KERALA, along with China, Costa Rica, Cuba and Sri Lanka, was held up to the world as a model of ‘good health at low cost’ in a conference held in Bellagio, Italy under the auspices of the Rockefeller Foundation.¹ The theme running through the conference proceedings was that it is possible, at low levels of resources, to achieve commendable health status, at least by the measures of mortality and gross morbidity readily available to us. This view was subsequently re-emphasized in a number of scholarly publications. Kerala became a ‘model’ for the right kind of social policies to be pursued by developing societies, which would ensure balanced, equitable development and steady improvement in health indices.

If we examine Kerala’s mortality statistics through the 20th century, we see a steady improvement in life expectancy. This is evident in available estimates from Travancore and Cochin states, which were integrated into the state of Kerala along with the district of Malabar from the erstwhile Madras Presidency. There is a striking contrast to the rest of India, even in the early years of the 20th century. This was accompanied by a sex ratio in favour of the female, also from early years of the last century, indicating longer survival of women. Later, this decline in mortality was augmented by a sharp decline in fertility, which continues even now.

Vital statistics from other states indicate that this decline in mortality, followed by a decline in fertility, is taking place elsewhere in India, but at a much slower pace in all except a few states. The southern states seem to be travelling the same route, but at a faster pace compared to the northern states in India. In itself, this trend is not surprising: this is the ‘demographic transition’ that happened in Europe, North America and Japan much earlier. What is surprising in the case of Kerala, however, is that this happened without the accompanying thrust of large-scale industrialization or urbanization.

However, even by 1984, serious doubts were being expressed as to the desirability of the Kerala ‘model’ in health. Panikkar and Soman, in a book appropriately titled ‘the paradox of economic backwardness and health development’, pointed out that while mortality was low in Kerala, the prevalence of morbidity was found to be quite high.² Though the book did not depend on data from any large-scale survey, this view was soon corroborated by a statewide study undertaken by the Kerala Sastra Sahitya Parishad – better known by its acronym KSSP – that claims to spearhead a people’s science movement, which showed that reported sickness in Kerala was indeed high.³ Subsequently, Lincoln Chen and others pointed out that the ‘perception’ factor may be at work in Kerala; perhaps owing to the high levels of education, more people may perceive themselves to be sick compared to other states in India. Even this view was later challenged when several micro-studies in various districts of Kerala reported a high prevalence of chronic non-communicable diseases like coronary heart disease and diabetes.

 

After the year 2000, a number of studies focused on the increasing burden of disease in Kerala: besides heart disease and diabetes, road traffic accidents and their consequences were on the rise, as were suicides. Particularly distressing was the finding that suicides were the most frequent cause of death among young females; the state arguably has perhaps one of the highest rates of suicide in young females in the world. In causes of death, Kerala resembled USA or UK rather than other states of India: about a third of the deaths were attributable to heart disease, and deaths due to infections were only a small proportion.

Apart from these ‘lifestyle’ diseases, which could be attributed to large-scale transformations in society, Kerala at this juncture also witnessed the reappearance, or even the resurgence, of infectious diseases: epidemics of dengue, chikungunya, rat fever and hepatitis became an annual feature in the state. This indicated large-scale environmental degradation. Most water sources were polluted, and garbage disposal in urban areas loomed large as an insurmountable problem. Many micro-level studies pointed to the high expenditure in health care, which were driving many families to financial ruin and suicide.

Data from economic indicators showed that by the turn of the millennium, Kerala was no longer a poor state in India: its per capita GDP was better than the national average. A large proportion of families, both in rural and urban areas, depended on private health care. Data also indicated that Kerala had become, ranked by income inequality, one of India’s leading states. In health, as in many other things, Kerala had become a ‘non-model’.

 

Has Kerala’s health deteriorated all that much in a span of less than fifty years? If we go by infant mortality, life expectancy and sex ratio, Kerala still tops the list of Indian states. It is no doubt one of the few Indian states to have reached most of the millennium development goals in health set for the whole country. The original writings, which set the tone for the entire literature on the Kerala ‘model’ in health, had also pointed out the remarkable mortality and fertility decline in the state; this seems to continue to the present day. So how right is it to say that the Kerala model has failed?

