അഭിപ്രായം രേഖപ്പെടുത്തുക
അഭിപ്രായം രേഖപ്പെടുത്തുക

4. Recommendations for Health System Strengthening

4.1 Strengthen Infrastructure, Emergency Readiness, and System Resilience
Expand and upgrade health infrastructure
  • Close infrastructure gaps at the frontline: Scale up Sub-Centres, PHCs, CHCs, and Taluk hospitals to meet IPHS, with priority to districts and regions that remain under-served.
  • Strengthen secondary-care capacity: Upgrade Taluk and District Hospitals to function as effective first-referral units by expanding specialty services, diagnostics, high-dependency units, and essential critical-care capacity.
  • Decongest tertiary hospitals: Reduce excessive dependence on medical colleges by enabling secondary hospitals to manage moderately complex medical, surgical, obstetric, and emergency cases locally. Coordinated patient navigation will be ensured for all through effective use of existing e-health platforms.
  • Address regional and population inequities: Ensure balanced distribution of facilities across tribal, coastal, highland, and urban informal settlements, with focused investment in northern districts and fast-growing urban areas.
  • Use data-driven facility planning: Map population density, travel time, terrain, and service gaps to guide the location of new facilities and optimise catchment coverage.
  • Ensure inclusive facility design: Adopt universal design principles in all new and upgraded facilities to ensure disability-friendly, elder-friendly, and gender-sensitive infrastructure.
  • Build climate-resilient health facilities: Retrofit and design facilities to withstand floods, heatwaves, and extreme weather, ensuring uninterrupted power, water supply, and safe access during emergencies.
  • Improve infrastructure reliability: Expand renewable energy use, including solar power and energy-efficient systems, to reduce disruptions and operational vulnerabilities.
Improve emergency care and referral transport systems
  • Stabilise and expand the public ambulance network: Ensure reliable emergency coverage across rural, coastal, urban, and hilly regions, with adequate fleet strength and staffing.
  • Upgrade emergency response capability: Increase the proportion of ambulances equipped for advanced life support and staffed with trained emergency medical personnel.
  • Improve ambulance–hospital coordination: Establish real-time preintimation communication and standardised referral protocols between ambulance services and emergency departments.
  • Develop district-level emergency hubs: Establish trauma, cardiac, and stroke care hubs at district or regional levels to enable rapid stabilisation closer to communities.
  • Strengthen inter-facility referral transport: Ensure safe, timely, and medically supervised transfers between facilities, reducing delays and avoidable mortality.
Institutionalise disaster preparedness and hospital safety
  • Mandate hospital disaster preparedness plans: Require all health facilities to maintain updated preparedness plans covering floods, heatwaves, landslides, fires, epidemics, and mass-casualty events.
  • Conduct regular safety and readiness audits: Institutionalise audits covering fire safety, structural integrity, oxygen systems, infection prevention, and surge capacity.
  • Ensure emergency stock readiness: Maintain buffer stockpiles of essential medicines, oxygen, consumables, and equipment at district and regional levels.
  • Integrate health with disaster management systems: Align hospital preparedness and emergency response with state and district disaster management authorities for coordinated action.

4.2 Build a Strong, Modern Health Workforce & Improve Medical Education

Strategic workforce planning and equitable deployment
  • Establish a state-level health workforce planning mechanism: Create a dedicated Health Human Resources Policy to regularly assess staffing needs across primary, secondary, and tertiary care, aligned with population health needs, disease burden, and service load. This should include real-time vacancy tracking and district-wise workforce mapping.
  • Accelerate recruitment and reduce appointment delays: Streamline recruitment processes to address prolonged delays between post sanctioning and appointments. Time-bound recruitment cycles are essential to prevent long-standing vacancies in specialist, nursing, and technical cadres.
  • Correct regional and rural imbalances: Introduce targeted deployment policies to address persistent shortages in northern districts, tribal areas, and remote regions. Incentives such as hardship allowances, housing support, priority promotions, and local recruitment should be institutionalised.
  • Strengthen accountability at the local level: Enable district health administrations and local self-governments to play a greater role in monitoring attendance, service delivery, and workforce utilisation, while maintaining clear lines of administrative authority.

Strengthening specialist capacity and public sector retention
  • Expand specialist availability in secondary care: Prioritise recruitment and retention of specialists such as anaesthetists, gynaecologists, pathologists, emergency physicians, and psychiatrists at CHCs, taluk hospitals, and district hospitals to reduce avoidable referrals and overload at tertiary centres.
  • Address burnout and excessive workload: Rationalise duty rosters, improve nurse-to-bed ratios, and ensure adequate staffing to reduce chronic overwork in public hospitals, particularly in medical colleges and high-volume district hospitals.
  • Improve retention through service conditions: Ensure timely salary payments, transparent transfer policies, and predictable career progression to reduce attrition and outward migration, especially among nurses and young doctors.
  • Enhance workplace safety: Strengthen hospital security, enforce zero-tolerance policies against violence, and ensure safe working conditions—particularly for women healthcare workers during night duties.
  • Institutionalise safety mechanisms: Mandate functional SOS and panic alarm systems in all emergency, casualty, and high-risk clinical areas; ensure the presence of senior on-call supervision during medico-legal or custodial examinations; and formalise rapid response protocols with police and hospital security units. Previous commitments to designate hospitals as “safe zones” must be operationalised with clear standards, monitoring, and accountability rather than remaining symbolic.

