1. Introduction
Kerala’s public health achievements are not an overnight success, but the cumulative outcome of decades of sustained public investment, institutional continuity, social reform, and community participation. These foundations have enabled the state to achieve remarkable health outcomes, including high life expectancy, low maternal and infant mortality, and near-universal institutional deliveries. However, Kerala now faces a new generation of health challenges that place growing pressure on its health system. Meeting these demands requires not just preservation of past gains, but strategic transformation.
1.1 History and evolution of the health system in Kerala
Kerala’s public health system has deep historical roots that extend to the period long before the state formation in 1956. In the erstwhile princely states of Travancore and Cochin, and in parts of Malabar, early investments in public welfare laid the foundations for organised healthcare. In Travancore, for example, palace dispensaries, civil hospitals, and vaccination services were established as early as the nineteenth century, and immunisation was made mandatory for specific population groups well before India’s independence. Christian missions, local administrations, and early public health initiatives further expanded access to clinical care, sanitation, and preventive services, alongside long-standing indigenous systems of medicine such as Ayurveda, supported by strong community participation at the household level. It’s believed that Ayurveda also helped prevent food- and water-borne diseases by promoting strict hygiene practices, safe food preparation, boiling and purification of drinking water, and the use of herbs and spices with natural antimicrobial properties. As a result of these early investments, Travancore recorded a life expectancy significantly higher than the national average, marking Kerala’s early emergence as a public health frontrunner in colonial and pre-independence India.
These early health-service arrangements were carried forward and systematically expanded after independence, when Kerala emerged as a unified state. Successive governments placed sustained emphasis on building a state-wide public health infrastructure, including sub-centres, primary health centres, community health centres, taluk and district hospitals, medical colleges, and specialised institutions. This expansion significantly improved geographical access to healthcare across rural, urban, coastal, and tribal areas. Kerala’s approach was closely linked with broader social development efforts, including universal education, land reforms, strengthened local self-governments, women’s empowerment, and policies aimed at reducing poverty while improving sanitation and nutrition. Favourable climatic conditions, with two monsoon seasons bringing plentiful rains and 41 rivers historically providing potable water, supported health outcomes. Cultural influences from social reformers embedded hygiene norms, such as using boiled water for drinking and child nutrition alongside personal cleanliness, elevating Kerala’s unique health indices. The establishment of the first state-sponsored medical college in Thiruvananthapuram in 1951, followed by medical colleges in Kozhikode (1957) and Alappuzha (1963), strengthened the state’s clinical and training capacity and expanded access to advanced medical care.
Over subsequent decades, this integrated public health and social development approach led to sustained improvements in population health outcomes. Kerala achieved low infant and maternal mortality, high life expectancy, and wide immunisation coverage well ahead of national trends. These achievements came to be recognised from the 1970s onwards as the “Kerala model” of development, where improvements in living conditions and social equity progressed alongside the delivery of public healthcare services. The experience reflects long-standing political commitment across successive governments to public provisioning of healthcare and preventive services, positioning Kerala as an important example of improved population health despite relatively modest income levels. Kerala’s public health achievements were not an overnight success, but the cumulative outcome of decades of sustained public investment, institutional continuity, social reform, and community participation.
1.2 Kerala health profile: a snapshot
Kerala’s health system is serving a population with rapidly changing demographic and health needs. As per the Health at a Glance 2023–24 report by the Directorate of Health Services (DHS), Kerala’s population is estimated at 3.59 crore in 2024. The state has undergone a sharp urban transition: projections indicate 77% (27.8 million) of residents now live in urban areas, while only 23% (0.81 crore) reside in rural areas—representing a major shift from Census 2011, when 52% of the population was rural. This shift has significant implications for the health system, increasing pressure on urban primary care, referral systems, emergency response, sanitation and environmental health services, and the provision and regulation of mixed public–private service delivery.
Kerala is also ageing faster than most Indian states. The proportion of people aged 60 years and above increased from 13% in 2011 and is projected to reach 23% by 2036, meaning nearly one in four residents will be elderly. Combined with low fertility, high life expectancy (75 years), and slow population growth, this demographic transition is fundamentally reshaping health needs—away from short-term, episodic care towards chronic disease management, geriatric care, long-term follow-up, mental health services, rehabilitation, and palliative care.
