Social Service

Major Health Problems In Kerala

Communicable Diseases

Kerala is witnessing an increasing burden of communicable and non-communicable diseases. Although the State has been successful in controlling a number of communicable diseases earlier, the emergence of Dengue, AIDS, Malaria, Leptospirosis, Hepatitis, Chikungunya, and H5N1 in recent years has led to considerable increase in morbidity and mortality.

Bird Flu

The bird flu, highly infectious virus strain, has affected largely the southern districts of Kerala viz., Pathanamthitta, Kottayam and Alappuzha during 2014, and Kottayam and Alappuzha during 2016. There have been no reports of the virus affecting humans. Avian influenza, commonly called bird flu, is an infectious viral disease affecting birds. Influenza virus circulating in animals poses threat to human health. Humans can become ill when infected with viruses from animal sources. Controlling the disease in animals is the first step in decreasing risks to humans. According to the World Health Organisation, while millions of fowls have died due to the Avian Influenza, 452 human deaths (zero in India) have been recorded globally between 2003 and 2016.


Leptospirosis has been causing a large number of deaths during the last few years in the State. Out of the 510 Leptospirosis cases reported in 2012, 11 deaths were reported. The number of cases increased to 613 with 15 deaths during 2013. During 2014, a total of 717 cases were confirmed resulting in 19 deaths. During 2015, 666 cases and 15 deaths have been reported. Number of patients treated during 2016 was 13339 and death reported was 21 which are slightly higher compared to previous years. The details of district wise patients treated for leptospirosis and death reported during 2016 is given in Appendix 4.52.


It is estimated that around 2.4 million people in India are currently living with HIV. Kerala State Aids Control Society is the pioneer organization in the State working with the objective of controlling the spread of HIV as well as strengthening the State’s capacity to respond to HIV/AIDS. It was formed to implement the National Aids Control Programme in the State.

In Kerala, the prevalence of HIV / AIDS is 4.95 per cent among injecting drug users (IDU), 0.36 per cent among men having sex with men (MSM) and 0.73 per cent among Female Sex Workers (FSW). The HIV prevalence among FSWs and MSM is nearly 1 per cent, but the prevalence among IDUs is 4.95 per cent, though it shows downward trend from 9.57 per cent in 2007, 5.3 per cent in 2008 and 4.95 per cent in 2011. Current data suggest that the HIV epidemic in the State is largely confined to individuals with high risk behaviour and their sexual partners.


During 2006, Chikungunya emerged as a major epidemic in India affecting 151 districts in 8 States including Kerala. During 2011, while 58 chikungunya cases were reported in Kerala, it increased to 169 cases during 2013. Among the districts, highest number of cases (149) was reported in Thiruvananthapuram and 11 cases were reported in Idukki. During 2014, out of the 139 cases of chikungunya reported 106 were from Thiruvananthapuram. During 2015, 104 cases were reported and 99 were from Thiruvananthapuram district alone, it was 106 and 77 respectively during 2016 (up to September). A total of 2,046,455 viral fever cases were reported in Kerala during 2014 and in 2015 it was 1,925,690 cases. It was 2,040,667 cases during 2016 (upto September 2016). The details of district wise patients treated for Chikungunya and viral fever during 2016 (up to September) is given in Appendix 4.53.


The National Leprosy Eradication Program (NLEP) of the Government of India is implemented throughout the State for the control and eradication of leprosy. It has become a Centrally Sponsored Program with 60 percent funding support from Central Government from 2015-16 onwards.

Kerala is a low endemic state for leprosy. The Annual New Case Detection Rate (ANCDR) is 1.88 per lakh population and Prevalence rate (PR) is 0.17 per 10,000 (as on October 31, 2016). Kerala contributes 0.45 per cent of the total annual case detection in India. Total number of leprosy cases under treatment in Kerala as on September 30, 2016 is 745. The number of reconstructive surgeries done during the year was 26 in 2015-16 and 6 in 2016-17 (up to September). During 2015-16, MCR chappals distributed was 587 and self-care kits distributed was 230. The same were 102 and 89 respectively during 2016-17 (up to October). The present scenario of leprosy is given in Appendix 4.54. There are three leprosy sanatoriums in Kerala with bed strength of 1692 and the details of leprosy cases during 2016 are given in Table 4.10.