Modernising medical education and training capacity
  • Balance undergraduate expansion with postgraduate growth: Align medical college intake with available faculty, infrastructure, and training capacity. Expand postgraduate and super-specialty seats in line with public system needs, especially in emergency medicine, family medicine, geriatrics, oncology, and mental health.
  • Upgrade teaching infrastructure and faculty strength: Address faculty shortages in government medical and nursing colleges through timely recruitment and academic incentives. Ensure that newly established medical colleges meet full infrastructure and teaching hospital requirements.
  • Strengthen district hospitals as teaching platforms: Develop district and taluk hospitals as accredited teaching centres for postgraduate and diploma training to decentralise specialist education and improve service delivery outside major cities.
  • Reform curricula towards public health relevance: Shift medical and nursing education towards stronger clinical exposure, primary care orientation, emergency response skills, and applied public health, including community postings and district-level training.

Public health leadership, research, and academic governance
  • Establish a Public Health Management Cadre: Implement a dedicated public health leadership cadre to strengthen disease surveillance, prevention planning, emergency preparedness, and health system governance.
  • Decentralise academic and research governance: Reduce over-centralisation in medical education administration to allow greater institutional autonomy, faster curriculum updates, and region-specific training and research priorities.
  • Create a State Medical Research Board: Establish a dedicated body to guide health research priorities aligned with Kerala’s epidemiological profile, support applied health systems research, and translate evidence into policy and practice.
  • Strengthen research capacity in public institutions: Provide protected research time, funding support, and academic incentives for faculty in government medical colleges to promote innovation and evidence-based policymaking.
  • Reposition and strengthen Kerala Health Research and Welfare Society (KHRWS): Clearly define KHRWS’s mandate as a nodal platform for public health research coordination, innovation pilots, and policy-relevant evidence generation.

