The challenges outlined in this report point to a clear and uncomfortable truth: Kerala’s health system does not suffer from a lack of history, institutions, or schemes. It suffers from a gradual loss of direction. Over time, the system has drifted away from the simple idea that once defined it—that healthcare exists first and foremost to serve people, especially in moments of vulnerability. This loss of direction is visible in lack of vision and political will, delayed decisions, fragmented responsibility, rising household costs, and an expanding gap between policy claims and everyday patient experience. At its core, it reflects a weakening commitment to ensuring health as a guaranteed public entitlement.

This erosion is most clearly expressed in the retreat from the principle of Universal Health Coverage (UHC). UHC does not mean the mere existence of hospitals, schemes, or insurance cards. It means that every person, regardless of income, location, age, or social status, can access timely and quality health services without fear of financial hardship. Kerala’s health system once moved decisively in this direction, combining strong public provisioning with broad access and meaningful financial protection. Today, however, the gap between this promise and lived reality is widening. Rising out-of-pocket expenditure (OOPE), forced reliance on private care, uneven service availability, and weak continuity of care suggest that universal coverage in practice is being replaced by selective and conditional access. Reclaiming Universal Health Coverage, rooted in public services, equity, and financial protection, must therefore become the central organising principle of health reform in Kerala.

A people-centred health system begins not with buildings, budgets, or announcements, but with the lived experience of citizens. It asks whether a pregnant woman feels safe and respected in a government hospital; whether an elderly person with multiple illnesses can navigate care without confusion or repeated referrals; whether a family is pushed into debt for basic diagnostics or medicines; and whether health workers are supported to deliver care with dignity, confidence, and professional autonomy. When these experiences fail, no amount of infrastructure expansion or publicity can be called success.

Rebuilding a people-centred health system therefore requires a clear political choice. It means placing patients, families, and frontline health workers at the centre of decision-making, rather than allowing administrative convenience, publicity, or short-term optics to shape priorities. It demands leadership that listens to evidence, accepts uncomfortable truths, and acts early—before crises, court interventions, or tragedies force correction.

First, a people-centred approach requires stronger public accountability. Kerala’s health system today is spread across multiple departments, programmes, institutions, and levels of government, often without clear responsibility for outcomes. Citizens do not care which department controls which function; they care whether services work when needed. Yet fragmentation has allowed failures to be passed between institutions without correction, leaving patients without answers and frontline workers without support. Future reform must therefore focus on clarity of roles, effective coordination across state and local governments, and accountability for performance—not merely for spending or announcements.

Second, restoring confidence in public healthcare must be a central priority. When government facilities are overcrowded, understaffed, or unable to provide timely diagnostics, medicines, or specialist care, people are pushed into the private sector regardless of cost. This is not choice; it is compulsion. Over time, such compulsion erodes trust in public institutions and weakens the social contract that once defined Kerala’s health system. A people-centred approach demands renewed investment in public hospitals, primary care, diagnostics, and drug availability, so that public facilities once again become the first and trusted point of care.

Third, the system must be organised around continuity of care, not isolated visits. Kerala’s population is ageing rapidly, and chronic illnesses now dominate health needs. Yet patients are often left to move between hospitals, departments, and providers without coordination or follow-up. There is no single system that takes responsibility for a patient’s journey across time and levels of care, particularly for the elderly, those with long-term illness, or families requiring repeated treatment. A people-centred system ensures that care follows the patient—not the other way around—and that services are designed around life-long needs rather than episodic encounters.

Fourth, health workers must be treated as partners, not expendable resources. Doctors, nurses, and paramedical staff carry the daily burden of system failures, yet their voices are rarely part of reform processes. Burnout, contractual insecurity, delayed payments, and unsafe workplaces directly affect patient care. Repeated protests, court interventions, and public incidents have exposed a system that listens only after damage has occurred. A people-centred health system protects those who protect public health, values professional judgement, ensures workplace safety, and creates conditions where staff can focus on care rather than survival.

Fifth, quality and patient safety must be non-negotiable. Access without quality erodes trust and dignity. Citizens must be confident that care provided in public facilities meets basic standards of safety, competence, and respect. This requires clear standards, routine monitoring, and the courage to acknowledge and correct failures rather than deny them. Avoidance of scrutiny and reluctance to admit gaps have repeatedly delayed corrective action, allowing risks to persist. Transparency strengthens health systems; silence weakens them.

Sixth, affordability must once again define public healthcare. Rising out-of-pocket expenditure is not a secondary concern; it is a warning sign. For many households, health expenses now represent one of the largest sources of financial stress, particularly for chronic illness, elderly care, diagnostics, and specialised treatment. When families fear medical costs, they delay care, avoid follow-up, or fall into debt. A people-centred health system measures success not only by clinical outcomes, but by whether citizens are protected from financial distress when they fall ill.

Seventh, Kerala’s future health security depends on strong public health and prevention. Climate change, zoonotic diseases, migration, and urban crowding demand constant readiness, not episodic response. Surveillance, community outreach, early detection, and preparedness save both lives and resources. Repeated outbreaks and emergency responses have exposed gaps in staffing, coordination, and sustained preparedness between crises. Public health functions must be visible, funded, empowered, and professionally led—not activated only when emergencies occur.

Finally, a people-centred health system requires openness and respect for public dialogue. Health systems improve when professionals, civil society, and communities are heard. Treating criticism as opposition and feedback as political risk weakens governance and public trust. Over time, such defensiveness narrows institutional learning and discourages honest internal assessment. Political leadership in health must be confident enough to listen, correct course, and engage transparently with evidence and experience.

This section sets the direction for reform. It is not a list of slogans or promises, but a statement of intent rooted in Kerala’s values and present realities. The recommendations that follow translate this people-centred vision into concrete actions—actions aimed at restoring trust, strengthening public services, protecting families from financial harm, supporting frontline workers, and preparing Kerala’s health system for the demands of an ageing, more complex, and more uncertain future.