Health outcomes in Kerala - a southwestern state in India - have surpassed those in the rest of the country for decades.  Among several other factors, this positive deviance can be attributed to community participation in the health system. Health care reform in the 1980s focused on decentralization, and as a result, villages assumed decision-making power over the functioning of PHC centers.1 The rationale behind this change was that villages would be more aware of health needs, and village-level stakeholders could help identify smaller-level changes in service delivery that would contribute to better access and positive health outcomes.2 This system resulted in increased collaboration between providers and communities with community members actively solicited for determining important health priorities. This case highlights the intersection between community engagement and local priority setting, and in Kerala this process was facilitated through decentralization. More information on Kerala’s PHC system is available here.


  1. Kerala, India: Decentralized governance and community engagement strengthen primary care. 
  2. Varatharajan D, Thankappan R, Jayapalan S. Assessing the performance of primary health centres under decentralized government in Kerala, India. Health Policy Plan. 2004 Jan;19(1):41–51.