4.3 Building Robust Systems for Medicines, Diagnostics & Technology Systems
Strengthen medicine and vaccine procurement & supply chains
  • Establish Public Finance Management Systems (PFMS) for financial management: Establish PFMS systems for budget forecasting for procurement of drugs and consumables, timely payment to vendors and monitoring of financial flow to facilities, districts and at the apex level.
  • Modernise public procurement systems: Implement a fully integrated, digital, end-to-end procurement platform covering forecasting, tendering, procurement, storage, and last-mile distribution. Link facility-level consumption data with state dashboards to prevent under-ordering and stock-outs.
  • Reform and strengthen KMSCL: Diversify supplier pools, break large tenders into flexible lots, adopt framework and call-off contracts, and strictly enforce delivery timelines with penalties for delays or quality failures.
  • Ensure uninterrupted vaccine and biologics supply: Strengthen demand forecasting and pooled procurement mechanisms for essential vaccines and biologics, including rabies immunoglobulin, to prevent treatment interruptions.
  • Maintain resilient cold-chain systems: Upgrade cold-chain infrastructure at all levels with backup power, continuous temperature monitoring, and trained handlers, especially in remote, tribal, and disaster-prone areas.
  • Create strategic emergency reserves: Establish district- and regional-level buffer stocks of essential medicines, vaccines, oxygen, and consumables to ensure rapid deployment during outbreaks, disasters, and supply disruptions.
Improve availability and affordability of essential medicines
  • Guarantee free and uninterrupted access to essential medicines: Ensure consistent availability of medicines prescribed in public facilities, particularly for non-communicable diseases, mental health conditions, and long-term therapies.
  • Strengthen generic medicine availability: Expand low-cost generic medicine provision within public facilities, ensure adequate stocking beyond limited formularies, and build public confidence in quality-assured generics.
  • Reduce dependence on private purchases: Eliminate routine referrals to private pharmacies by aligning public procurement with prescribing patterns and ensuring last-mile availability at all public facilities.
Strengthen drug quality assurance, regulation, and rational use
  • Reinforce drug regulation and quality control: Strengthen the State Drugs Control Department, expand routine batch testing of all procured medicines, and ensure strict action against substandard or expired drugs.
  • Strengthen pharmacovigilance systems: Enable easy reporting of adverse drug and vaccine reactions by health workers and patients, with clear mechanisms for investigation and corrective action.
  • Address AMR: Enforce prescription-only antibiotic sales, conduct regular prescription audits in public facilities, and operationalise antibiotic stewardship committees in hospitals.
  • Ensure pharmacy and diagnostic regulation: Mandate licensing and compliance with standards for pharmacies and diagnostic providers, with consistent enforcement under existing regulatory frameworks.
Expand and maintain diagnostic capacity across the health system
  • Ensure basic diagnostics at primary and secondary levels: Provide functional laboratory services, ECG, and X-ray facilities at all PHCs, CHCs, and Taluk hospitals in line with IPHS norms.
  • Expand access to advanced diagnostics: Ensure availability of imaging and pathology services at district hospitals, supported by tele-radiology and tele-pathology where specialists are limited.
  • Strengthen equipment maintenance systems: Establish district-level biomedical engineering units for preventive maintenance, repairs, calibration, and enforcement of uptime obligations under maintenance contracts.
  • Improve laboratory quality systems: Implement standard operating procedures, infection-control protocols, and external quality assurance participation for all public laboratories.
Strengthen digital health systems and technology integration
  • Adopt e-health systems aligned with latest technologies: Ensure that digital health and e-health solutions are continuously upgraded and aligned with evolving technologies, interoperability standards, and national digital health architectures to enable seamless data exchange, improve efficiency, enhance quality of care, and strengthen overall system responsiveness.
  • Implement a unified health information system: Ensure Unique Health Identity (UHID) number for entire population of the state and disallow any temporary UHID creation for any health department programs. Facilitate integration of patient records, laboratories, pharmacies, and diagnostics across all public facilities to ensure continuity of care across referral levels.
  • Ensure interoperability of digital platforms: Enable real-time data sharing across programmes, facilities, and levels of care to support monitoring, planning, and outbreak preparedness.
  • Expand e-prescription and digital inventory systems: Mandate digital prescribing and real-time stock tracking in public facilities to improve rational drug use and accountability.
  • Scale up telemedicine and digital outreach: Expand specialist access to peripheral facilities through teleconsultation, particularly in rural, tribal, and hard-to-reach areas.
  • Safeguard data privacy and public oversight: Ensure strong data protection, transparency, and public accountability in all digital health initiatives and technology partnerships.
Ensure equitable reach of medicines, diagnostics, and technology
  • Strengthen outreach to remote and vulnerable populations: Deploy mobile health units and fixed-day medicine distribution services for tribal, coastal, migrant, and hard-to-reach communities.
  • Ensure last-mile delivery for high-need groups: Enable home-based medicine access for the elderly, persons with disabilities, and patients with limited mobility through strengthened primary care systems.
  • Expand access to essential assistive technologies: Ensure availability of spectacles, hearing aids, mobility aids, prosthetics, and basic rehabilitation equipment through public facilities and state-supported schemes.
  • Use population and geographic mapping: Identify persistent gaps in access and supply to ensure no region or community is systematically excluded from essential medicines and diagnostics.
4.4 Improve Service Delivery & Guarantee Quality of Care
Strengthen primary and community-level service delivery
  • Functional primary care as the first point of contact: Ensure that PHCs and FHCs consistently deliver the full package of essential services—including maternal and child care, NCD management, mental health screening, and elderly care—so that patients do not bypass primary care for routine conditions.
  • Continuity of care across levels through care coordination: Establish care coordination systems leveraging digital health applications for all patients entering the public system and referred to secondary or tertiary facilities for treatment and follow-up.
  • Outreach for hard-to-reach populations: Expand regular outreach services for tribal, coastal, migrant, and urban informal populations through mobile clinics and fixed outreach days linked to nearby PHCs.
  • Community engagement in service planning: Strengthen ward- and panchayat-level participation in identifying service gaps, monitoring facility functioning, and improving patient experience at local health institutions.
  • Ensure language-accessible services: Provide multilingual signage, forms, and interpreter support at public health facilities to improve access for migrant and tribal populations.
Improve maternal, child, and adolescent service quality
  • Respectful maternity care: Ensure consistent adherence to respectful maternity care standards, including informed consent, effective communication, privacy, pain management, and emotional support during labour and delivery.
  • Reliable antenatal and postnatal follow-up: Strengthen continuity of antenatal and postnatal care through scheduled facility visits and home follow-up, especially for high-risk pregnancies and first-time mothers.
  • Child health service integration: Improve coordination between health facilities and nutrition, early childhood, and school health services to ensure seamless care from infancy through adolescence.
  • Adolescent-friendly services: Institutionalise adolescent health services at the primary level, including counselling for mental health, nutrition, substance use, and reproductive health, with clear referral pathways for specialised care.
Expand quality of chronic, elderly, and palliative care
  • Structured chronic disease management: Ensure standardised follow-up, counselling, and treatment continuity for patients with diabetes, hypertension, cardiovascular disease, cancer, and chronic respiratory conditions at the primary and secondary levels.
  • Integrated geriatric care: Strengthen age-friendly service delivery in public facilities, including prioritised access, coordinated care for multimorbidity, and linkage with social support services.
  • Community-based palliative care: Expand home-based palliative care coverage through coordinated facility–community models, ensuring dignity, pain relief, and continuity of support for patients with life-limiting illnesses.
  • Provide home-based service options: Enable provision of essential care—including physiotherapy, wound care, medication follow-up—for elderly, disabled, or immobile patients through trained health teams.
Strengthen mental health and disability service delivery
  • Mental health integration into routine care: Embed screening, basic counselling, and referral for common mental health conditions within primary care services rather than limiting care to specialist centres.
  • Continuity and follow-up: Ensure that patients receiving mental health care are tracked for follow-up and adherence, particularly after hospitalisation or crisis episodes.
  • Disability-inclusive services: Improve early identification, referral, and follow-up for children with developmental delays and persons with disabilities within the public health system, ensuring continuity across care levels.
Reduce fragmentation and improve care coordination
  • Functional gatekeeping: Reinforce the role of primary care in coordinating patient journeys across services, reducing unnecessary self-referrals and repeated consultations by leveraging digital health technology.
  • Integrated care pathways: Align vertical health programmes (NCDs, communicable diseases especially TB elimination, mental health, maternal–child health) to reduce duplication and ensure coordinated care for patients with multiple conditions.
  • Enable electronic referral tracking: Integrate patient movement across facilities into the eHealth platform to support real-time status tracking and clinical decision continuity.
  • Public–private interface management: Strengthen coordination mechanisms where patients move between public and private providers under public schemes, ensuring continuity, information flow, and treatment consistency.
  • Establish family physician concept: Explore the scope for family physician model as an operational research to understand the feasibility of assigning the responsibility for ensuring the role of first point of care, coordinated referral, back referral and maintaining patient data and its confidentiality.
Strengthen quality standards, patient safety, and accountability
  • Standard treatment adherence: Ensure uniform application of evidence-based clinical protocols and availability of infrastructure across public healthcare facilities to reduce unwarranted variation in care quality.
  • Infection prevention and patient safety: Strengthen routine monitoring of hospital-acquired infections, surgical outcomes, and post-procedure complications, particularly in high-volume public hospitals.
  • Facility-level quality assurance: Expand and sustain quality improvement processes across all levels of care, not limited to selected accredited institutions.
  • Patient rights and grievance redressal: Ensure that all public health facilities operate accessible, responsive, round the clock, online grievance mechanisms and that complaints are systematically reviewed and linked to corrective action.
  • Promote quality-linked incentives: Link performance-based incentives for facilities to quality, safety, and equity outcomes, not just service volume or patient load.
Ensure equity in service experience and outcomes
  • Targeted attention to marginalised groups: Address persistent service-quality gaps affecting Scheduled Castes, Scheduled Tribes, migrants, fisherfolk, persons with disabilities, transgender persons, and the elderly.
  • Culturally sensitive service delivery: Adapt service delivery models to local social, occupational, and cultural contexts to improve trust, uptake, and continuity of care.
  • Monitoring inequities in care: Regularly assess service quality, outcomes, and patient experience across districts and population groups to identify and correct inequities hidden by aggregate indicators.
4.5 Strengthen Governance, Financing, and Financial Protection

