In Kerala, young doctors have the panchayats on their side

Rajeev Sadanandan

It is often forgotten that, as late as the 1930s, Kerala suffered from a gamut of infectious diseases such as malaria, filariasis, smallpox and cholera. The state is justly celebrated for having effectively managed them and stabilized the population. Public health interventions including health, education, environmental management and vaccination, were all funded and managed by the government.

Initially, it was the princely kingdoms of Thiruvithamkoor and Kochi that tackled these diseases. This gave parts of Kerala a head-start on healthcare provisions at Independence. While Thiruvithamkoor had 22.56 facilities per 1,000 sq. km and 46.81 beds per lakh population in 1940, British India had only 6.8 institutions and 21.27 beds, respectively.

Thus, social intermediation by the princely states created the demand for western healthcare, which democratically elected governments continued to cater to. The two princely states were combined with the Malayalam speaking Malabar district of the Madras Presidency to form the state of Kerala on November 1, 1956.

The health status of the population also benefitted from many non-health factors such as education, especially of women, social protection of landless labour and lower castes through land reforms, good access facilitated by the density of population and transportation infrastructure, and improved nutrition through the public distribution system.

Today Kerala has a Primary Health Centre (PHC), an Ayurveda and homoeopathic dispensary in almost every gram panchayat. Health continues to be politically salient and performance or lack of it in the health sector is electorally rewarded or punished.

The focus on the social sector, instead of revenue yielding investments, in successive Plans improved the state’s Human Development Indicators (HDI) but had unintended consequences. Since health and education require substantial human resources, the cost of maintaining them after the Plan period fell on the state government. This led to high revenue expenditure that had to be met from the state’s revenues which did not improve substantially due to stagnating industry and commerce.

This led to a fiscal crisis in the mid-1970s, limiting the government’s ability to continue to upgrade or even ensure the quality of health services. Curative services were not reduced as the private sector stepped in to meet the strong demand for secondary and tertiary care. But primary healthcare services, which are mostly public goods and will not be provided by the private sector, were affected.

 

THE DOWNWARD SLIDE

In the development world, Kerala, along with countries such as Sri Lanka and Costa Rica, were celebrated as examples of ‘Good Health at Low Cost’. While such acclaim was richly deserved, the celebratory mood that ensued frowned upon any criticism of the Kerala health system. It, thereby, suppressed any demand for continued reassessment of strategies for the state of affairs that emerged from these very successes.

For instance, Kerala did not set up a dynamic observatory to track the epidemiological changes that were occurring in the state. Meanwhile, the state’s success in controlling infectious diseases and early deaths pushed it into a trajectory of epidemiological and demographic transition resulting in an epidemic of non-communicable diseases (NCDs) and health problems of an ageing population.

Had this been noticed in time and been responded to in the primary healthcare system, NCDs like hypertension and diabetes may not have reached the epidemic levels they have. Kerala lost at least a decade in recognizing the problem. By then the public health machinery, long used to basking in its past success and stagnant in fieldwork and monitoring, had lost its edge.

Despite adequate staff, the peripheral units are not equipped or trained to successfully control NCDs. Data collected more than 10 years ago showed that one-third of the adult population was hypertensive and one-fourth diabetic. In spite of launching a programme in 2011 to control NCDs, less than 25 percent of people put on treatment have their hypertension and diabetes under control even today. This has seriously impacted the health system.

Since a considerable size of the population has been suffering from uncontrolled hypertension and diabetes for long periods, downstream complications such as chronic kidney disease, stroke and heart attack are high in incidence and increasing.

The impact of these conditions is mitigated to some extent by curative services which have continued to grow in the government and in the private sector. But failure to control these conditions is leading to large expenditure for complicated procedures in both the government and private sector. This has made Kerala the state with the highest Total Health Expenditure per capita in India.

 

DOCTORS AND PANCHAYATS

In 1996, according to the 73rd Amendment of the Constitution which directs strengthening local governance at the grassroots, Kerala transferred the management of primary and secondary hospitals to rural and urban local governments. Management of PHCs in rural areas was transferred to gram panchayats with the health department retaining technical control and recruitment of government personnel.

This was resented by the doctors’ association. But young doctors, who wanted to make a difference, found powerful allies in politicians at the grassroots who also wanted to make a mark. These doctors were able to convince panchayat presidents and samitis of their
ideas and persuade them to invest the flexible funds allotted to the panchayat in improving the health sector.

This helped the doctors bypass the stifling bureaucracy of the health department. While most investments were in infrastructure, equipment and new services, innovative ideas on disease prevention and health promotion were also implemented in some panchayats.

In the planning process, technical working groups assess the data and prepare intervention proposals. These are then placed before the ward gram sabha for approval. Once passed, the proposals of the gram panchayats are discussed at a development seminar. Technical vetting of the proposal is done at district level. Medical officers of western medicine, Ayurveda and homoeopathy streams implement the proposed interventions.

While the efficiency of execution is patchy, the template is a powerful tool to involve the community in co-creating healthcare. If this process is integrated with the activities of community organizations like women’s Self-Help Groups and sports clubs, it can strengthen the social prescription component of primary care.

