Uneven Service Delivery, Regional Inequities, and Access Gaps

• Inconsistent staffing and service readiness across facilities: Public health facilities in Kerala show wide variation in service delivery capacity due to uneven staffing and operational readiness. Recent audits report doctor shortages across all levels of care, with specialist gaps most pronounced at secondary and tertiary facilities. District-level disparities persist, with northern districts recording lower doctor-to-population ratios. In many facilities, outpatient staffing does not align with patient load, resulting in long waiting times and overburdened providers.
• Variable service packages and minimum standards compliance: Many public hospitals do not consistently deliver the “minimum essential services” mandated under IPHS. Even among FHCs upgraded under the Aardram Mission, intended service improvements have not been uniformly realised due to staffing and operational constraints. As a result, patients experience significant variation in available services depending on facility type and location.
• Geographic inequities in quality of care: Kerala’s public health network is extensive, but effective access and service quality vary significantly by geography. Public healthcare utilisation remains higher in rural Kerala (approximately 42–43%) than in urban areas (around 34%), reflecting greater rural dependence on government facilities. However, rural users more frequently face delays due to limited access to specialists, diagnostics, and follow-up services, driving referrals and additional out-of-pocket costs. Rural CHCs and facilities in northern Kerala often provide fewer services and lower-quality care than better-performing counterparts elsewhere. As of 2025, only a limited number of CHCs had achieved national quality certification, indicating that most remain below benchmark.
• Persistent disadvantage in tribal, coastal, and remote regions: Tribal regions, including Attappady and parts of Wayanad, continue to face higher barriers to timely care due to difficult terrain, scattered hamlets, transport constraints, and weak continuity of services. Evidence highlights significantly poorer health and nutritional indicators in tribal communities, including underweight prevalence of around 46% and anaemia levels of approximately 10%, demonstrating that Kerala’s strong aggregate indicators mask deep pockets of deprivation. Coastal and fishing communities experience discontinuous access due to occupational mobility, rigid facility timings, and wage-linked opportunity costs. Delayed diagnosis and interrupted follow-up for chronic diseases are common, even when public consultations and medicines are available.
• Diagnostics access and quality as a service delivery constraint: Despite clinical consultations being available, many patients are forced to move across facilities—or rely on private laboratories—for even basic diagnostic tests, delaying diagnosis and treatment. The CAG report (2024) noted that several PHCs and CHCs lacked functional diagnostic services on all working days, resulting in external referrals for routine investigations. Weak diagnostic stewardship—marked by inconsistent quality assurance, inappropriate or repeated testing, and limited feedback to clinicians—undermines clinical decision-making. These gaps contribute to fragmented care journeys, higher OOPE, and avoidable referrals to private or higher-level facilities.
• Hospital-acquired infections (HAI) and patient safety surveillance: Surveillance of hospital-acquired infections (HAI) remains weak and fragmented. Recent state-level reviews indicate that only a minority of public hospitals conduct regular, documented audits of nosocomial infections. Infection control committees exist on paper in most facilities, but routine data reporting on Surgical Site Infections (SSI), catheter-associated infections, and neonatal sepsis is inconsistent. Public hospitals continue to report outbreaks of severe postnatal and post-operative infections, suggesting gaps in sterilisation protocols, overcrowding-related risks, and limited accountability mechanisms. The absence of systematic infection surveillance and public reporting undermines patient safety and erodes trust in institutional care.
• Limited public–private collaboration: The large private health sector operates with minimal coordination or oversight from the public system. Though Kerala has demonstrated successful projects of public–private partnership (PPP) in national programmes for addressing diseases such as TB, HIV and Polio, the state lacks equivalent PPP interventions in engaging private hospitals and clinics in the remaining areas of healthcare provision.
• Traditional and alternative medicine: Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy (AYUSH) services run in parallel to the modern medicine system with little coordination. Referrals or co-management between modern and AYUSH providers are rare, resulting in fragmented care pathways for patients who utilize both systems.