Strengthen health financing and financial accountability
  • Ensure predictable and timely flow of health funds: Establish robust mechanisms to guarantee uninterrupted flow of operational budgets, infrastructure funds, insurance reimbursements, and emergency allocations to public health facilities, reducing service disruptions caused by payment delays.
  • Stabilise public insurance financing: Improve the sustainability of publicly funded insurance schemes by ensuring timely claim settlements, realistic budgeting aligned with utilisation levels, and preventing accumulation of arrears that undermine provider participation.
  • Increase fiscal space for health: Prioritise health within the state budget framework by protecting both capital and operational spending for infrastructure, workforce expansion, medicines, diagnostics, and emergency preparedness. Ensuring strategic reforms in the mobilisation of resources at the facility level by HMC/HDCs to improve service delivery and strengthen transparency and accountability in resource use.
  • Reduce fund-flow complexity and fragmentation: Simplify and streamline health financing channels across state departments, centrally sponsored schemes, and local governments to minimise delays, duplication, and administrative bottlenecks.
  • Create a dedicated health contingency fund: Establish a protected health fund to buffer public health programmes and insurance payments during fiscal stress, ensuring continuity of essential services even in constrained fiscal periods.
  • Strengthen financial oversight and expenditure tracking: Enable PFMS of health expenditures at facility, district, and state levels to detect delays, leakages, and underutilisation early and ensure funds are used as intended.
  • Increase institutional local spending caps based on capacity and workload: Increase the allowable ceiling for local health spending for individual institutions based on their service capacity and workload.

Strengthen health governance, decentralisation, and institutional coordination
  • Clarify roles and reduce administrative fragmentation: Clearly define responsibilities across the Health Department, NHM, LSGD, and line departments to address overlapping mandates and improve operational coordination.
  • Align planning and budgeting across levels: Integrate state, district, and local health plans and budgets to ensure needs-driven service delivery and reduce duplication across programmes and infrastructure investments.
  • Empower district and local health governance: Strengthen district health societies and local self-government institutions with authority, technical capacity, and financial flexibility to plan infrastructure, oversee emergency readiness, support disease prevention, and monitor service delivery.
  • Enhance intersectoral coordination: Institutionalise coordination between health, water and sanitation, public works, education, animal husbandry, social welfare, and disaster management to address environment-linked diseases, maternal and child health risks, and zoonotic threats.
  • Build governance capacity at the frontline: Invest in administrative, technical, and planning capacity at district and facility levels so decentralisation translates into effective implementation rather than procedural burden.
  • Leveraging external resources for implementation support and academic research: Establish systems to leverage external resources from national and international academic institutions, foundations and Corporate Social Responsibility (CSR) funding for supporting innovative projects and research in state health system.

Strengthen regulation, accountability, and transparency
  • Strengthen regulation of private healthcare costs: Enforce transparent pricing, standard treatment rates, and compliance with regulatory frameworks across private hospitals, diagnostics, and pharmacies to prevent unpredictable charges and protect patients.
  • Improve oversight of public–private arrangements: Strengthen regulatory scrutiny of PPPs and empanelled facilities to ensure adherence to pricing norms, service standards, and patient protections.
  • Enhance accountability and transparency mechanisms: Mandate regular audits, performance reviews, and public disclosure of outcomes related to infrastructure projects, procurement, insurance performance, and emergency preparedness.
  • Expand citizen oversight and grievance redressal: Strengthen social audits, community health committees, and patient grievance mechanisms, including independent review and escalation pathways, to enable public monitoring and accountability.