The e-Health programme, which commenced in 2013 with funding from the Ministry of Electronics and Information Technology (MeitY), Government of India, sought to digitize transactions in the government health system and build electronic health records.

Health transactions in all PHCs have been partly digitized. But electronic health records could not be completed due to challenges in system architecture and lack of capacity to meet them. If there is a policy direction and adequate support, either with government funds or through partnerships, the e-Health system has the potential to build longitudinal data for all patients who visit the PHC. Such data can be developed into an individual electronic health record which can become the skeleton of individual and panchayat care plans.

 

THE PHC MISSION

The Aardram Mission started in 2016, as an expansion of the Universal Health Coverage or UHC-PHC pilot project implemented in 2012, was another effort at reforming PHC services. It aimed at improving the share of government hospitals in providing health services from 34 percent to 50 percent by enhancing the quality of services and consumer experience.

Client experience at PHCs was substantially improved with better waiting rooms and improved facilities, as well as by posting three doctors, four nurses, two pharmacists and two lab technicians. Working hours were increased from 2 pm to 6 pm. Laboratories were improved to provide additional tests, including HbA1C for diabetes patients. Additional packages, such as screening and management of chronic obstructive pulmonary disease, screening for diabetic retinopathy and depression were added.

The improved PHCs were renamed Family Health Centres and were branded with a distinct colour scheme and layout. Using their flexible funds, many gram panchayats took their institutions much higher than what the state had envisaged. It is no surprise that out of the 240 PHCs that have been certified by the National Quality Accreditation Services (NQAS) in Kerala, 160 are Family Health Centres.

During the first three years of the Aardram Mission, the percentage of people  choosing outpatient services in rural PHCs went up to 51 percent. There were other achievements too: the maternal mortality rate came down to less than 30 and infant mortality rate reached single digits.

However, it is symptomatic of Kerala’s obsession with curative care that outreach services, which were meant to be part of the Aardram reform and were to be carried out by additional staff, did not take off. But, instead of rectifying these shortcomings, the pace of the programme came down during the Covid-19 pandemic and the focus of the mission shifted with the change of government in 2021.

Although its progress was not sustained, the Aardram Mission demonstrated that if health workers and local governments are trusted and supported with resources, some of them will develop their institutions into centres of excellence. This is promising for future reforms in Kerala.

 

FILLING IN THE GAPS 

Kerala’s health system has been criticized for its failure to ensure health equity for the marginalized population, especially its tribal population. The state’s health services are driven by health awareness of the population and the demand for services that arise from it. They lack the skill to generate demand by educating a population that is not convinced of the need for western medicine. They have also not learnt to work with traditional systems of medicine. This limits their ability to provide services to the tribal population.

There is also no link between primary healthcare and the health insuranceprogramme. Such a link could strengthen both systems and reduce outflow in the insurance programme. Despite leading the country in disease and demographic transition and having pioneered innovative policy initiatives like decentrallization and the Aardram Mission, Kerala has not nurtured health systems research.

This results in Kerala failing to develop evidence for policymaking which could lead to systemic changes appropriate for the state. Kerala is thus forced to manage tomorrow’s problems with yesterday’s systems, often drafted at the national level, without any understanding of the current and future needs of the state.

Since the fiscal crisis shows no signs of alleviating, Kerala will have to develop sophisticated tools to channel its high expenditure on healthcare into an income-differentiated, pooled and pre-paid system. Such a system can purchase services from government hospitals and small, decentrallized private hospitals.

These hospitals, which had contributed in improving the health profile of the state, are now facing extinction due to pressure from corporate hospitals funded by international financiers. Service provision, combined with appropriate financing mechanisms, should be re-engineered to provide comprehensive healthcare with the primary healthcare system managed by the government and small private hospitals as its foundation and gatekeepers.

Lack of vision, inability to learn from global examples and from Kerala’s own pilots, complacency stemming from comparing Kerala’s performance with other worse-off Indian states, have condemned Kerala to languish at a level of mediocrity far below its potential.

 

THE STATE'S POTENTIAL

Given the health status Kerala had achieved by the 1970s and the social advantages it had, the state’s health system could have reached levels comparable to many Southeast Asian countries like Thailand and Vietnam.

For this to happen, Kerala has to shed its hubris of being the leading state in India and recognize the serious issues plaguing its health system. It should stop blindly following the playbook developed by the Union government. The state government must build the capacity to analyze its situation and develop solutions appropriate to the challenges it will face.

Kerala has to collect accurate data and develop the skills to analyze and apply it to guide practice and admit defective performance rather than windowdressing facts. The e-Health programme, if improved, is capable of supporting this.

Decentrallization of powers to local governments is a useful template to build on. Re-engineering financial and service provision systems needs knowledge and information systems that Kerala lacks. Academic institutions have to improve their research skills to generate and validate templates that Kerala could use.

Kerala needs bipartisan political commitment, vision, knowledge and determination to see reforms through and to update them, instead of resting on laurels. 

 

Rajeev Sadanandan is a former health secretary of Kerala.