Kerala, India: Governance

Emphasis on health reform

India is a middle-income South Asian country with a population of over 1.2 billion.1 India was formed in 1947 and was divided into states starting in 1956. At present, there are 29 states and 7 union territories.2 In India, healthcare is managed at the state level. Over the last six decades, the Indian states have had varying levels of success in health outcomes. Notably, Kerala, a southwestern state of 33.3 million people3 has consistently been a prominent outlier with better health outcomes in a number of areas compared to most states in India. In 2011, Kerala attained the highest Human Development Index of all Indian states based on its performance in key measures:5

  • Lower infant mortality rate of 12 per 1,000 live births in Kerala vs. 40 per 1,000 live births in India),
  • Lower maternal mortality ratio of 66 per 100,000 live births in Kerala vs. 178 per 100,000 live births in India,
  • Higher literacy among both males at 96% in Kerala vs. 82% in India and females with 92% in Kerala vs. 65% in India4

The health gains made in Kerala can be attributed to several factors, including strong emphasis from the state government on public health and primary health care (PHC), health infrastructure, decentralized governance, financial planning, girls’ education, community participation and a willingness to improve systems in response to identified gaps567891011 

When it established statehood, the area that made up Kerala already had a long history of health-focused policies; for example, vaccinations were made mandatory for certain segments of the community - including public workers and students - ad early as 1879612."

Once it achieved statehood, Kerala invested in infrastructure to create a multilayered health system designed to provide first-contact access for basic services at the community level and expanded integrated primary health care coverage to achieve access to a range of preventive and curative services.13

Additionally, Kerala rapidly expanded the number of medical facilities, hospital beds, and doctors. From 1960 to 2010, the number of doctors increased from 1200 to 36,000, and the number of primary health care facilities increased from 369 to 1356 between 1960 and 2004.14 This increase in the number of PHC centres and doctors allowed for the provision of the right care in the right place, reduced the costs of patient care and lowered the burden on secondary and tertiary care facilities.712 Additional public health and social development initiatives that began soon after Kerala was made a state—such as a push for safe drinking water in the state’s capital, Trivandrum, and primary education for men and women—aided in creating the environment for a strong and effective primary care system.6

Decentralized health care reform

Despite this investment in expanded infrastructure, by the early 1980s, there were reports of reduced access to medicine, lab supplies, and adequate sanitation (including drinking water and latrines) in public health centres in Kerala.12  In 1982, the National Health Policy, recognizing the limited resources in the public sector across all Indian states, encouraged nationwide policies that favoured privatized health care. Over the next 15 years, while public governmental institutions in India increased the number of beds by 5%, the private sector across the country expanded to manage 80% of ambulatory care and 60% of inpatient care15 As the private health sector grew in Kerala, many residents sought care in these new locations. However, private health care was significantly more expensive and often unaffordable, with the poor spending up to 40% of their income on out-of-pocket payments to access care.16

In 1996, recognizing the eroding trust in the public system, Kerala underwent a major overhaul when the state government implemented the People's Campaign for Decentralized Planning movement. Through this reform, the state government decentralized and relinquished a significant amount of power."

For example, new budgetary allocations gave local governments control of 35 to 40% of the state budget.12 The campaign emphasized improving care and access, regardless of income level, caste, tribe, or gender, reflecting a goal of not just effective but also equitable coverage.12

Within the campaign, a three-tier system of self-governance was established, comprised of 900 villages (panchayats), 152 blocks, and 14 districts.16  The current PHC system consists of sub-centres, primary health centres that support five to six sub-centres and serve a village, and community health centres.17 The sub-centres serve the smallest population and do not have inpatient capacity, while PHC facilities serve about 26,000 citizens and provide maternity services and limited inpatient services, and CHCs provide care to approximately 230,000 individuals.17 In 2012, there were 23,940 PHC centres in Kerala.18

Under the new system, the PHC centres and their referring sub-centres were brought under the jurisdiction of villages in order to engage more closely with the community to identify and implement effective changes to respond to local health needs and encourage of use of PHC centres and sub-centres as the first point of care.16 Communities were brought together to determine which health topics were important and needed attention, with selected topics ranging from strengthening PHC facilities to improving water and sanitation safety.12 This decentralization resulted in physicians and community members working together and many facilities undergoing significant renovations to address community priorities. As another component of the new system, individuals, especially in lower socioeconomic groups, were encouraged to utilize public health centres. Particularly in villages with strong panchayat governance, there have been improvements in access to medications and health outcomes, as well as increased patient utilization of care at PHC centres.12

Health successes

Kerala provides an example of an approach that can provide vastly improved health at a rapid rate. Overall, Kerala has maintained low infant and maternal mortality rates, and higher literacy rates, when compared to the national average.19 Kerala has also continued to innovate to meet the needs of more vulnerable populations including establishing a Weekly Iron and Folic acid Supplementation (WIFS) Program and Adolescent Friendly Health Clinics (AFHCs) to benefit adolescent health.19

Kerala is also forward-thinking in its health policy planning. The proportion of the population made up of adults over the age of 60 is expected to double by 2050, and Kerala is already developing geriatric care wards and geriatric-friendly facilities in preparation. The state is also a leader in palliative care with its own Pain and Palliative Care policy (2008), which focuses on community-based home care initiatives.2021 Kerala’s palliative care network contains over 60 units and serves more than 12 million individuals.20  In addition, Kerala is investing in health information systems to compile household-level data designed to help with population health management and surveillance of communicable diseases.19