Fragmented Care Pathways and Weak Continuity

• Weak gatekeeping and referral inefficiencies: Primary care does not function effectively as the first point of contact for many conditions, particularly chronic diseases such as diabetes and hypertension. As a result, patients frequently bypass PHCs and CHCs and directly access medical colleges and tertiary hospitals, contributing to a steadily increasing patient load, overcrowding of outpatient services, longer waiting times, and diversion of tertiary resources away from complex and referral-appropriate care. In parallel, a significant proportion of patients seek care directly from private clinics and hospitals, driven by perceived quality and faster access to diagnostics and specialists, which in turn leads to high OOPE even for conditions that could be managed at the primary-care level. Referral systems largely operate as one-way transfers, with limited advance communication, weak referral documentation, and minimal feedback from higher-level facilities to referring centres, resulting in poor continuity of care, duplication of investigations, and inefficient use of secondary and tertiary health services.
• Absence of back-referral and follow-up mechanisms: There is no robust system to track referred patients or ensure their return to primary care after stabilisation. PHCs seldom receive feedback from secondary or tertiary hospitals, and discharged patients are not proactively recalled. These gaps severely weaken continuity of care for chronic illnesses, post-hospitalisation recovery, and emergency follow-up.
• Siloed vertical programmes limiting integrated care: Major health programmes—covering non-communicable diseases, communicable diseases, mental health, and maternal–child health—often function as parallel verticals with separate reporting and service delivery arrangements. Patients with multiple conditions navigate fragmented pathways, attending different clinics and providers without coordinated care plans.
• Public–private fragmentation in the care continuum: Public and private providers operate largely in parallel, with no integrated referral tracking, shared medical records, or continuity protocols. State insurance schemes facilitate private-sector treatment, but coordination and quality oversight remain limited. Patients frequently move between sectors, leading to duplication of services, inconsistent treatment plans, and higher out-of-pocket expenditure.
• Prescription practices and pharmacy accountability: Inappropriate prescribing remains a systemic concern. State drug-control inspections and audit findings indicate widespread non-compliance with prescription-only regulations, particularly for antibiotics and high-risk medicines. Antibiotics continue to be dispensed without valid prescriptions across a large share of retail pharmacies, contributing to rising antimicrobial resistance. Prescription audits in public facilities remain sporadic, and digital prescription monitoring is not yet universal. These gaps weaken rational drug use, increase treatment failures, and add to avoidable household expenditure.
• Limited monitoring of quality and outcomes under public insurance schemes: While Karunya Arogya Suraksha Padhathi (KASP) and Pradhan Mantri Jan Arogya Yojana (PMJAY) have expanded access to private-sector care, systematic quality oversight remains weak. Available grievance data show that a significant proportion of complaints relate to denial of services, informal payments, and incomplete coverage of diagnostics and medicines. National PMJAY reviews indicate that only a small fraction of empanelled hospitals undergo regular quality audits, and outcome indicators such as complication rates or readmissions are not routinely tracked or disclosed. As a result, patients, particularly those with complex conditions, experience variable quality of care despite being insured.
• Cancer care equity concerns despite insurance coverage: Cancer patients in Kerala continue to face geographic and financial inequities. Studies indicate that nearly half of cancer patients travel over 50 km for treatment, disproportionately affecting rural and low-income households. Even among insured patients, out-of-pocket expenditure remains substantial—driven by diagnostics, medicines, and radiation therapy not fully covered under insurance packages. This contributes to delayed treatment initiation and unequal outcomes.

