Kerala's Health Status & Challenges

• Improvement in health status is crucial for social development, achievable by improving access to health services for underprivileged people.
• Kerala has achieved good health status due to accessible medical care, high literacy, well-functioning public distribution system, and strong worker organizations.
• The Decentralized Planning in 1996 improved healthcare infrastructure and delivery.
• Both modern medicine and AYUSH systems play a crucial role in providing healthcare in Kerala.
• Kerala has high life expectancy and low mortality rates but faces challenges like lifestyle diseases (Diabetes, Hypertension, Heart Disease, Cancer) and communicable diseases (Chikungunya, Dengue, Leptospirosis, Swine Flu).
• Mental health issues, substance abuse, adolescent health, and road accidents are also growing concerns. Marginalized communities have poorer health.
• Inter-sectoral coordination is essential to tackle these health issues.

Health Indicators of Kerala (Compared to India)

• Total population (2011 Census): Kerala - 3.34 crore, India - 121.06 crore.
• Decadal Growth (2011 Census): Kerala - 4.90%, India - 17.7%.
• Sex Ratio (2011 Census): Kerala - 1084, India - 943.
• Child Sex Ratio (2011 Census): Kerala - 964, India - 919.
• Birth Rate: Kerala - 14.3, India - 20.4.
• Death Rate: Kerala - 7.6, India - 6.4. Male: Kerala - 8.5, India - 6.8. Female: Kerala - 6.7, India - 5.9.
• Natural Growth Rate: Kerala - 6.8, India - 14.
• Infant Mortality Rate: Kerala - 10, India - 34. Male: Kerala - 9, India - 33. Female: Kerala - 11, India - 36.
• Neo Natal Mortality Rate: Kerala - 6.00, India - 25.00.
• Perinatal Mortality Rate: Kerala - 9.00, India - 23.00.
• Child Mortality Rate: Kerala - 3.00, India - 10.00.
• Under 5 mortality Rate: Kerala - 13.00, India - 43.00.
• Early Neo-natal Mortality Rate: Kerala - 4.00, India - 19.00.
• Late Neo-natal Mortality Rate: Kerala - 2.00, India - 6.00.
• Post Neo-natal Mortality Rate: Kerala - 6.00, India - 12.00.
• Children (0-4) Death Rate: Kerala -2.9, India - 13.4.
• Children (5-14) Death Rate: Kerala - 0.3, India - 0.7.
• Children (15-49) Death Rate: Kerala - 2.60, India - 3.10.
• Persons (60 and above) Death Rate: Kerala - 35.4, India - 42.3.
• Percentage of death receiving medical attention: Government: Kerala - 41.3, India - 27.5. Private: Kerala - 35.3, India - 16.9. Qualified professional: Kerala - 16.4, India - 34.9. Untrained/others: Kerala - 7.1, India - 20.7.
• Still Birth Rate: Kerala - 5, India - 4.
• Total Fertility Rate: Kerala - 1.80, India - 2.30.
• General Fertility Rate: Kerala - 53.00, India - 76.2.
• Total Marital Fertility Rate: Kerala - 4, India - 4.6.
• Gross Reproduction Rate: Kerala - 0.9, India - 1.1.
• Female age at effective marriage Below 18: Kerala - 16.70, India - 16.30. 18-20: Kerala - 19.20, India - 19.00. Above 21: Kerala - 24.40, India - 23.90. All age: Kerala - 24.40, India - 20.70
• Couple Protection Rate: Kerala - 62.30, India - 52.00.
• Maternal Mortality Ratio: Kerala - 61.00, India - 167.00.
• Expectancy of Life at Birth: Kerala - 74.9, India - 67.9. Male: Kerala - 72, India - 66.4. Female: Kerala - 77.8, India - 69.6

Working Groups on Health Sector for 13th Five-Year Plan

• The State Planning Board formed Working Groups for Medical & Public Health and AYUSH for the 13th Five-Year Plan.
• Priority areas in the health sector were identified, reports submitted, and recommendations are being incorporated into health sector schemes.

Major Recommendations of Working Group

Ayush

• Develop ISM institutions for Indian Public Health; implement Kerala Accreditation Standards for hospitals.
• Provide specialty services in district and taluk hospitals.
• Form an Ayurveda tourism consortium to harness tourism.