Challenges and thinking ahead

Despite these health improvements, Kerala’s PHC system has recently faced a number of challenges: the epidemiological transition towards chronic disease,619 erosion of public health funding,6 and the continued presence of private health care at much higher cost2223 have pushed the health system to its limits. The rise of non-communicable diseases in the state has challenged the healthcare system: Kerala has a high prevalence of diabetes—14.8 percent of its population between the ages of 15 and 64 years is diabetic, compared with only 8 percent in India overall.2425 Furthermore, the prevalence of many NCD risk factors in the state is estimated to be very high; a 2010 study found that 42 percent of adult males smoked and that 40 percent of the adult population ate diets low in fruits and vegetables, while 25 percent were overweight.2627

Improvement in socioeconomic conditions has prompted the growth of the private sector as public institutions failed to keep up with the population’s increasing demand for quality care. The return of the shift from the public to the private sector is concerning because individual household spending on health fees is increasing while many public facilities are underutilized and understaffed as a result of employees seeking higher-paying jobs in the private sector.617 The new national government in India elected in May 2014 has reduced spending on health care,2628 and this is likely to also have a negative effect on the public health care system—including in Kerala—further increasing the stress on the fragile public health care system.

Overall, Kerala has made significant strides through investing in infrastructure, decentralized governance, and community engagement. Though many challenges remain, it is working towards making health care accessible, affordable, and responsive to an increasing burden of non-communicable diseases.


  1. The World Bank. India. Available from:
  2. Library of Congress. Country Studies. Available from:
  3. Government of India. Office of the Registrar General & Census Commissioner, India. Available from:
  4. Ministry of Health & Family Welfare GoI. State Wise Information Kerala  [cited August 2015].
  5. Government of India Planning Commission. Twelfth Five Year Plan 2012-17. Available from:
  6. Kutty VR. Historical analysis of the development of health care facilities in Kerala State, India. Health Policy Plan. 2000;15(1):103-9.
  7. Rao M, Pilot E. The missing link--the role of primary care in global health. Glob Health Action. 2014;7:23693.
  8. Sen A. Critical reflection. Health and development. Bull World Health Organ. 1999;77(8).
  9. Evans JR, Hall KL, Warford J. Health Care in the Developing World: Problems of Scarcity and Choice (Shattuck Lecture). population. 1981;61:74.
  10. Filmer D, Hammer JS, Pritchett LH. Weak links in the chain: a diagnosis of health policy in poor countries. The World Bank Research Observer. 2000;15(2):199-224.
  11. Warren KS. The evolution of selective primary health care. Soc Sci Med. 1988;26(9):891-8.
  12. Elamon J, Franke RW, Ekbal B. Decentralization of health services: the Kerala People's Campaign. Int J Health Serv. 2004;34(4):681-708.
  13. Bhutta Z, Lalji Dewraj, H. Is there hope for South Asia? Br Med J. 2004;328(7443):777-88.
  14. Chandran SR, Pankaj, R. Primary Health Centres and Patients Satisfaction Levels in Haripad Community Development Block of Kerala, India. International Journal of Current Research. 2014;6(12):11118-22.
  15. World Health Organization. Case study: India  [cited 2015 September]. Available from:
  16. Varatharajan D, Thankappan R, Jayapalan S. Assessing the performance of primary health centres under decentralized government in Kerala, India. Health Policy Plan. 2004;19(1):41-51.
  17. Nabae K. The Health Care System in Kerala-Its Past Accomplishments and New Challenges Journal of the National Institute of Public Health. 2003;52(2).
  18. Government of India. Rural Health Statistics in Rural India 2012. Statistics Division Ministry of Health and Family Welfare, 2012.
  19. Government of Kerala. Health Policy Kerala. 2013.
  20. Khosla D, Patel FD, Sharma SC. Palliative care in India: current progress and future needs. Indian J Palliat Care. 2012;18(3):149-54.
  21. Thayyil J, Cherumanalil JM. Assessment of status of patients receiving palliative home care and services provided in a rural area-kerala, India. Indian J Palliat Care. 2012;18(3):213-8.
  22. Nair VM, Thankappan KR, Vasan RS, Sarma PS. Community utilisation of subcentres in primary health care--an analysis of determinants in Kerala. Indian J Public Health. 2004;48(1):17-20.
  23. Levesque JF, Haddad S, Narayana D, Fournier P. Outpatient care utilization in urban Kerala, India. Health Policy Plan. 2006;21(4):289-301.
  24. Sivasankaran S, Thankappan KR. Prevention of non-communicable diseases requires a life course approach: a case study from Kerala. Indian J Med Res. 2013;137(5):874-7.
  25. Shamima A, Rahman, M., Abe, S., Sultana, P. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Bull World Health Organ. 2013.
  26. Ghosh J. Deep cuts to India's health spending will delay universal access to healthcare. BMJ. 2015;350:h1632.
  27. Thankappan KR., Shah B., Mathur P., et al. Risk factor profile for chronic non-communicable diseases: results of a community-based study in Kerala, India. Indian J. Med. Res. 2010;131:53-63.
  28. Sharma DC. India's BJP Government and health: 1 year on. Lancet. 2015;385(9982):2031-2.