Much of the writing on Kerala’s health reminds one of the blind men who tried to ‘see’ the elephant: each interpreting the animal according to the information available to him. The remarkable fall in death rates and birth rates – and it is remarkable – is only one dimension of the changing health experience in the state. Most early writers on the low mortality and fertility in Kerala tended to attribute these to social and political influences. Prominent among these were the high levels of literacy among women, general acceptance of schooling cutting across caste and class, a political situation conducive to supporting rights of disadvantaged people, and governments ready to intervene strongly in education and health.

 

However, it should be emphasized that changes in the health system also contributed to improving health status. As early as the 1970s, Kerala had a network of government health institutions in almost all rural areas that catered to the general population. Most national health programmes were vigorously implemented. Within no time, fuelled by the demand for medical care created by government health institutions, there was an accelerated growth of the private sector in health care. But this became a boom with the onset – or rather onslaught – of the wide-ranging economic reform policies initiated by the Government of India in the early nineties. The philanthropic character of the earlier private health sector soon declined, making way for a new breed of highly commercialized and explicitly profit-seeking institutions.

Large-scale privatization of health created a big market in health related goods and services, many of them unproven and perhaps even unnecessary. Growing international tourism in health and the successful marketing of Ayurvedic ‘health promoting’ products became part of the story. Many people in the know allege that the diagnostic imaging and clinical laboratory industry thrived through unethical practices such as cutbacks to referring doctors, though this could never be proved.

While the private sector thrived, the government health sector saw a steady erosion in quality. The almost exclusive emphasis on curative care in the state meant that public health functions were neglected, leading to conditions ripe for infectious epidemics. Public health training of doctors was de-emphasized; medical specialization was over-emphasized, leading to a health sector dominated by specialists and procedures, but woefully lacking skills in meeting basic public health functions.

 

In 1996, the Left Democratic Front (LDF) government in Kerala initiated a bold policy move bringing health institutions such as primary health centres (PHC) and community health centres (CHC) under local self-governments (LSG). The expectation was that this would result in more accountable and efficient running of health institutions, and thus thereby address many of the ills in the system. This was part of a broader policy of decentralized planning and governance, whereby powers of the state government were passed onto the LSG. In practice, however, this gave rise to a wide variation in quality in services offered by these institutions: while some thrived under responsible political management, others suffered from the conflicts between local political leaders and the medical officers. One key element of this failure was that the medical staff of the health institutions was still answerable largely to the parent department, and felt they had no responsibility to satisfy the local government.

 

The remarkable part of the story is that the lead that Kerala had in low infant and crude mortality continues to be maintained, despite many of these other deviations. However, it is doubtful whether it could still be called good health ‘at low cost’: studies point out that Kerala now has one of the highest per capita payments for health and hospitalization. The Kerala ‘model’ in health is currently dominated by privatized health care, where services of doubtful quality are offered to an unsuspecting public through advertising and other inducements, many of them unethical, purely as a profit-making venture.

The public sector in health caters largely to the poorer sections of society; recently there is a policy thrust to push even the poor people to the private sector under the guise of insurance coverage propelled by a national social insurance for health called the Rashtriya Swasthya Bhima Yojana. The public seems to have lost trust in the health system, both public and private. Medical care is reduced to shopping around for services of doubtful quality, constrained only by one’s purse. The Kerala model was once characterized by health security: whatever one’s station in life, one had reasonable assurance that the state would provide health care. Moreover, the quality of this care would not depend on one’s status. Now, however, health care availability is dependent on one’s ability to pay, though even that does not assure quality.

There are three questions that demand our attention: (i) Is there a Kerala ‘model’ in health care and, if so, what are its features? Is it on the decline now? (ii) Is the current metamorphosis of the Kerala health scene a natural evolution from the model? If not, what led to the deterioration of this ‘model’? And (iii) Arising from (i) and (ii), can we construct a new Kerala model in health?