Directorate of Ayurveda Medical Education (DAME)

• Develop Government Ayurveda college hospitals as tertiary specialty care centers.
• Establish new Ayurveda colleges
• Establish a State Research Institute for revalidating Ayurveda to evidence-based medicine.
• Implement e-Health program.

Homoeopathy

• Implement e-Health program.
• Develop HOMCO (The Kerala State Homoeopathic Co-operative Pharmacy Ltd).
• Establish a Drug Control Wing for Homoeopathy.
• Establish a Directorate of Homoeopathic Medical Education.

Medical and Public Health

• Implement Aardram Mission.
• Develop Primary Health Centres into Family Health Centres.
• Standardize district and taluk level hospitals.
• Implement e-Health program to create a centralized database of healthcare information.
• Establish a Public Health Cadre.
• Implement Human Resource Development Planning in the health sector.

Approach for the 13th Five-Year Plan

• Provide the best preventive, curative, and palliative care in the public sector.
• Expand insurance coverage.
• Achieve total sanitation, waste disposal, and mosquito eradication.
• Improve infrastructure in the public sector.
• Make Aardram Mission a success by converting Primary Health Centres into Family Health Centres.
• Provide quality treatment services at the secondary level.
• Create a Patient-Friendly Environment in government hospitals.
• Promote study and research in different branches of Ayurveda.

Aardram Mission

• The government identified 170 PHCs for development into Family Health Centers in 2017-18.
• Additional posts were created, resulting in a minimum of 3 doctors and 4 nurses in the Primary Health Centres.
• 29 Family Health Centres are already inaugurated and functional, with another 26 ready for inauguration.
• Transformation of PHCs into Family Health Centers is well-accepted by society.
• Service delivery has been augmented, and outpatient care is provided until 6:00 PM.
• The e-Health project is expected to further develop individual patient care and family health plans.
• Registration procedure for e-Health services has been initiated.
• Ward and Panchayat level health plans will focus on preventive, promotive, and rehabilitative healthcare.
• A new health volunteer system called Arogyasena is being launched.
• Public health interventions focus on reorganizing primary healthcare based on epidemiological needs.
• Treatment guidelines for 53 common medical conditions have been prepared for Medical Officers.

Patient-Friendly Transformation of Outpatient Wings

• Outpatient wings of medical college hospitals and district hospitals are being prioritized under Aardram Mission.
• Improvements include OP registration counters, waiting areas, seating, token systems, drinking water, toilet facilities, public address systems, and signage systems.
• Patient care coordinators will be provided on a temporary basis.

Objectives of Aardram Mission

• Transform outpatient (OP) wings to be more patient-friendly.
• Standardize district and taluk level hospitals.
• Develop Primary Health Centres into Family Health Centres.
• Ensure protocol-based treatment guidelines.

e-Health Project

• Targets linking health institutions across Kerala to build a database of individual medical records.
• Aims to provide unique patient identification and data exchange between healthcare units at all levels.
• Reduces repeated medical tests and out-of-pocket expenses and is being piloted in Thiruvananthapuram.

National Health Policy 2017

• Aims to strengthen the government's role in shaping health systems, including investments, organization of services, disease prevention, and health promotion.

Salient features of the National Health Policy 2017

• Increase health expenditure to 2.5% of GDP by 2025.
• Increase state sector health spending to 8% of their budget by 2020.
• Decrease catastrophic health expenditure by 25% by 2025.
• Ensure district-level electronic health information database by 2020.
• Strengthen health surveillance and establish disease registries by 2020.
• Increase life expectancy to 70 by 2025.
• Reduce under-five Mortality to 23 by 2025 and MMR to 100 by 2020.
• Reduce infant mortality rate to 28 by 2019.
• Reduce neo-natal mortality to 16 and stillbirth rate to single digits by 2025.
• Increase public health facility utilization by 50% by 2025.
• Immunize over 90% of newborns by 2025.
• Reduce tobacco use by 15% by 2020 and 30% by 2025.

