This report presents a forward-looking assessment of Kerala’s health system using the World Health Organisation’s (WHO) Health System Strengthening (HSS) framework, structured around six core building blocks: service delivery, health workforce, infrastructure and emergency preparedness, medicines and technologies, health information systems, and governance and financing.

Kerala’s demographic profile is shifting rapidly. Accelerated population ageing and low fertility are placing sustained demand on the system for long-term, integrated, and geriatric care. At the same time, a dual burden of communicable and noncommunicable diseases has taken hold. Communicable diseases such as dengue, leptospirosis, and scrub typhus continue to cause seasonal outbreaks, while non-communicable conditions like diabetes, hypertension, and cancer dominate everyday morbidity and healthcare utilisation. This epidemiological transition is straining a hospital-centric system that remains poorly equipped to deliver home-based, rehabilitative, or long-term chronic care.

Urbanisation has intensified, with more than three-fourths of the population now living in urban areas. While this has increased pressure on urban primary care and referral systems, service access in rural, coastal, and tribal areas continues to be uneven. At the same time, Kerala’s exposure to zoonotic outbreaks, heatwaves, floods, and environmental degradation has underscored systemic vulnerabilities in climate preparedness and coordination across sectors. Despite the state’s strong tradition of public provisioning, out-of-pocket health expenditure remains high, particularly in relation to diagnostics, chronic medications, and long-term care. These costs have raised growing concerns about affordability, trust in the system, and financial protection for vulnerable households.

The health system also faces a range of operational and institutional challenges. Fragmented coordination between departments, overlapping mandates, and weak accountability mechanisms have hampered effective disease surveillance, emergency preparedness, and referral efficiency. Many public health facilities do not meet Indian Public Health Standards (IPHS), with significant deficits in secondary hospitals, emergency care units, and infrastructure resilient to climate risks. The health workforce remains unevenly distributed and overstretched, especially in high-demand areas. Furthermore, medical and paramedical education systems have not yet adapted to the emerging requirements of an ageing population and the growing need for integrated, team-based care. Community-level public health functions, once a hallmark of Kerala’s success, have weakened due to insufficient investment in surveillance, health promotion, and outreach. Digital platforms and health information systems also remain fragmented, underutilised, and poorly integrated, limiting their potential to support continuity of care and evidence-based decision-making.

This report does not offer a programme-by-programme inventory. Instead, it distils key systemic weaknesses, emerging risks, and priority areas for action across six transformation themes:

1. Strengthening infrastructure, emergency readiness, and system resilience
2. Building a strong, modern health workforce and medical education system
3. Building robust systems for medicines, vaccines, diagnostics, and technology systems
4. Improving service delivery and guaranteeing quality of care
5. Strengthening governance, financing, and financial protection
6. Building strong public health systems, surveillance, and disease preparedness

The report draws on a combination of public datasets, official government reports, academic literature, media reviews, and consultations with health professionals, administrators, and public health experts across the state and international. As Kerala becomes older, more urban, and more vulnerable to both chronic conditions and public health emergencies, its health system must transition from episodic care to lifelong, people-centred, and equitable service delivery. This report aims to support that transition with actionable insights to strengthen Kerala’s public health legacy and build a more resilient, inclusive, and future-ready health system.

Keywords: Kerala, health policy, health equity, determinants of health, epidemiology, One Health, UDF Health Commission.