states.


Among the larger states, the overall health index score of the best-performing Kerala  is more than two and half times of the overall score of the least-performing state-Uttar Pradesh.  The top five best performing states in the reference year based on the overall performance were: Kerala (74.01), Andhra Pradesh (65.13), Maharashtra (63.99), Gujarat (63.52) and Punjab (63.01). While the least performing states in the reference period were: Uttar Pradesh (28.61), Bihar (32.11), Odisha (35.97) and Madhya Pradesh (38.39).

Kerala’s performance is remarkable; the state has already overtaken many of the Sustainable Development Goals(SDGs) in health sector  for 2020. For example, as per the report, the neonatal mortality has already come down to 6 and the ‘under-five’ mortality is only 11. In most of the health indices Kerala has reached the health status of well performing countries of the developing parts of the world like Sri Lanka, Cuba and Costa Rica and in several indicators almost on par with that of the developed countries.

Kerala’s achievements in health have already been acclaimed all over the world and several international agencies has described Kerala model of health as ‘good health at low cost’ and based upon social justice and equity. There are many socio-economic conditions unique to Kerala, which have been postulated to make this health model possible. Kerala has a highly literate population compared to other Indian states. This especially, the high female literacy, has to be given due credit when we look for explanatory factors. All over, the world indices such as infant mortality have shown an inverse relationship with female literacy.

It is also to be noted that Kerala has nurtured a political climate wherein the rights of the poor and the under privileged have been upheld and fought for. This was the result of a fairly long period of struggle for social reforms emphasising dignity of people who were considered socially ‘inferior’ which later found expression in secular-democratic movements culminating in nationalist and socialist movements. One common thrust of all such movements was on education and organisation of the downtrodden people. Hence, as has been pointed by many social scientists there is a remarkable reduction in the rate of exploitation of the underprivileged in Kerala compared to other Indian states.

The agrarian reforms that were implemented by Communist ministry in 1957 ended the feudal relationship in agriculture and giving land to the tillers. This improved the social living conditions of the landless poor in the rural areas. This might have contributed to the alleviation of poverty among the agricultural labourers leading to the improvement of their health status.  The public distribution system of food through fair-priced rations shops distributed throughout Kerala assures minimum food materials at relatively cheap cost to the people. This has assured certain amount of nutritional status to the poor, warding of poverty related diseases.

Apart from the socio-economic factors outlined above the universally available public health, system in Kerala has also contributed to the high health status of the people. Kerala has a three-tier system of health care, the primary health centres (PHC) and the community health centres (CHC), taluk and district hospitals and the medical colleges evenly distributed both in the urban and the rural areas.


The Aardram Mission initiated by the Left Democratic Front(LDF) government   to transform hospitals from primary health centres to medical colleges has already made remarkable improvements  of the government health sector. Through Aardram mission the state is trying to transform public health sector accessible for all citizens, especially the poor. The mission is engaged in strengthening the facilities in primary health centres to develop them into patient –friendly family health centres to provide qualitative medical care for all. The mission has already surpassed its expectations. Initially the mission has been implemented in 170 primary health centres. Another 500 would be brought under the mission in 2019 and eventually all the 940 primary health centres will be included. The number of doctors working in each primary health centre has already been increased from two to three. OPD(outpatient department) time has been extended from 1 PM to 6 PM. Provision has been made for special care of pulmonary diseases, mental illnesses and non communicable diseases. Facilities have been set up in PHCs for blood test. All essential drugs are made available. Under the aegis of Aardram, facilities are being provided for dialysis in taluk hospitals and ‘catheterization labs’ in district hospitals. Medical colleges are being converted into centres of excellence for tertiary care and medical education. 


The inherent vibrancy and resilience of the Kerala health system was evident during major challenges the state faced during the Ockhi cyclone in 2017, the unprecedented floods in 2018 and two episodes of Nipah virus epidemics in 2018 and 2019.  There were very few incidences of water borne and vector borne diseases during Ockhi cyclone and the floods.  A few deaths took place owing to rat fever. The efficiency with which Kerala managed to control the Nipah epidemic that affected the state within the short span of six months had been widely acclaimed all over the world.


The national RSBY health insurance system was further expanded in Kerala including more families as beneficiaries and was one of the best performing health insurance system in the country. As per the national selection criteria while only 28.5 lakhs families were eligible for the insurance coverage Kerala has widened the coverage so that 42.5 lakhs families were benefited. Apart from RSBY there were other programmes like Thalolam and Karunya(social security mission)that provided free treatment to high cost medical conditions. Currently Kerala government has introduced the Karunya Comprehensive Health Insurance Scheme incorporating the Ayushman Bharath Scheme of the national government. Apart from this, health insurance schemes for the state government employees and the pensioners are also being implemented by the state. With all these schemes every family in Kerala will be covered by the health insurance system reducing the catastrophic health expenditure that was plaguing the state for the last so many years.


Along with the public health system the state-owned drug company the Kerala State Drugs and Pharmaceuticals Limited(KSDP) is also being revamped by the LDF government. KSDP is already producing drugs worth of Rs 150 crores and hopes to increase the production to Rs 500 crores within two years. The company has taken steps to produce drugs necessary for post transplant patients and also oral and injection penicillin necessary for the management of rheumatic fever and post rheumatic heart diseases. The industries department has taken the initiative to set up a pharma park where at least Rs 1,000 crores worth of drugs is expected to be produced.

With the overall improvement of the government hospitals, the coverage of the public hospitals has increased from 28 per cent of the population to 40 per cent by the end of 2018. The health department is expecting to increase this to 50 per cent during the tenure of the LDF government.