State Health Policy

• A 17-member panel drafted a new health policy for Kerala, emphasizing strengthening primary healthcare and disease surveillance. The draft report has been submitted to the government for further action.
• The policy aims to establish a free, universal, comprehensive healthcare system, reduce mortality rates and increase healthy life expectancy.

Sustainable Development Goal: Targets Set by Kerala

• The government declared short and medium-term health sector targets aligned with UN's Sustainable Development Goals (SDG).
• Kerala included targets in dental, ophthalmic, and palliative care.
• Key strategies to achieve targets were recommended.
• A survey in 2021 will evaluate the performance of the State.

Health Sector Financing During Plan Periods

• Health is a major area of allocation in the State Budget.
• Kerala invests less than 5% of its total State Plan outlay on healthcare.
• The outlay for the 12th Five-Year Plan was 331,888.00 lakh (BE), with an expenditure of 300,600.50 lakh (90.57%).
• During the first year of the 13th Five-Year Plan (2017-18), 131,495 lakh was allotted, with 26.88% expended up to September 2017.

Major Health Problems in Kerala

Communicable Diseases

• Kerala faces an increasing burden of communicable and non-communicable diseases.
• While successful in controlling some diseases, the emergence of Dengue, Chikungunya, Leptospirosis, Malaria, Hepatitis, and H1N1 has led to morbidity and mortality.
• Vector-borne diseases and waterborne infections are increasing.
• Vaccine-preventable diseases have not been eliminated.
• Deaths from these diseases are drawing national and international attention.

Dengue

• Dengue has become the single largest cause of vector-borne diseases since surfacing in 1998.
• In 2017, all districts reported Dengue in large numbers due to changes in environmental factors.
• Aedes mosquitoes have spread to both rural and urban areas due to changes in human behavior, mosquito bionomics, and climatic changes.

Leptospirosis

• Leptospirosis is an emerging public health challenge, now endemic in all districts.
• It spreads through urine of infected rodents and affects domestic animals, posing an occupational risk.
• Mortality due to Leptospirosis is rising.
• Veterinary and Animal Husbandry departments need to make joint efforts for the effective control of this disease.

Chikungunya

• Chikungunya spread rapidly in Kerala after originating in the Arabian Sea during 2005-06.
• The disease is fading out, resulting in lifelong immunity for those affected. Only sporadic cases are being reported.
• Aedes mosquitoes transmit chikungunya.

Malaria

• Malaria, transmitted by Anopheles mosquitoes, is re-emerging as a public health challenge in Kerala.
• Urbanization, infrastructure development, construction, and climate changes hinder the attainment of SDG goals for Malaria elimination.

Japanese Encephalitis

• Japanese Encephalitis is a mosquito-borne infection that causes inflammation of the brain.
• The peculiar nature of the culex mosquito to breed in contaminated water also, increases the potential threat in other areas as well.
• Migratory birds pose a risk, but vaccination efforts can strengthen control.

Water-Borne Diseases

• Acute diarrheal diseases (ADD) decreased in 2017 compared to previous years.
• Hepatitis A and Typhoid also decreased, but suspected Hepatitis deaths increased.
• Waterborne diseases are attributed to unsafe drinking water, unhygienic sources, and waste contamination.

HIV/AIDS

• Around 2.4 million people in India are estimated to be living with HIV.
• Kerala State Aids Control Society works to control the spread of HIV and strengthen the State’s capacity to respond to HIV/AIDS.
• HIV prevalence is high among injecting drug users (IDU), men having sex with men (MSM), and Female Sex Workers (FSW).

Prevalence of Major Communicable Diseases in Kerala

Non-Communicable Diseases

• Diabetes, hypertension, cardiovascular diseases, cancer, and lung diseases are major threats.
• The burden of NCDs is likely to increase due to an aging population and lifestyle changes.
• High costs of medicines and long treatment durations place a financial burden on low-income groups.
• Modernization, lifestyle changes, alcohol and tobacco use, and high-stress levels contribute to NCD prevalence.
• The productive age group of 30-59, over 52 per cent of deaths are due to NCD.
• Hypertension, diabetes mellitus, cardio vascular diseases, stroke and cancer are the major non communicable diseases seen.
• Studies show a high prevalence of diabetes and hypertension in Kerala compared to India.
• Genetic predisposition, dietary habits, and sedentary lifestyles explain this phenomenon.
• Cancer mortality is high in males in Kerala.

