Kerala’s public health system has long been recognised as one of the strongest in India, built through decades of public investment, social reform, and political commitment across governments. From the early foundations laid in the princely states of Travancore and Cochin to the systematic expansion of public health services after Independence, Kerala created a health system that delivered results well ahead of national trends. By the 1970s, this approach to health and social development came to be recognised as the “Kerala model”, demonstrating that strong public services, education, equity, and community participation could produce outstanding population health outcomes even at modest income levels. This legacy mostly belongs to the people, especially the women, of Kerala for their unwavering commitment to health, education and community participation. The model evolved through public trust in institutions, sustained public financing, and the shared understanding that health is not a commodity, but a public responsibility. At its core, the system was designed to be people-centred, organised around the needs, dignity, safety, and lived realities of patients, families, and communities. Any weakening of the state’s health system hence represents not merely a policy failure, but a breach of trust that must be addressed and remedied.

Over the past two terms of the current government, growing evidence suggests that Kerala’s public health system is no longer being governed with the seriousness, transparency, or urgency that its complexity demands. While the government continues to rely heavily on past achievements to project success, the lived experiences of patients, families, and health workers increasingly point to a system under strain, uneven in performance, overstretched in capacity, and drifting away from its core public-service ethos.

Kerala today faces a radically different health context from the one that produced the Kerala model. The population is ageing rapidly, urbanisation has accelerated, non-communicable diseases are rapidly escalating, and communicable diseases continue to pose serious and new threats further straining the healthcare demands. Climate-linked outbreaks, zoonotic threats, and environmental risks have become recurrent realities. These shifts require a health system that is adaptive, well-governed, adequately staffed, and financially protective. Yet, instead of strengthening the foundations of public healthcare to meet these emerging challenges, the current government has presided over fragmented planning, delayed implementation, and declining system readiness. In practice, health system decision-making has increasingly prioritised administrative convenience, budgetary optics, and political messaging instead of continuity of care, patient safety, affordability, and the lived experiences of patients and frontline health workers. This shift has weakened the people-centred orientation that once defined Kerala’s public health approach.

Despite repeated announcements and flagship schemes, critical gaps remain unaddressed. Infrastructure projects are delayed or unevenly implemented. Hospitals in urban and high-burden districts continue to face overcrowding and persistent shortages of specialist doctors, nurses, and paramedical staff. Primary care reforms have plateaued, referral systems remain weak, and continuity of care for chronic diseases and the elderly is poorly organised. Health workers report burnout, contractual insecurity, delayed payments, and unsafe working conditions, while governance mechanisms to address these structural issues remain inadequate or reactive. At the same time, quality and patient safety concerns are becoming increasingly visible. Declining immunisation coverage, rising suicide rates, persistent road-traffic fatalities, and uneven adherence to clinical and public health standards point to deeper failures of oversight, monitoring, and accountability. These are not isolated indicators or temporary setbacks. They reflect systemic weaknesses that the current government has failed to address openly and decisively.

Perhaps the most worrying signal of governance failure is the rising financial burden on households. Despite Kerala’s strong public health tradition, out-of-pocket expenditure on healthcare in the state remains among the highest in the country. Families are increasingly forced to rely on private providers for drugs, diagnostics, and specialised care due to gaps in public provision. This shift has transformed healthcare into a source of financial anxiety rather than social protection. It reflects years of under-investment in public capacity, weak regulatory frameworks, sub-optimal engagement with the private sector, and the gradual normalisation of healthcare as a market service rather than a public good. The private health sector in Kerala has changed rapidly in recent years, but without effective regulation of costs, quality, or transparency. There is little evidence of consistent enforcement of standard treatment protocols, price controls, or accountability mechanisms. As a result, households face unpredictable expenses, unnecessary procedures, and escalating costs, while the government fails to protect citizens from financial exploitation in healthcare. This abdication of regulatory responsibility stands in sharp contrast to Kerala’s historic commitment to equity, affordability, and public welfare.

Serious concerns have also emerged regarding financial management, procurement practices, and transparency within the health sector. Audit findings, media reports, and legislative debates have repeatedly raised questions about delays, cost overruns, opaque procurement decisions, and inadequate monitoring of large health-related expenditures. Instead of responding with openness and corrective action, the current government has often dismissed criticism, weakened scrutiny, and avoided accountability. The absence of transparent disclosure, timely public explanation, and independent follow-up has allowed serious questions to remain unanswered, weakening institutional integrity and public confidence.

Equally troubling is the government’s growing tendency to conflate political communication with system performance. Announcements and publicity increasingly substitute for measurable outcomes, while dissenting voices from health professionals, civil society, and opposition representatives are marginalised rather than constructively engaged. This has contributed to a culture of caution within the system, where raising concerns about gaps or failures is perceived as political risk rather than professional responsibility. Increasingly, decision-making within the health sector appears shaped by political considerations rather than professional judgement, weakening autonomy, evidence-based planning, and accountability.

This report is therefore presented as a necessary intervention in the public interest. It is not an attack on Kerala’s public health legacy; it is a defence of it. It seeks to examine, honestly and systematically, where the current and previous administrations have failed to protect, strengthen, and modernise the health system in line with Kerala’s changing needs. Moving beyond the celebration of past achievements, the report offers a forward-looking, evidence-informed roadmap for health system reform—identifying critical gaps, emerging risks, and priority areas for action to help the state respond effectively to evolving population demands. It aims to restore focus on what truly matters: accessible, high-quality, affordable, and people-centred healthcare for every citizen.

The analysis draws on government health data, academic and public health evidence, field reports, expert consultations, and stakeholder perspectives. While not an exhaustive review of every programme or scheme, the report provides a concise, systems-level assessment intended to inform timely policy dialogue, strategic planning, and practical reforms. This report is informed by consultations and representations from over 550 individuals, reflecting a broad cross-section of stakeholders, including health professionals, elected representatives, community leaders, women’s health organisations, professional bodies, representatives of marginalised populations, patient associations, and inputs received through the UDF Health Commission website, UDF Health Conclave proceedings, district and local sittings, and site visits to healthcare facilities.

Kerala’s health system now stands at a crossroads. Continuing on the present path risks the gradual erosion of public services, deepening inequality, rising household distress, and irreversible loss of public trust. This report argues that another path is both possible and necessary: one that restores people-centred healthcare as the organising principle of the system, strengthens public provisioning, reins in unchecked privatisation, restores regulatory authority, and rebuilds trust between the state and its citizens. The sections that follow lay out the evidence for why change is urgently needed, and what a credible, people-centred reform agenda must now address.