How Keralas People-Centric Health System Built Over 24 Years Is Paying Off Now

It has been more than two months since India reported its first Covid-19 case—on January 31, the Kerala government announced that a Malayali student who had returned from China ’s Wuhan had tested positive for the novel coronavirus. In the days since then, the disease has infected more than 2900 people across India and led to a national lockdown. 

While Kerala has till now reported 286 cases, behind Tamil Nadu and Maharashtra with 309 and 423 positive cases, its death toll is still comparatively low — 2 deaths (as compared to 26 in Maharashtra). The state has won praise for its adept handling of the pandemic that has killed more than 50,000 people around the world and overwhelmed health systems even in resource-rich countries.  

This has occurred even though the southern state faces challenges such as a high population density, a high proportion of the elderly (12.6% of the total population) who are particularly vulnerable to the disease and financial constraints that followed two devastating floods and the Nipah virus outbreak in 2018 and 2019. The Kerala government’s early preparedness to the pandemic and the investments it made towards widespread testing and surveillance bear testament to the state’s commitment to public health and welfare—an anomaly in the current national and political global climate. For over 60 years, Kerala’s health indicators—infant and child mortality rates, birth rates, life expectancy, sex ratio and maternal mortality ratios—have consistently topped the country, despite its middling economic achievements and high unemployment rates. 

Health economist V. Raman Kutty has attributed these health outcomes to a “tradition of support for health development” from successive state governments, irrespective of political leanings. 

The Pinarayi Vijayan -led government’s response to the Covid19 outbreak provides a glimpse of what goes into building a robust response to a public health crisis of this magnitude. In the past few weeks, the government has instituted much-praised interventions such as providing logistical support to quarantined people to buy supplies; counselling and better internet data packages for those in isolation; and soaps and sanitisers at bus stops and at the entrance of public buildings. All these steps, which address individual-level impediments to sustain the preventive measures crucial to checking the spread of new infections, exemplify the application of scientific knowledge with empathy. 

Further, the government’s efforts at transparent communication (press conferences every evening) coupled with tangible relief measures addressing livelihood and food security concerns, speak of a public health wisdom that focuses on inspiring social solidarity and trust to encourage informed public cooperation. For a crisis of this magnitude, Kerala’s response might be among the best examples of respectful, sustainable and harmonious public health intervention at a large scale.

The current system’s ability to function effectively and democratically hinges on the cooperative participation of people, bodies of local self-government (LSGs), health workers and the state government. It has also been decades in the making, if not a century.

People at the centre

From the Kerala state’s inception in 1956 up to the 1980s, state governments invested heavily in the expansion of healthcare infrastructure, facilitating the demand for modern healthcare services. Political scientist Prerna Singh attributes Kerala’s above average performance in health and education to this high demand for welfare services, which she suggests is also rooted in a 130-year-old history of social justice movements and welfarist responses that came to prioritize the welfare of the ‘Malayali’ over narrow caste and communal identities. 

The more immediate intervention responsible for the successes of the present system came in 1996 when the People’s Plan Campaign (PPC) for decentralised governance was adopted following the 73 and 74 amendments to the Constitution of India. In Kerala, unlike in other states, these reforms went beyond intent and operationalised people’s participation in planning and decision-making regarding local development. The state was the first to transfer the control of sub-centres (SCs) and primary healthcare centres (PHCs) (panchayat-level healthcare facilities) to the LSGs and also to allocate over a third of its health budget to LSGs. 

Further methodological guidelines, mechanisms and structures have been created to facilitate participatory planning for developmental activities starting below the panchayat level. 

