With a population of 138 crore, India is categorised as a middle income South Asian country on the health index. Though we became independent in 1947, formation of states happened only in 1956 and now with 28 States and 8 Union Territories, health care in India falls under the responsibility of the states. Over the last seven decades, Indian states have experienced different levels of success and failure in health index results. Kerala, a small southwestern state with a population of 34.6 million, is one of the leading states in India with excellent health indicator results in many areas as compared to most other states. Kerala has surpassed all other Indian states in terms of health sector performance for more than a decade now.
According to the available census, the infant mortality rate in Kerala is 12 per 1,000 live births, while in India it is estimated that 40 infants per 1,000 live births die. Maternal mortality rate is 66 per 100,000 and 178 per 100,000 births in India. Male literacy is 96% in Kerala, and 82% in India. It is at 92% for women in Kerala and 65% in India. The overall literacy rate in India is 74% and in Kerala it is at 94%.The health achievements of Kerala today are largely due to a number of factors, including the strong emphasis of the State Government on public health and primary health care, health infrastructure, decentralised governance, economic planning, girls' education, community participation and readiness. But COVID 19, which has rocked this century, has shown us that it is time for India and Kerala to redefine the health policy that's been pursued for 70 years now.
Our region, which became Kerala in 1956, had a long history of health-centric policies. For example, vaccination was made compulsory in Kerala as early as 1879 for certain sections of society, including public servants and students. With the attainment of state status, we should realise that Kerala had invested in infrastructure to create a multi-layered health system designed to provide the first contact level at the community level.
In addition, Kerala has rapidly expanded the number of medical facilities, hospital beds and doctors decade after decade. From 1960 to 2010, the number of doctors increased from 1,200 to 36,000 and between 1960 and 2004 the number of primary health centers increased from 369 to 1356 which is a success indicator of the health policy we have implemented. This increase in the number of PHC centres and doctors has led to the improvement of secondary and tertiary care facilities in Kerala to provide proper care in the right place and reduce the cost of patient care. Additional public health and community development initiatives launched shortly after Kerala became a state, have helped create a strong and effective environment in the health sector. But will the health policy formulated decades ago suffice in this new age? The catastrophic epidemic that followed, points towards the need for a new health policy.
Reforms in our decentralised health care system
What should be the direction of our new health policy? Despite investment in expanded infrastructure in the health sector, the availability of medicines, lab supplies and adequate sanitation (including drinking water and toilets) in public health centres in Kerala was low in the early 1980s. In 1982, the National Health Policy recognised the limited resources of the public sector in all Indian states and promoted nationwide policies in favour of privatized health care. Over the next 15 years, public sector institutions in India increased the number of beds by 5%, while the private sector across the country was able to handle 80% of ambulatory care and 60% of inpatient care. As the private health sector grew in Kerala, many people sought care in this new sector. However, health care has become significantly more expensive. In 1996, when our government launched the People's Campaign for Decentralised Planning, the health sector in Kerala underwent a major overhaul. However, the growing demand in the health sector has once again created a crisis. We also realised its limitations during the COVID period. Therefore, the need for a review of this existing policy and the formulation of a new policy for the future has become critical at this juncture.
We are going through a period when decentralised care schemes should be reimagined as a new policy in the health sector. Ensuring public-government-private participation in this sector is the need of the hour. We need to be able to allocate 35 to 40% of the state budget for the health sector. It can improve care and hospital access, regardless of income level, caste, tribe or gender. In Kerala, there is a three-tier self-governing system comprising 900 villages (panchayats), 152 blocks and 14 districts. The current PHC system includes sub-centres, primary health centres supported by five to six sub-centres, and village and community health centres’ sub-centres are of great benefit to the general public. Primary care centres are of paramount importance in the field of health care. Kerala exemplifies an approach that strengthens our public health indices. Kerala still maintains a low infant mortality rate owing to its high literacy rate compared to the national average. However there are other indicators like adolescent health and mental health that the state now needs to focus on. Programmes need to be formulated to improve adolescent health and innovative programmes to meet the needs of more vulnerable populations in the community.
Our health indicators owe its success to excellence in health policy planning. In seven decades the health demography of the state has gone through a paradigm shift, bringing new challenges to the forefront for the health professionals in the state. Statistics indicate that the proportion of adults over the age of 60 will double by 2050, so the development of geriatric wards and geriatric friendly facilities should be part of Kerala's health policy. We need to focus on community-based home care initiatives and redefine pain and palliative care policy and focus on palliative care. In the context of COVID 19, Kerala should invest heavily in health information systems to compile household data to facilitate health management and monitoring of infectious diseases and make our healthcare management flawless. Despite all the achievements, the PHC system in Kerala has recently been facing many challenges. The epidemic of chronic diseases, the financial crisis in the public health sector and the rising cost of health care are still rampant. The increase in non-communicable diseases in the state is now challenging the health care system. The highest prevalence of diabetes in the country is recorded in Kerala at 14.8% of the population aged between 15 and 64 years against a national average of 8% in India. In addition, the prevalence of other risk factors in the health sector is considered to be very high in the state. A 2010 study found that 42% of adult males smoke, 40% of the adult population ate less fruits and vegetables, and 25% are overweight. Although these figures are likely to have slightly improved over the past decade, they remain a major challenge.
Overall, the indicators show that Kerala's edge on the health sector will be lost if we do not make significant progress by investing heavily in infrastructure development, decentralised governance and community engagement to address the new challenges posed by the demographic shift in our population. Despite the high HDI that we are proud of, a core overhaul of the existing health policy is essential to make health care accessible and affordable to all.
It's time to revisit the healthy policy that stays ahead of the curve to keep the indices healthy for the next marathon ahead. The right approach would be to constitute a committee of public health experts and policy makers in Kerala in coordination with innovation in research leveraging information technology to envision a comprehensive health plan for the first 10 years and the next 50 years. Kerala should adopt an action plan for implementation of projects envisioned with the participation of government agencies, private agencies and the public.
It is the duty of each and every one of us to take on the collective responsibility of maintaining the pre-eminence that our State has achieved over the decades and improving our position in the Community Development Index.
Rev. Dr. Binu Kunnath,Director, Caritas Hospital & President, CHAI Catholic Hospital Association of India
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