Recent Survey Findings

• One in three has hypertension, and one in five has diabetes.
• Control of blood sugar and blood pressure is significantly low.
• One in four adults reported using tobacco, and over 30% reported alcohol use.
• Salt consumption is above the recommended level.
• Most people consume less than the recommended servings of vegetables and fruits daily.
• Reduction of tobacco use in Kerala by about eight percentage as per the latest Global Adult Tobacco Survey figures.

Strategy

• Risk reduction strategies for NCD risk factors are being implemented through local self-governments and schools. Secondary prevention is enhanced to improve control rates of diabetes and hypertension.

Cancer

• Every year, 35,000 new cases of cancer are detected in Kerala and Nearly 1 lakh people are under treatment for cancer disease annually.
• Delay in early detection, high treatment costs, minimal treatment centers, and lack of awareness contribute to high mortality.

Malabar Cancer Centre

• Malabar Cancer Centre in Kannur provides oncological care to North Kerala with 200 beds and latest facilities.
• In 2016-17, 3,971 in-patients and 60,834 out-patients were treated, with 4,392 new cases detected annually.

Mental Health

• Kerala reports higher levels of mental illness compared to the national average.
• A mental health policy approved in 2013 suggests treatment starting from Primary Health Centres and upgrading mental hospitals.
• The policy encourages research, awareness programs, and proper training for doctors.

District Mental Health Programme

• The District Mental Health Programme (DMHP) is functioning in all the 14 districts of the State.
• Mental Health Clinics are being conducted in all PHCs and CHCs in the district by trained doctors.
• Key activities include information education and communication (IEC) activities.
• Around 17,000 patients are receiving treatment every month, from DMHPs in the State.

Aswasam: Depression management in Primary Care

• Aswasam: Depression management in Primary Care was started in 170 Family Health Centres across the State.
• 4,588 persons have been screened till date, of which 626 were positive for depression.
• Pharmacotherapy started for 400 and psychosocial intervention for 472.

Modern Medicine

Health Care Institutions under DHS

• There are 1,280 health institutions with 38,004 beds and 5,465 doctors under Health Services Department (DHS).
• Primary Health Centres provide comprehensive primary care services.
• District hospitals and General Hospitals provide specialty and super specialty services.
• The bed population ratio is 878, and the average Doctor Bed Ratio is 6.95.

Financial Protection Against Catastrophic Health Care Expenditure

Rashtriya Swasthya Bima Yojana (RSBY)

• (RSBY) is a Health Insurance Scheme, sponsored by the Government of India, for providing free and quality inpatient care to the families falling below poverty line (BPL) in the society.
• A special purpose vehicle by name CHIAK (Comprehensive Health Insurance Agency, Kerala) has been formed and entrusted with the task of running the schemes.
• RSBY offers inpatient treatment up to ₹30,000 for a family of five and covers existing diseases.
• Extended to cover families of Mahatma Gandhi National Rural Employment Guarantee Scheme, street vendors and domestic workers

Comprehensive Health Insurance Scheme (CHIS)

• The State Government formulated its own scheme for catering to the needs of the additional 10 lakh population
• Includes members of welfare fund boards, Scheduled Caste/Tribe population, and fishing workers.
• The number of families covered in 2017-18 was 34.83 lakh.

CHISPLUS

• Provides tertiary care treatment with a benefit package of maximum 70,000 for critical illness like cancer, cardiac and renal failure to all the RSBY and CHIS card holder families.
• The scheme, implemented through a non-insurance route, has benefited 357,036 patients till 2016-17 with a total claim of 361.43 crore.

Karunya Benevolent Fund (KBF)

• Designed to meet the tertiary care expenditure of deserving individuals.
• Requires prior authorization and payment to the hospital with utilization certificate.
• Treatment can be availed at all government hospitals and empaneled private hospitals.

Arogyakiranam

• Program provides free treatment and related medical services to all patients from birth to 18 years, as an entitlement
• During 2016-17 alone, the scheme has benefitted 7,642,497 patients.