The answer to the first set of questions is that there never was a Kerala model in health, in the sense that there was no conscious policy effort to create an equitable health system which would offer health security to all. What was described as the Kerala ‘model’ in health, is a demographic transition that occurred faster than in many other parts of the world, bringing down death and birth rates within the span of a single generation. This was the result of a political environment that emphasized rights, and a policy thrust that ensured rights in education and health.

 

The fall in mortality has more or less reached a plateau; achieving a further decline in infant mortality, for instance, from the current levels of 10-15/1000 live births, will involve heavy investment in hospital care for very small birth weight infants to ensure that they survive into adulthood. Likewise, having achieved near universal institutional pregnancy care and delivery, bringing down maternal mortality further involves investment of a high order in complex systems such as ambulances and blood storage and delivery. An increasingly aging population inevitably faces a huge burden of non-communicable diseases, and treatment facilities for these would put more and more stress on the health services. Health is also influenced in a negative way by developments in other sectors: growing traffic congestion, booming consumption of alcohol, environmental damage, and behavioural traits like an increasingly sedentary society.

It follows from what is described above that the deterioration of the ‘model’ is also not the result of any conscious policy decisions. However, if we follow the health development of Sri Lanka, which had comparable health indicators to Kerala even in the seventies, large-scale privatization is not a natural phenomenon in health care; it happens, to a large extent, when the public sector in health fails to provide services. In the political environment of Kerala, where two political formations, the LDF and the United Democratic Front (UDF) have alternated in holding the reins of power since the eighties, health was never a policy priority. Unfortunately, this attitude has been reinforced by comparisons with other states: Kerala even now has good health indices compared to them. Consequently, no one seems to have realized that this is more a reflection of the poor performance of the other states, rather than any particular effort by Kerala. This created an attitude of smugness in policy makers as well as experts – that the state is doing well in health care.

 

This brings us to the third question: Is it possible to construct a new Kerala model in health care? To answer this question we need to define the features of the model that we want to build. What are the components that we would like to see in an ideal health sector? Do we need to ensure that the ‘latest’ in health technology will be available in the state, albeit at a high cost and to a select few with resources? Are we satisfied by ‘distributional equality’, which ensures that everyone has a chance, within a resource use limit set by the government, to choose any fancy health intervention that he or she (or the doctor) ‘wants’ (but may not need)?

The health system that I would like to see in Kerala would ensure that everyone, however humble her station in life and wherever she might choose to live, has access to a qualified physician and a reasonable range of health care options and medication within easy reach. Such a system would also ensure that should the need arise, even complex high cost medical interventions like a coronary bypass graft, cochlear implant or cancer therapy would not be beyond the reach of even the poorest, while protecting them from a predatory market to make sure that these same interventions are not thrust on them unnecessarily, driving them to financial desperation.

 

This new Kerala model in health cannot be built by focusing on the health sector alone; it requires social security for the poor, protecting them from economic catastrophe. It should also be one where there is employment guarantee, gender equity and control on exposure to harmful substances in the environment. Above all, it should ensure the rights of the people to question the quality of service that they receive from both government and private players.

Is it possible to build such a model? More than any other state in India, perhaps Kerala can once again take the lead in health. Kerala is no longer a resource-poor state; only governments seem to be lost for ways to raise resources. We live in times when people in decision making can use technology in innovative ways to ensure participation. Kerala has a highly educated population, a large proportion of whom have been exposed to living abroad in countries with better systems. If the political leadership has the courage to develop a vision for Kerala’s health that will incorporate some of the principles outlined above, and the will to execute it, a new Kerala ‘model’ can emerge for ensuring a healthy society.

 

Footnotes:

1. See, Good Health at Low Cost. Proceedings of the Bellagio Conference, Bellagio, Italy, The Rockefeller Foundation, 1985.

2. P.G.K. Panikar and C.R. Soman, Health Status of Kerala: The Paradox of Economic Backwardness and Health Development. Centre for Development Studies, Trivandrum, 1985.

3. See, K.P. Kannan, K.R. Thankappan, V. Ramankutty and K. P. Aravindan, Health and Development in Rural Kerala. Kerala Sastra Sahitya Parishad, Trivandrum, 1991.