Strengthen financial protection for households
  • Expand universal and effective insurance coverage: Integrate and strengthen publicly funded insurance schemes to ensure automatic enrolment of all eligible households including missing middle, simplified benefit packages, and genuinely cashless treatment.
  • Reduce out-of-pocket expenditure: Ensure essential medicines, diagnostics, and follow-up care are free or fully covered under public schemes for all eligible poor and vulnerable population.
  • Address catastrophic costs from chronic illness: Introduce targeted financial safeguards for poor and vulnerable households facing high recurring expenses due to chronic conditions such as kidney disease, cancer, diabetes, mental illness, and disability.
  • Protect the “missing middle”: Develop financial protection mechanisms for households that fall outside eligibility for public schemes but lack the capacity to absorb health shocks, preventing distress financing among middle-income families.
  • Ensure continuity of welfare-linked health benefits: Protect elderly care, disability support, and disease-specific assistance programmes from funding interruptions and administrative delays to prevent forced reliance on private expenditure.
4.6 Build Strong Public Health Systems, Surveillance & Disease Preparedness
Strengthen Surveillance, Early Warning, and Outbreak Response
  • Integrated, real-time surveillance: Consolidate routine reporting, event-based surveillance, and laboratory reporting into a single state public health early-warning workflow. Establish clear district-level escalation triggers and mandate daily situational reviews during high-risk periods such as monsoon months, festivals, and extreme weather events.
  • District surveillance strengthening: Fully resource District Surveillance Units with dedicated epidemiology teams, including trained data analysts and field investigation staff, to ensure rapid alert verification, contact tracing, cluster investigation, and containment support during outbreaks.
  • Laboratory-linked surveillance: Expand routine laboratory confirmation for priority syndromes—acute fever, acute diarrhoea, jaundice/hepatitis, respiratory illness clusters—by strengthening sample transport systems, defining turnaround-time targets, and expanding district-level laboratory capacity.
  • Public and private reporting compliance: Enforce mandatory, time-bound reporting of notifiable diseases by all private hospitals, clinics, and laboratories through standardized digital reporting formats. Introduce a tiered accountability framework for non-compliance, paired with simple, user-friendly reporting tools and training for private providers to support consistent and accurate reporting.
  • Event-based and community surveillance: Strengthen mechanisms for capturing early warning signals from communities, schools, local governments, and media monitoring to detect unusual health events that may not yet appear in routine reporting systems.
Build “One Health” Capacity for Zoonoses and AMR
  • Institutionalise One Health coordination: Establish standing One Health platforms at state and district levels involving Health, Animal Husbandry, Local Self-Governments (LSG), Environment, and Forest departments, with clearly defined roles for surveillance, risk reduction, and coordinated outbreak response.
  • Rabies prevention system strengthening: Strengthen bite-management pathways through standardised triage, strict protocol adherence, follow-up tracking, and uninterrupted availability of all post-exposure prophylaxis components. Coordinate with local bodies to ensure sustained stray-dog population management, animal birth control, and vaccination programmes. A special drive and campaign with additional funding should be established to strengthen Animal Birth Control (ABC) programmes. There should be monthly review at state and district levels.
  • Hospital infection surveillance and AMR intelligence: Strengthen infection prevention and control governance by mandating routine surveillance of hospital-acquired infections and regular antibiogram generation in all major public hospitals, with findings directly linked to antimicrobial stewardship actions. Decide a roadmap for engaging the private hospitals in a phased manner with annual milestones and performance measurement.
  • Regulate antibiotic access: Enforce prescription-only sale of antibiotics through strengthened pharmacy inspections, prescription audits, and penalties for violations. Expand provider and public education on rational antibiotic use to slow the spread of resistance.
Environmental Health, Water Sanitation and Hygiene (WASH), and Food Safety for Disease Prevention
  • Water-quality-linked outbreak prevention: Strengthen joint response protocols for drinking-water contamination, including routine chlorination verification, rapid water testing, source mapping, and immediate corrective action, with clearly defined responsibilities across Health, Local Self-Governments, Water Authority, and district administration.
  • Food safety and outbreak control: Enhance inspection and outbreak investigation capacity for food-borne illness clusters through rapid response teams, strict closure and penalty protocols for repeat offenders, and improved traceability in high-risk food settings.
  • Vector control as a year-round program: Shift from seasonal, reactive vector control to continuous risk mapping and source-reduction activities in urban wards, construction sites, waste hotspots, and flood-prone areas, with routine performance monitoring at municipal and panchayat levels.
Prevention-Focused Public Health Action on NCDs and Mental Health
  • Risk-factor reduction at population scale: Implement district-level action plans targeting tobacco use, alcohol harm, unhealthy diets, physical inactivity, and obesity, linked to measurable outputs such as screening coverage, follow-up rates, community programmes, and school-based interventions.
  • Strengthen chronic disease prevention and follow-up: Improve continuity systems that link community screening to treatment initiation and long-term follow-up, supported by primary-care tracking, community health workers, and adherence support, rather than reliance on episodic facility-based care.
  • Mental health as a core public health function: Strengthen district-level community mental-health outreach, crisis referral pathways, and school-linked screening and referral coordination, positioning mental health as routine public-health work rather than solely specialist-driven care.
Climate, Disaster Preparedness, and Health Emergency Readiness
  • Health-sector climate risk preparedness: Establish district-level health emergency preparedness plans addressing floods, heat stress, landslides, epidemic surges, and mass-casualty events, with clearly defined surge staffing, referral rerouting, and continuity-of-care arrangements.
  • Facility readiness for public health emergencies: Standardise hospital and primary-care emergency stock protocols, rapid procurement triggers, and service continuity plans for high-risk seasons, fully integrated with district disaster-management systems.
  • Community risk communication: Strengthen rapid, credible public communication mechanisms for safe-water advisories, fever management, bite-management guidance, heat-risk actions, and outbreak alerts, delivered through local governments, primary-care networks, and trusted community channels.
Health Literacy, Community Engagement, and Trust
  • Structured community engagement: Strengthen ward-level health committees and community platforms to identify local health risks, improve uptake of prevention programmes, and create continuous feedback loops beyond grievance-based systems.
  • Targeted health literacy: Implement sustained health-literacy campaigns on priority public-health issues—rabies prevention, fever care, diarrhoeal disease prevention, NCD risk factors, and antimicrobial misuse—tailored for migrants, coastal communities, tribal hamlets, and urban informal settlements.
  • Transparent public reporting: Publish regular district-level dashboards on priority public-health risks and response actions, including outbreak trends, vector-control performance, and water-quality alerts, to build trust, accountability, and public confidence.
Evidence, Data Use, and Learning Systems
  • Routine analytics for decisions: Require district teams to translate surveillance and programme data into short, action-oriented briefs highlighting what is increasing, where, why, and what response is triggered, ensuring data actively drives decisions.
  • Independent evaluation culture: Institutionalise periodic third-party reviews of outbreak responses, risk communication, and prevention programmes, focused on identifying implementation gaps and corrective actions rather than fault-finding.
  • Research-to-policy linkage: Prioritise state-specific operational research on outbreak drivers, AMR patterns, health behaviours, and prevention effectiveness, with clear mechanisms to translate findings into updated guidelines, training curricula, and enforcement practices.
4.7 Strengthening the Invisible Backbone of Kerala’s Health Workforce