National Health Mission (NHM)

• Includes NUHM and NRHM, supporting Health Services Department, Directorate of Medical Education, and AYUSH Departments.
• Funds are allocated for NRHM/RCH, NUHM, communicable diseases, non-communicable diseases, and infrastructure maintenance. Under the infrastructure maintenance component,support has been given over several Plan periods
• Aims to provide accessible, affordable, and accountable quality health services to the poorest rural households.

Pradhan Manthri Swasthya Suraksha Yojana (PMSSY)

• Government of India supported scheme to improve infrastructure facilities and technology in Government Medical College,
• Thiruvananthapuram (Phase I) and Kozhikode and Alappuzha (Phase III) with a total outlay of 150 crore each,of which 30 crore is the State share.

State Institute of Medical Education and Technology (SI-MET)

• Established to promote medical education and research.
• Seven nursing colleges function under SI-MET with an annual intake of 340 students.

Child Development Centre (CDC)

• Child Development Centre (CDC) established by the Government of Kerala is an autonomous centre of excellence in early child care and education, adolescent care and education, pre-marital counseling, women’s welfare and other related fields.
• The number of patients treated was 14,174 in 2015-16 and was 19,051 in 2016-17.

Drugs Control Department

• Ensure the availability of quality drugs to the public and see that the market is free from counterfeit, spurious and substandard drugs.
• The Department has 6 Regional Offices, 11 District Offices, 4 Ayurveda Wing Offices and 2 Drugs Testing Laboratories.

Medical Education

• In Kerala, Medical Education is imparted through 9 Medical Colleges and Nursing Education through 6 Nursing Colleges.
• Five Dental Colleges are functioning in the State.

Major achievements of Medical Education Department in 2016-17

• Aardram project started in all Medical Colleges
• Biometric punching system started in all Medical Colleges
• Initiated steps for implementing e-governance
• Heart transplantation surgery successfully done in Medical College, Kottayam.
• Construction of poly trauma building.
• PMSSY project and burns unit completed in Thiruvananthapuram Medical College
• Burns unit started in Medical College, Thrissur
• 390 posts created in Parippally Medical College
• First phase construction completed in Medical College, Idukki

Kerala University of Health and Allied Sciences

• Kerala University of Health Sciences was established as per the Kerala University of Health Science Act, 2010
• The number of institutions affiliated to University is 284.

Indian System of Medicine

• Ayurveda is a science dealing not only with treatment of some diseases but also a complete way of life

AYUSH

• Government of India has set up two regulatory bodies to set standards of medical education.
• The Central Council of Indian Medicine (CCIM) under Indian Medicine Central Council (IMCC) Act
• Yoga and Naturopathy, being drugless systems, are not regulated.

National AYUSH Mission

• Department of AYUSH (Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homoeopathy), Ministry of Health and Family Welfare, Government of India has launched National AYUSH Mission (NAM).
• Government of Kerala started the Ayush Department in the State on August 8, 2015

Ayurveda Medicine Manufacturing- OUSHADHI

• OUSHADHI is the largest manufacturer of Ayurvedic medicines functioning in India in the public sector a
• Exclusive supplier of Ayurvedic medicines to government hospitals and dispensaries of Ayurveda Department.

Ayurveda Colleges

• There are 3 Government Ayurveda Colleges situated at Thiruvananthapuram, Thrippunithura and Kannur having bed strength of 1,389.
• Special projects were implemented by the ISM Department in 2016-17 in addition to the normal medical treatment.

HOMOEOPATHY

• One Homoeo dispensary in each district was upgraded as model dispensary and Clinical lab was set up in Government Homoeo Hospital Kayamkulam.
• De-addiction centres and infertility clinics are also functioning as part of Seethalayam programme.
• 14 Homoeo Dispensaries (one Dispensary in each district) were upgraded as Model Homoeo Dispensaries.

Immunisation Coverage

• Immunisation is one of the most successful and cost effective health interventions

Outlook:

• Good health is indispensible for the enjoyment of every phase of life.
• High levels of education especially among women and greater health consciousness have played a key role in the attainment of good health standards in Kerala.
• However, the issues to be addressed are the health problems of the tribal population and other marginalised communities, re-emergence of communicable diseases, second generation issues like increasing incidence of non communicable diseases, health problems of the aged especially women and increasing health expenditure etc.