Kerala, India: Decentralized governance and community engagement strengthen primary care
Emphasis on health reform
SPRING Project/John Nicholson/Courtesy of Photoshare
India is a middle-income South Asian country with a population of over 1.2 billion . India was formed in 1947, and was divided into states starting in 1956. At present, there are 29 states and 7 union territories . 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 people  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: .
- 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 India 
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 gaps [5-11].
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 - includig public workers and students - ad early as 1879 [6,12]."
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 .
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 from increased from 369 to 1356 between 1960 and 2004 . This increase in the number of PHC centers 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 [7, 12]. 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 .
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 centers in Kerala . In 1982, the National Health Policy, recognizing the limited resources in the public sector across all Indian states, encouraged nationwide policies that favored 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 care . 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 .
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 . 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 .
Within the campaign, a three-tier system of self-governance was established, comprised of 900 villages (panchayats), 152 blocks, and 14 districts . The current PHC system consists of sub-centers, primary health centers that support five to six sub-centers and serve a village, and community health centers . The sub-centers 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 . In 2012, there were 23,940 PHC centers in Kerala .
Under the new system, the PHC centers and their referring sub-centers 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 centers and sub-centers as the first point of care . 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 . 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 centers. 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 centers .
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 . 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 .
SPRING Project/John Nicholson/Courtesy of Photoshare
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 [20, 21]. Kerala’s palliative care network contains over 60 units and serves more than 12 million individuals . 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 .
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 [6,19], erosion of public health funding , and the continued presence of private health care at much higher cost [22, 23] 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 [24, 25]. 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 [26, 27].
Improvement in socioeconomic conditions has prompted 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 [6, 17]. The new national government in India elected in May 2014 has reduced spending on health care [26, 28], 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.
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