Strengthening Medical Equipment, Maintenance, and Infrastructure Reliability
  • Upgrade health facilities to meet IPHS norms: Conduct a state-wide gap assessment of all public health facilities against IPHS and address critical shortfalls on priority. Expand ICU and high-dependency units, operation theatres, maternity services, diagnostics, and blood banks at secondary-level hospitals to reduce avoidable referrals to tertiary centres. Ensure every PHC, CHC, taluk, and district hospital meets prescribed IPHS space, equipment, and service requirements, supported by dedicated capital investment through state funds, central schemes, and structured PPP models where appropriate.
  • Audit, retrofit, and replace unsafe health infrastructure: Launch a time-bound programme to rehabilitate or replace structurally unsafe hospital buildings identified through audits. Prioritise immediate repairs, retrofitting, or reconstruction of high-risk facilities, with interim relocation of services where required. Institutionalise rolling infrastructure maintenance plans at district level, including periodic structural, electrical, plumbing, and fire safety audits. All new and renovated facilities should be climate-resilient, incorporating flood protection, seismic safety, and assured backup power and water systems, particularly in coastal and flood-prone districts.
  • Strengthen biomedical equipment maintenance systems: Institutionalise district-level biomedical engineering units responsible for preventive maintenance, calibration, and timely repair of all medical equipment. Expand and strengthen the Biomedical Equipment Maintenance Programme (BEMP) to ensure 100% coverage of public-sector equipment, including out-of-warranty devices, with clearly defined uptime standards (e.g. minimum 95% functionality). Enforce annual and comprehensive maintenance contracts (AMCs/CMCs), conduct regular district and state-level performance reviews, and impose penalties for delayed response or prolonged downtime.
  • Ensure timely procurement, installation, and commissioning of equipment: Streamline procurement workflows to reduce delays from sanction to commissioning. Delegate approval powers to enable faster procurement through rate contracts and the Government e-Marketplace (GeM). Establish a rapid-response procurement mechanism for emergency or critical equipment needs. Mandate that all newly procured equipment is commissioned promptly with parallel staff training and ensure availability of biomedical engineers or trained technicians at hospital or district level. Monitor equipment functionality through regular audits, with escalation mechanisms for devices remaining non-functional beyond defined timelines.
  • Improve infrastructure maintenance and utilities reliability: Treat facility maintenance as a core service delivery function by earmarking dedicated budgets for routine upkeep of buildings, power systems, plumbing, lifts, and HVAC infrastructure. Ensure uninterrupted electricity supply through functional generators or renewable energy backups at all facilities, including PHCs, to safeguard essential services and cold-chain systems. Introduce digital facility management systems to log, track, and resolve maintenance issues, with clear accountability timelines. Engage local self-governments in routine monitoring and minor maintenance of primary care facilities to sustain service readiness.

