Health Crisis in Kerala


Kerala’s achievements in health are almost comparable to any developed country despite state’s economic backwardness.  India’s first ever human development report published in 2002, placed Kerala on top of all states.  Over the years, Kerala underwent through a transition from a society with high population growth rate, high death rate and high infant mortality rate to one with moderate population growth rate, low crude death rate and relatively low infant mortality rate.

                State’s population density is 860 persons per whereas national average is 382.  State has highly impressive health indicators and these indicators are above national level and even comparable to developed countries.  Despite all the shortcomings of the health care system, birth rate in Kerala is 15.2 and the death rate is 7.0, while at national level they are 21.8 and 7 respectively.  Infant mortality rate is 12 in Kerala against 44 at all India.  Child mortality rate (0-4 years) in Kerala is 3 and the maternal mortality rate (per lakh live birth) is 81 while at national level they are 17 and 212 respectively.  Total fertility rate in the state is 1.8 and in India it is 2.4.  Couple protection rate is 72.3% and life at birth is 74 years against the national level of 52 and 63.5 respectively.

                Kerala has done exemplary progress in providing access to basic health services.  The immunization coverage has been 80% for over a decade now.  Over 99.3% of deliveries are conducted by skilled birth attendants, of which 99% are institutional births.  High level of literacy rate, especially among women, and greater general health awareness has played a key role in attaining these health standards. The wide network of health infrastructure, manpower and policies of state government added to the success.  The hallmarks of Kerala model health were low cost health care and its universal accessibility and availability.

                The health care system in Kerala consists of 2915 institutions 42390 beds and 7127 medical doctors.  Out of the total health institutions 1281 are under allopathy, 942 are under Ayurveda and 692 are under homeopathy.  Similarly, out of total beds, 38421 (90.6%) are under allopathy, 3014 (7.1%) are under Ayurveda and 955 (2.3%) are under homeopathy. 

However, despite this widespread and elaborate health care system, the health delivery service in Kerala is faced with varied and complex issues.  The plan outlay spent on health sector increased by 213 times from Rs.195 lakh in the first five year plan to Rs.40840 lakh in the 10th plan and to nearly Rs.1000 crore in the 11th plan.  Health care facilities and functions at each level of institution is defined but physical facilities, health personnel, medicines and medical equipments are not available as per defined norms.  Quality of medical services delivered therefore became inadequate and poor. Standardization of facilities at each level of institution is very rare leading to poor service delivery.  When government provides good healthcare facility to all sections of people in all areas evenly uniformly and qualitatively, there is social justice.  But it requires quantitative as well as qualitative assessment of the existing health care facilities and its delivery.  Table - 1 below shows the health care infrastructure in Kerala under three systems of medicine namely allopathy, Ayurveda and Homeopathy.

Table - 1                   Medical Institutions and Beds in Kerala

Sl. No.   Category               Institutions (Nos.)      Beds   (Nos.)           Medical Officers   (Nos.)   

 1.         Allopathy                       1281                       38421                        5214

 2.        Ayurveda                       942                          3014                          1151      

 3.        Homeopathy                 692                            955                           762

             Total                               2915                      42390                         7127

Note:    Excludes Medical Colleges.

                Despite all the achievements, as mentioned, the major challenges in the present health scenario of Kerala are the simultaneous presence of widespread infectious diseases and the life style diseases, escalation of health care cost and marginalization of the poor.  Uncontrolled growth of the private sector is also a major challenge.  The morbidity rates are higher in Kerala than other Indian states though the mortality is comparatively low.  Kerala’s prevalence of LBW is substantially higher than the developed nations (13.3%).  The maternal mortality rate is slowly showing an increasing trend and the immunization coverage, a declining trend.

                Structure of public healthcare system in Kerala is three-tier as follows.  On the bottom level we have primary healthcare centres to provide healthcare to rural population and to promote public health at Grama Panchayath level.  We have at secondary level, hospitals with bed facility, medical equipment, specialty clinics, surgical theatre facilities with out-patient, in-patient treatment at CHC/Taluk level.  At tertiary level we have General hospitals/Government Medical College hospitals with different testing laboratory facility apart from speciality hospitals for TB, leprosy psychiatry and contagious diseases.  At bottom level under allopathy in Kerala, we have 853 Primary Health centres and 230 community health centres at grama panchayat level.  Similarly there are 815 rural Ayurveda dispensaries and 661 rural Homeo dispensaries.  In other words, there are 2569 health institutions at Grama Panchayat level delivering health service to rural people.  However, there institutions fail to deliver the health beds of the poor people.

                There are 852 Primary Health Centres with 4405 beds and among them 171 PHcs with 3283 beds are 24 x 7 hour working centres.  Similarly there are 230 CHCs with 6529 beds and specialist doctors.  It hence shows that at rural level PHC and CHC institutions together are 1982 with 11394 beds which share 31% percent of beds and 84.5% of institutions under Health service directorate.  However, health facilities like building, beds, medical equipments, operation theatre, laboratories, medical officers, nurses, pharmacists and health inspectors vary institution-wise despite there exist standard norms.  In such context creation of health facilities at PHC and CHC level without seriously examining the defined standards for each level of care and entitlements of the citizens based on local socio-political needs cause to under utilisation/over utilisation of facilities and often lead to poor quality of services.  Similarly hospital infrastructure facilities are created under MP/MLA fund and Local Governments in PHCs/CHCs without a proper master plan hampering effective service utilisation.  Health care system build for primary care service and its effective use would reduce private health expenditure considerably helping poor people.  Studies have suggested that if we increase health care in PHCs and CHCs as per standards that exist, Government could address nearly 70-80% of disease burden at rural level substantially and transforms the health systems from high cost to a low cost system and reduce out of pocket expenditure of people.  In Kerala since PHCs and CHCs are transferred to Grama Panchayats and Block Panchayats respectively intervention of these LGs could have strongly strengthened the health services provided.

                Even though, medical care to public is a service; the recent trend is that it has transformed into a profit-making business.  Health care services are corporatized and it has ushered a new era where world class medical facilities and global services are now available in cities and towns.  In fact the new health care industry caters to the needs of patients as a valuable customer and services are provided on the basis of the thickness of the pocket.  It all indicates that, a clear division has emerged in the field of healthcare service, namely, private healthcare and public healthcare.  High cost modern medical care is available in corporate hospitals because corporatization has infused professionalism at every level in medical field.  But the access to corporate hospital is only to those who can afford the cost.  In Kerala middle class families will not be in a position to avail medical services from private medical hospitals.  The need of strengthening the medical facilities in public domain for all therefore became a necessity. There must not be a situation where; ‘I have an ailment, there is a treatment also.  But I cannot pay for it, hence I may not get the treatment and I have to die’. 

Social scientists on public healthcare have been concerned about access to health care particularly to the biomedical development initiatives driven by modern medicines.  In a welfare state we need a public health policy to make healthcare free and equitable.  Government of India has started lot of initiative to make public healthcare strong and to provide quality medical services to all.  Let us look on the status of public healthcare service in Kerala.  We can say it is very bleak.  It is suffering from infrastructure gap, manpower gap and quality gap.  The major problems are lack of critical drugs, outdated diagnostic tools, paucity of trained medical personnel and inaccessible healthcare facility.  We can dream one day we will attain all these.

(Author is former Joint Director, State Planning Board)

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