In many respects, Kerala's health status is almost on par with that of developed economies. The state has succeeded in increasing life expectancy as well as reducing infant and maternal mortalities. The implementation of land reforms ended feudalism in Kerala and improved the standard of living of poor farmers and tenants. Public Distribution System of Kerala played an important role in improving nutritional status. Kerala's public health care system has helped in providing healthcare facilities to people of all strata of society. Changes in educational and health care sectors are mutually dependent.
Improvement in female literacy is considered as the single most important factor that enhance health status of a society. Most of the social reform movements in Kerala gave importance to education. The thrust on education was sustained by efforts of the democratic governments. As a result of all these developments Kerala's health model succeeded in attaining higher health standards based upon social justice. World Health Organization has described the Kerala Model of Health as "Good Health at low cost based upon social justice and equity."
From Success to Crisis
During the past few years, Kerala's health care sector has been facing serious crises. Important among them are: Return of previously eradicated infectious diseases and the emergence of new ones, rapid increase in the incidence of lifestyle diseases, prevalence of the health problems specific to women and the aged, constraints of government hospitals, excessive privatisation of health sector, rising treatment costs, entry of self-financing medical education, dearth of human resource in health care sector and lack of health sciences research.
Kerala's health sector had begun to face crises by early 1980s itself. Doubts regarding existence of cracks in Kerala health model emerged with the return of epidemics (like Hepatitis, Cholera, Rat fever and Malaria) which were once considered as completely eradicated. Soon, new epidemics appeared in Kerala (ex: Dengue Fever, Chickunguniya, Japanese Encephalitis and H1N1).. In the mean time, incidence of lifestyle diseases like diabetics, hypertension and cancer cases increased at an alarming rate. By the beginning of 1990s, Kerala society started to bear the double burden of resurgent epidemics and emergent lifestyle diseases. High incidence of suicides indicating a low mental health status and casualties due to motor accidents are also signs of the crisis faced by Kerala model of health. The severity of health crises faced by marginalised groups (like Adivasis, fishing communities and people dependent on traditional occupations) is greater than that faced by 'mainstream' society. Recent largescale deaths of tribal infants in Attappadi highlight this problem.
Privatisation and Super Specialty Culture
We have built up a curative treatment-focused public health system to solve Kerala's problem of rising morbidity. This system is mostly based on the super specialty care through big multi-specialty private hospitals. Government medical colleges and hospitals failed to transform according to quantitative and qualitative change in Kerala's morbid people. This vacuum is exploited by the profiteering private investors. As a result, big private hospitals mushroomed in Kerala. Health care became an attractive avenue for profit-motivated investors where anyone with funds can invest without any restrictions. The erstwhile government-dominated health sector is now dominated largely by corporate hospital chains. Many of the small and medium sized private hospitals who provided affordable medical care to people became unable to hire highly specialised technology and manpower and faced crisis and are getting closed down. Apart from the financial implications the current super specialty culture totally neglects preventive health care and health education.
Towards an American Model?
Excessive privatisation and commercialisation of health sector lead to an escalation in health care expenses in Kerala. According to a study conducted by Kerala Sastra Sahitya Parishad (KSSP), per capita annual out-of-pocket health care expenditure increased from Rs 88 in 1987 to Rs 1,710 in 2004 and Rs 5,029 in 2011. The Kerala State Planning Board report (Report of the Expert Committee on Health 2014) says that Kerala has the highest out-of-pocket health expenditure in India and that 12% of rural households and 8% or urban households were pushed below poverty line due to health expenditure in 2004. This trend is still continuing unabated. Kerala seems to be moving towards an American Model of Healthcare characterised by the coexistence of cutting edge modern treatment facilities and lack of accessibility of health care to the poor.
Decentralisation and Health care
People's Planning and the decentralisation of governance initiated in 1996 had made positive impacts in the health sector. Government hospitals from PHCs to district hospitals came under Local Self Governments (LSGs). Condition of hospitals in grassroots level began to improve. Enhancement in the availability of drinking water and sanitation facilities helped to control epidemics. The very first years of implementation of people's planning witnessed a significant increase in the number of people who use government hospitals. Condition of government hospitals improved because of the effective usage of funds from National Rural Health Mission. LSGs are now implementing more schemes focusing on preventive health and health education. Joint efforts of patients, doctors and health volunteers have led to emergence and spread of palliative care movement in Kerala. However, there is need for the more effective coordination of the activities of health service department and health-related activities of LSGs. By the united efforts of health department, LSGs, people's representatives, doctors and hospital staff can establish a new Decentralised and Participatory Health Care Model for Kerala.
Medical Research
With the termination of the system of private practice of medical college doctors and the establishment of the University of Health and Allied Sciences the preconditions for the initiation of serious medical research focusing on Kerala's health problems are realised. Formulating and implementing suitable action plans for medical research should not be delayed any more. Kerala's biodiversity, availability of medicinal plants and traditional knowledge can play a major role in pharmaceutical research in Kerala. All facilities and infrastructure are available for establishing a modern pharmaceutical R & D centre in Kerala with the cooperation of institutions like Tropical Botanical Garden and Research Institute, Rajiv Gandhi Centre for Biotechnology, Agricultural University and Kerala Forest Research Institute. Financial assistance of central government can also be mobilised for the establishment of such a centre.
People's Health Policy
Kerala has policies for sectors ranging from water supply to liquor. But we don't have a health policy that takes into account the challenges faced by the state's health sector. We have to formulate a health policy that takes note of the spread of epidemics and LSDs, rising health expenditure, health problems of the aged, the marginalised and women and must give equal importance to preventive health and curative care. Improving the facilities and services provided by the government hospitals catering to the needs of the poor must be the sheet anchor of such a policy. Corporate private hospitals must be subjected to social control.
The central government must provide funds and other facilities to complement the health projects formulated by the state government. Currently, expenditure on health by the central government is only 1.1 % of GDP. This is not enough to tackle the health issues faced by the nation. Central government must implement the WHO recommendation of allocating at least 5% of GDP for health care in the current plan period itself and provide enough funds to the state government to tackle the ever increasing health needs of the people. The decision of the Central Government to cut down the health funding to the state because of the increase in the 14th Finance Commission recommendation to increase the present state share from 32% to 42 % will adversely affect the health budgeting in Kerala. The central funding to National Rural Health Mission has been already reduced. This is going to further worsen the financial crisis of the state government.
Kerala's achievements in health care are the outcome of peoples' interventions and the implementation of public health provisions by various governmental agencies. But Kerala is moving away from success to severe crisis in health sector and possibly from social equity to social exclusion. Comprehensive efforts to tackle these problems must form an integral part of the struggle for a new Kerala Model of Health Care.
(Author is a consultant neurosurgeon, former professor of neurosurgery and former Vice-Chancellor, University of Kerala. He can be reached at ekbalb@gmail.com)
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