Variable Quality Standards, Equity, and Patient Experience

• Inconsistent application of clinical protocols: Adherence to standard treatment guidelines varies widely across public facilities. Audit findings highlight gaps in infection control, antenatal care protocols, and emergency procedures. Only 10% of procured drug batches are routinely quality tested, allowing large volumes of medicines to be used without laboratory verification. Equipment maintenance practices are irregular, affecting service reliability and patient safety.
• Partial coverage of quality assurance mechanisms: Kerala has expanded quality initiatives, with around 240 public facilities accredited under National Quality Assurance Standards (NQAS) by mid-2025, alongside Labour Room Quality Improvement initiative (LaQshya) and Making Unique Services Quality Assured for children (MUSQAN) certifications for maternity and child-friendly services. However, most facilities remain outside formal accreditation, and routine enforcement of quality standards remains weak. Although Kerala enacted its own Clinical Establishments (Registration and Regulation) Act, 2018 to regulate hospitals and clinics, full implementation of regulatory mechanisms—including inspection and enforcement—has been slow and uneven, and application of minimum standards under the Act has not yet been consistently enforced across the state.
• Programme-level quality gaps in key population groups: Continuity and quality of care remain uneven in priority areas. NCD services show variable follow-up and case management across districts, contributing to high out-of-pocket spending. Community mental health services remain underdeveloped, with limited integration into primary care. Elderly care services lag behind demographic needs, despite rapid population ageing. In maternal and child health, audits note uneven uptake of entitlement schemes, even as select facilities demonstrate high-quality care through certification programmes.
• Unequal quality of care for marginalised and special populations: Despite universal service intent, care quality and continuity remain uneven for marginalised groups. Scheduled Castes (SCs) and Scheduled Tribes (STs) experience higher unmet need due to geographic isolation, limited outreach, and uneven service quality, with women and children particularly vulnerable. Migrant workers face language barriers, documentation challenges, and episodic engagement with public health services, often limited to disease surveillance rather than continuous care. Fisherfolk encounter rigid service timings and wage-linked barriers to follow-up. Persons with disabilities face persistent physical and communication barriers—facility audits show that while ramps exist in many centres, fewer than 40% of public facilities are fully accessible. Transgender persons continue to report stigma, lack of trained providers, and inconsistent implementation of inclusive care policies. These patterns reflect a “one-size-fits-all” service design that fails to adapt to diverse social and occupational realities.
• Weak data-driven quality monitoring and feedback loops: Health system data are insufficiently disaggregated by district, gender, disability, social group, or migration status, limiting the detection of inequities in care quality and outcomes. There is no institutionalised mechanism for routine outcome audits, equity reviews, or public reporting of service quality indicators. Although grievance redress systems exist, reviews show that complaints are poorly categorised and rarely linked to corrective action or provider accountability, allowing systemic quality gaps to persist.

Maternal, New-born, and Early Childhood Care Quality Gaps

• Maternity care and patient experience deficits: While Kerala reports institutional delivery rates exceeding 99%, quality of maternity care remains uneven. Patient grievance records and facility-level audits indicate persistent instances of suboptimal maternity care, including inadequate communication, limited informed consent for obstetric interventions, and insufficient emotional support during labour and delivery. These experiences undermine trust in public facilities and disproportionately affect first-time mothers and socially vulnerable women.
• Antenatal workforce constraints: Auxiliary Nurse Midwives (ANMs) and nurses with midwifery training are critical providers of community-based antenatal care, tasked with antenatal monitoring, counselling, and risk identification. Yet, coverage and utilisation of these services remain uneven, particularly among marginalised populations. Recent analyses raise concerns about a reduced emphasis on dedicated midwifery roles and skill sets, resulting in gaps in continuity of care at the community level—especially for high-risk pregnancies. These workforce constraints weaken early detection of complications, weaken follow-up support, and reduce the effectiveness of preventive maternal care, underscoring the need for strengthened workforce capacity, enhanced training, and sustained antenatal engagement across communities.
• High caesarean section rates and post-operative safety risks: Kerala records one of the highest caesarean-section rates in India, exceeding 45% overall and crossing 60% in private hospitals—far above WHO-recommended thresholds. Public hospitals increasingly report post-caesarean complications, including surgical site infections and puerperal sepsis, contributing to avoidable maternal morbidity and ICU admissions. These trends point to gaps in infection prevention practices, post-operative monitoring, staffing adequacy, and clinical quality oversight in obstetric services.
• Limited early intervention for autism and neurodevelopmental disorders: Children with autism spectrum disorder and other neurodevelopmental conditions face significant delays and service gaps in the public health system. Limited specialist availability and capacity constraints result in long waiting periods for diagnosis and therapy at government facilities. Comprehensive developmental services are concentrated in a small number of tertiary centres, which are already overstretched. Consequently, many families turn to private providers for speech, behavioural, and occupational therapy. Private therapy costs range from ₹500 to ₹1,500 per session, imposing substantial financial strain on households requiring long-term care. The lack of affordable, decentralised early intervention services leads to delayed treatment during critical developmental periods and increases inequity in access to care.