AYUSH Systems
  • Define collaborative care pathways: Clearly delineate roles for AYUSH doctors in chronic disease management, wellness, rehabilitation, and palliative care within Kerala’s primary healthcare system, with linked referral protocols.
  • Strengthen public facility resourcing: Update norms for staffing, equipment, and specialist deployment in public AYUSH hospitals and dispensaries, ensuring equitable access and functional parity with allopathic institutions.
  • Mainstream AYUSH in public health programmes: Integrate AYUSH practitioners into national and state-level initiatives — such as school health, NCD screening, mental health, and tribal health — with appropriate supervision and training.
  • Modernise and digitise systems: Ensure full adoption of AHIMS and connect it with e-Health/ABDM; mandate digital records and documentation across all public AYUSH centres.
  • Ensure drug safety and supply stability: Establish a dedicated AYUSH pharmacovigilance centre and drug testing labs within Kerala, and strengthen production capacities of state AYUSH medicine units to avoid shortages.
  • Revamp training and cross-learning: Launch fellowships, research platforms, and joint clinical training programmes to modernise practice, reduce siloed functioning, and promote collaboration with modern medicine.
  • Create an AYUSH Commission for Kerala: Constitute a permanent AYUSH Commission to assess workforce planning, training quality, infrastructure needs, and system integration, and to guide AYUSH policy, financing, and long-term positioning within Kerala’s health system.

Nurses
  • Ensure safe nurse-to-patient ratios and expand recruitment: Mandate strict compliance with the IPHS of 1:6 nurse-to-bed ratio in general wards and 1:1 in ICUs. Prioritise recruitment in critical and rural areas and fill existing vacancies in government hospitals.
  • Regulate working hours and implement shift reforms: Operationalise the 6+6+12 shift model with a monthly cap of 208 working hours. Enforce limits on consecutive night shifts and ensure fair compensation and rest periods.
  • Develop career pathways and leadership roles: Create structured progression tracks such as Nurse Practitioners, Clinical Nurse Specialists, and Nursing Supervisors, and ensure nurse representation in policy and hospital administration.
  • Standardise education and strengthen training quality: Strengthen oversight of private nursing colleges, mandate transparent admissions, and expand in-service training in geriatrics, emergency response, and NCD management.
  • Enhance workplace safety and legal protections: Provide safe transport, adequate rest facilities, Internal Complaints Committees, health insurance, maternity protection, and risk allowances for high-risk wards.
  • End exploitative hiring practices: Prohibit misuse of “trainee” designations and progressively replace insecure contract hiring with stable, permanent employment structures.
  • Establish a Kerala Nursing Commission: Constitute an independent body to oversee workforce planning, education quality, service conditions, deployment patterns, and professional development across sectors.

ASHAs
  • Achieve full coverage in high-need areas: Recruit ASHAs in tribal and underserved regions using vulnerability indicators rather than population size alone.
  • Guarantee fair compensation: Introduce a fixed monthly honorarium in addition to performance incentives and ensure timely direct benefit transfers.
  • Build career mobility: Create structured pathways for ASHAs to transition into ANM or health educator roles through experience and upskilling.
  • Enhance support and safety: Provide digital tools, transport allowances, and consistent field supervision.
  • Strengthen system integration: Position ASHAs as core members of PHC teams with clear referral accountability and feedback mechanisms.

Allied Health Professionals and Paramedics
  • Regularise and expand staffing: Establish permanent positions across labs, imaging, therapy, and emergency care in all public facilities.
  • Standardise education and licensing: Strengthen oversight of private institutes and align allied training with national standards.
  • Reduce job insecurity: Absorb long-term contract workers into formal roles and strengthen protections for outsourced staff.
  • Create professional ladders: Define promotions and leadership roles across allied streams and ensure inclusion in multidisciplinary planning.
  • Invest in continuing education: Provide periodic training in emerging technologies, patient safety, and quality standards.

Pharmacists
  • Revise staffing norms: Allocate pharmacists based on workload, ensuring at least two per PHC and scaled teams at higher-level hospitals.
  • Utilise clinical expertise: Integrate pharmacists into chronic disease counselling, antibiotic stewardship, and patient safety initiatives.
  • Offer skill upgrades: Provide structured training in pharmacovigilance, clinical pharmacy, and toxicology.
  • Reduce non-clinical burdens: Digitise inventory management and assign logistics staff to free pharmacists for patient-facing work.
  • Enforce regulatory compliance: Strengthen oversight of ethical dispensing and record-keeping standards.

Dental and Oral Health Workforce
  • Expand dental services to PHCs and CHCs: Establish functional dental units beyond tertiary centres, particularly in rural and tribal areas.
  • Embed oral health in public programmes: Integrate dental screening into school health, NCD outreach, and health camps.
  • Increase public sector absorption: Create additional posts for dentists and auxiliary staff aligned with workforce production.
  • Invest in preventive care: Promote community dentistry rotations and oral health education campaigns.
  • Upgrade equipment and supplies: Modernise public dental units and ensure consistent consumable supply chains.

Public Health Professionals
  • Establish a public health cadre: Create a formal cadre with defined responsibilities at district, block, and state levels for surveillance, planning, and governance.
  • Strengthen recruitment and incentives: Prioritise hiring of MPH/MD (Community Medicine) professionals and incentivise service in remote areas.
  • Integrate fragmented functions: Consolidate surveillance, vector control, and outbreak response within cohesive district public health units.
  • Build capacity in data and analytics: Offer advanced training in GIS, modelling, health informatics, and climate-linked health planning.
  • Nurture leadership: Establish fellowships and mentorship programmes to develop and retain public health leaders.