In national comparisons, Kerala continues to perform strongly on many core health outcomes, but recent assessments show emerging weaknesses. In the NITI Aayog Sustainable Development Goal (SDG) Index 2023–24 (SDG 3: Good Health and Well-being), Kerala is ranked fourth with a score of 80 (after Gujarat (90), Maharashtra and Uttarakhand (84), and Himachal Pradesh (83)), above the national average of 77. The state exceeds or closely approaches national targets in several areas: maternal mortality stands at 19 per 100,000 live births (target: 90); under-five mortality at 8 per 1,000 live births (target: 25); life expectancy at 75 years (national benchmark: 73.63); health worker density at 144.03 per 10,000 population (target: 44.5); and institutional deliveries at 99.85%, nearing the 100% benchmark. However, performance on other indicators moderates Kerala’s overall ranking. Full immunisation among children aged 9–11 months is 85.4%, below the 100% target. Tuberculosis case reduction has reached 97.45%, short of elimination goals. HIV incidence remains at 0.01 per 1,000 population. The suicide rate is notably high at 28.5 per 100,000 population (benchmark: 3.5), and road traffic mortality is 12.1 per 100,000 (target: 5.81). Financial protection remains one of the weakest areas. Out-of-pocket expenditure (OOPE) in Kerala exceeds the recommended SDG benchmark ceiling by more than twofold. According to the Ministry of Health and Family Welfare, in 2021–22, OOPE constituted 59.1% of Total Health Expenditure in Kerala, placing the state among the highest in the country.
Kerala has built one of the most extensive public health service networks in India, spanning primary, secondary, and tertiary levels of care. As per Health at a Glance 2023–24, the public system includes 849 Primary Health Centres (of which 844 have been renamed Family Health Centres), 226 Community Health Centres, 88 sub-district hospitals, and 46 district hospitals, supported by 5,415 Health and Wellness Centres providing outpatient services. The system reports 38,525 sanctioned hospital beds (approximately one bed per 867 people), 1,104 ICU beds, 479 ambulances, and a blood network comprising 189 blood banks and 132 blood storage units. Tertiary care is provided through fourteen government medical colleges and specialised public institutions serving as referral centres for complex care. Despite this scale, system assessments—including the Comptroller and Auditor General (CAG) Performance Audit on Public Health Infrastructure and Management of Health Services (2024)—highlight uneven readiness across facilities, shortages of doctors and specialists, incomplete compliance with Indian Public Health Standards (IPHS), delays in infrastructure projects, and operational stress in high-burden urban hospitals.
Kerala faces a complex dual disease burden. Communicable diseases such as dengue, leptospirosis, scrub typhus, hepatitis A, acute diarrhoeal diseases, and amoebic meningoencephalitis continue to cause seasonal outbreaks. The state has also experienced repeated zoonotic threats, including multiple outbreaks of Nipah virus, exposing surveillance and One Health preparedness gaps. Simultaneously, non-communicable diseases dominate everyday morbidity. Roughly one-quarter to one-third of the adult population lives with diabetes or hypertension. These overlapping chronic and outbreak-prone burdens, combined with population ageing, generate sustained demand for medicines, diagnostics, rehabilitation, mental health services, and long-term care.
These growing needs are unfolding within fiscal constraints. According to NITI Aayog’s Fiscal Health Index (2025), Kerala scored 25.4 and ranked 15th among 18 major states in 2022–23. Development expenditure accounted for only 8.8% of total expenditure, significantly below the 15.2% average of comparable states, limiting fiscal space for health system expansion and modernisation. According to the Comprehensive Annual Modular Survey (CAMS) 2022–23, out-of-pocket expenditure for hospitalised treatment in Kerala is ₹8,655 per rural household and ₹10,341 per urban household, substantially above national averages. Per-person expenditure stands at ₹2,368 (rural) and ₹2,939 (urban). These costs disproportionately affect elderly households and those managing chronic illness, converting health needs into financial stress despite strong headline health indicators. Together, demographic change, disease transition, system readiness gaps, urban pressures, and household financial burden sharpen equity concerns within Kerala’s health framework.
Overall, Kerala’s health system reflects a paradox: strong foundations and impressive outcomes on one hand, and growing structural stress from demographic change, disease transition, workforce constraints, urban pressures, and financial vulnerability on the other. The central challenge is no longer preserving a public health legacy, but adapting it to an ageing, more urban, and more complex health profile—while ensuring quality, continuity, affordability, and preparedness for future risks.