For instance community members work together in ayala (neighbourhood) sabhas and gram sabhas to identify and prioritise health needs, select beneficiaries, monitor projects and mobilise voluntary contributions. Working groups on health bring together community members, women representatives from the community-based organisation Kudumbashree, elected representatives, health workers and experts in a forum to plan projects together for community-specific needs. Performance and social audit mechanisms enable the gram sabha and panchayat committees to review expenditures, oversee the effective utilisation of finances and fair selection of beneficiaries. All plans and projects are finally approved by the panchayat samithis, which bring together government officers and elected representatives. Hence, elected representatives, health functionaries and communities have the experience of over two decades of cooperative engagement that has also led to success in the realms of sanitation, drinking water provision and infrastructure for healthcare facilities at village and sub-district levels. 

Decentralisation’s critiques in the context of Kerala include its failure at collecting health information data or addressing the newer health problems of lifestyle diseases and concerns of the elderly. 

However what decentralised planning facilitated by public funding does is that it places people’s voice and their active participation at the centre, both in word and deed. It strengthens an existing political culture where people demand their health rights while remaining mindful of their duties. 

Governance of care

Community and voluntary effort though important, cannot sustain state-wide health care systems. They call for massive financial and managerial commitments that only governments can bear. In Kerala, devolution of planning, fiscal and decision-making responsibilities to LSGs has not been a substitute for public investment in healthcare. Over 60% of the state health department’s budget continues to be dedicated to human resources. Though Kerala’s physician ratios have been low in the past, the Niti Aayog’s Health Index Report for June 2019 shows that only 2.4% of the positions for medical officers were vacant at the PHCs in 2017-18. The specialists’ vacancies at district hospitals too had come down to 13.5% from over 20% in 2015-16.

Not just in hospitals, Kerala also boasts of the highest accessibility of care closest to home, at the primary level in the form of Accredited Social Health Activists (ASHAs) who provide the first line of services for minor ailments, to pregnant women and to infants. According to a national level evaluation of the ASHA programme by the National Health Systems Resource Centre, 2011 Kerala’s network of over 27,080 ASHAs ensures that 85% of beneficiaries are able to access primary level care. ASHAs in the state make more frequent home visits than in others and are most proactive in reaching out to marginalised sections. Their effectiveness is reflected in the widespread acceptance they enjoy in the Village Health and Sanitation Committees. 

Kerala’s health policy design, in the last decade has also been informed by lessons derived from critical research and people’s movements as well. Mission Aardram (literally meaning tenderness) launched in 2017, with a view to lowering out-of-pocket expenditure on healthcare, was a response to studies showing increasing costs of healthcare in the state that stemmed from a burgeoning private sector and a growing demand for higher quality care. Interventions under Mission Aardram have been designed to encourage the utilisation of public healthcare services by enhancing the care-seeking experience at these facilities. PHCs now upgraded to Family Health Centres boast of longer working hours, web-based appointment systems and virtual queues. With better staffing, these centres now also cater to individualised needs of those at risk of diabetes, hypertension and depression. At the district level the Mission has introduced new sub-specialties like cardiology, nephrology and neurology in hospitals providing high quality specialist care at subsidised rates. 

In a similar vein, the state government’s Palliative Care Policy adopted in 2008, the first of its kind in India, drew upon the work of the Pain and Palliative Care Society established in Calicut in 1993. The palliative care movement in North Kerala grew in response to the paucity of cost-effective care services for pain relief and the psychological and emotional needs of terminally ill patients. It has been the inspiration behind current policy provisions that budget and provide for palliative care as part of all healthcare planning at the LSG level. 

Kerala thus presents a model of health governance where the leadership has long been informed by a perspective of partnering with people by sharing power. The last two decades in particular, have taught leaders to look for solutions that address impediments to the fulfilment of a health need by listening to and learning from people’s experience with health and healthcare, while simultaneously ensuring the continuation of material and financial investments fundamental to sustaining responsive health service systems. Rather than treating people as passive ‘targets’ of scientific interventions or using strong-arm tactics, the government relies on a combination of transparent communication, substantive people’s participation and empathy for strong health governance—one that measures up to the task of a sustainable response to the challenges posed by health emergencies such as the coronavirus pandemic. 

The author is a freelance public health researcher.