4.8 Transforming Key System Interfaces

Strengthen Private Sector Engagement (PSE)
  • Establish a Health PSE policy and facilitation cell: Formulate state-specific PSE guidelines aligned with national models and create a dedicated unit to identify, design, and manage health PSE projects. Ensure private sector engagement fills gaps without replacing public services by setting clear performance standards, affordable pricing structures, and strong government oversight mechanisms.
  • Expand Public Private Partnerships (PPPs) for diagnostic and specialty care: Leverage partnerships to provide high-end diagnostics (e.g., CT/MRI, dialysis) and specialty treatments at government hospitals under well-structured contracts with capped costs or free care for public patients, ensuring quality standards and uptime guarantees.
  • Partner with private innovators for outreach: Extend services to remote and underserved areas through PPP-based e-clinics, telemedicine centres, and mobile units integrated with Kerala’s eHealth system to ensure seamless specialist consultations and follow-ups.
  • Integrate private sector in emergency response: Establish formal partnerships integrating private ambulance networks and contingency MOUs with private hospitals for epidemic surges or disaster response, with pre-arranged protocols, pricing, and data-sharing standards.
  • Enforce robust PPP oversight and accountability: Ensure transparent bidding, rigorous contracts, independent monitoring, regular public reporting, and strict penalties for contract breaches to maintain alignment with public health goals.

Harness Health Innovation and Technology
  • Implement a unified digital health information system: Accelerate statewide unified Health Information System implementation anchored on ABDM, ensuring ABHA IDs for all citizens and longitudinal electronic health records accessible across care levels.
  • Ensure interoperability across systems: Link health databases across departments and providers to enable secure, real-time data exchange supporting coordinated planning and surveillance.
  • Mandate e-prescriptions and digital inventory management: Adopt digital prescribing and real-time drug inventory tracking in all public facilities to reduce errors and stock-outs.
  • Scale up telemedicine services statewide: Establish permanent telemedicine nodes at PHCs and remote facilities, enabling specialist consultations without patient travel.
  • Leverage AI and advanced analytics: Deploy ethical AI tools for decision support, outbreak prediction, triage, and automation under strict regulatory oversight.
  • Establish health innovation hubs and incubators: Develop innovation centres supporting med-tech, digital health, and AI-based solutions through public-private-academic collaboration.
  • Strengthen data security and privacy protections: Enforce national data protection standards and establish oversight mechanisms to safeguard patient confidentiality and build public trust.

Pioneering Innovative Models for Care Delivery
  • Adopt women-led “She Hospital” models: Establish women-managed clinical wings to improve gender-responsive care and empower women professionals.
  • Scale up community-based palliative care: Expand home-based palliative networks integrating volunteers, primary care providers, and family support systems.
  • Expand the Family Health Centre model: Strengthen PHCs into comprehensive, people-friendly centres offering extended hours and broader services.
  • Expand neighborhood urban clinics: Establish small, free outpatient clinics in dense urban and slum areas to improve first-contact accessibility.
  • Implement doorstep health outreach programs: Introduce structured home-based care programs for chronic disease management, elderly care, and follow-ups.
  • Develop telemedicine hub-and-spoke networks: Link tertiary hubs with peripheral spokes for tele-consultation and tele-ICU services to enhance remote care quality.
  • Operationalise a Tribal Health Cluster model: Strengthen selected PHCs to serve tribal hamlets with specialist outreach, teleconsultation, and coordinated follow-up.
  • Implement a Coastal Primary Care and Emergency Readiness model: Strengthen coastal PHCs and CHCs for emergency stabilisation, monsoon response, and occupational health risks.

Leveraging Health Tourism for Economic and System Gains
  • Develop a medical & wellness tourism policy and council: Establish coordinated governance between Health, AYUSH, and Tourism departments with accreditation and centralized facilitation mechanisms.
  • Establish Medi-cities as healthcare hubs: Promote integrated specialty hubs combining hospitals, AYUSH centres, and hospitality services.
  • Standardize Ayurveda and wellness tourism: Accredit centres, enforce safety standards, and promote integrated treatment packages backed by research.
  • Facilitate seamless services for international patients: Enable visa support, remote consultations, insurer integration, and global outreach.
  • Offer incentives and enforce quality standards: Provide tax incentives and enforce ethical pricing and service quality oversight.
  • Channel health tourism gains to public care: Introduce mechanisms such as levies or CSR pools to strengthen public health infrastructure.

Mobilizing CSR, Philanthropy, and Innovative Financing
  • Create a Kerala Health CSR Fund and portal: Establish a transparent pooled funding platform for vetted public health projects.
  • Attract CSR and philanthropy for innovation: Launch a Health Innovation Challenge Fund supporting scalable health solutions.
  • Explore bonds and impact investment models: Pilot social impact and health bonds for priority health outcomes.
  • Partner with charitable institutions for tertiary care: Enable co-funded hospital and training centre development in underserved regions.
  • Ensure transparency and strategic use of external funds: Publish annual impact reports and streamline donor-government collaboration mechanisms.
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