Table 4.10
District wise distribution of Leprosy unit in Kerala, 2016

Sl No. District Institutions Sanctioned Bed Strength IP as on 31st Oct. -2016
1 Alappuzha Leprosy Sanatorium, Nooranadu 767 184
2 Thrissur Koratty Gandhi Gram Govt. Dermatology Hospital 660 173
3 Kozhikode Govt. Leprosy Hospital, Chevayoor 265 100
Total 1692 457

Source:Directorate of Health Services

Non Communicable Diseases

Common non–communicable diseases causing serious threat to life are cancer, diabetes, cardio vascular diseases and lung diseases. Unless interventions are made to prevent and control non-communicable diseases, their burden is likely to increase substantially in future, due to ageing population and changes in life style. Considering the high cost of medicines and longer duration of treatment, this constitutes a greater financial burden to low income groups.


Cancer is a major life threatening disease that is affecting many sections of human population. Every year, nearly 35,000 new cases of cancer are getting detected in Kerala. Nearly 1 lakh people are under treatment for this disease annually. Apart from Medical Colleges, Regional Cancer Centre, Malabar Cancer Centre and Cochin Cancer Centre, the hospitals in Government sector offer treatment for cancer patients. Delay in early detection, huge treatment cost, minimal treatment centres and lack of awareness contribute to high mortality rates due to this disease.

Malabar Cancer Centre

Malabar Cancer Centre, Kannur, an autonomous centre under the Government of Kerala, has been established with the aim of providing oncological care to the people of north Kerala. The Centre has bed strength of 200 and many latest facilities for the treatment of cancer patients. During 2015-16, a total of 60203 patients were treated in Malabar Cancer Centre including 3790 In-Patients and 56413 Out-Patients. The average number of new cases detected every year is 4034.

Indian Institute of Diabetes

The Indian Institute of Diabetes (IID), Thiruvananthapuram, is an autonomous institution under the Government of Kerala. It has been functioning for the last two decades and is the only institution under the Government offering services exclusively for Diabetes Mellitus and its complications. IID made operational in the year 2001, functions with main centre at Pulayanarkotta near Akkulam in Thiruvananthapuram city and one sub centre at Public Health Laboratory Campus, in Pattoor, Thiruvananthapuram. The major activities of this institute are to investigate the genetic basis of diabetes, to provide adequate training for physicians and paramedical staff, to provide research support to develop novel methods of treatment, to endow academic chairs in diabetes, and to organize state-of-the-art conferences in India on various aspects of the disease. Total bed strength of the IID is 60. Average number of new cases detected every year is between 300 to350. Out Patient treated in 2015-16 was 43,650, IP was 102 and new cases were 215.

Prevalence Of Other Public Health Diseases During 2015 And 2016

A comparative analysis of the prevalence of public health diseases during 2015 and 2016 is given in Table 4.11.

Table 4.11
Prevalence of Public Health Diseases during 2015 & 2016

Sl.No. Diseases 2015 2016*
Attack Death Attack Death
1 Diarrheal Diseases 448374 2 351427 8
2 Enteric fever 2862 0 2780 4
3 Measles 1782 0 1197 0
4 Chickenpox 17798 0 14711 1

*upto September
Source: Directorate of Health Services

Mental Health

As per Census of India 2011, 0.20 per cent of the population of Kerala suffers from mental illness and 0.20 per cent suffers from mental retardation compared to a national average of 0.06 per cent and 0.12 per cent respectively. Although Kerala reports higher levels of mental illness compared to all India, less importance is given to the field of mental health in Kerala.

A mental health policy was approved by the state government in May 2013. The policy suggests that the treatment for mental illness should start from the primary health centres making the mental hospitals and the Department of Psychiatric Medicines as referral centres by upgrading them. Research should be encouraged for prevention and cure of mental illness. An awareness programme among the general public about mental illness has also been suggested in the policy. Proper training should be imparted to the doctors free of cost whether they come from public or private sector if they show their willingness to undergo the training. The new State Mental Health Policy envisages convergence of various departments for the care and rehabilitation of the mentally ill.

In Kerala three mental health centres are functioning with bed strength of 1366. District Mental Health Programme is functioning in all the districts with a total of 10,080 OP per month. Rehabilitation facilities are offered through these centres. Lack of awareness, attitude of general public, neglect of family members, and lack of proper follow up are the major problems noticed in this area. State Government has started 26 day care homes and 506 cured mentally ill patients are being given day care.

Delivery, Maternal Death and Maternal Mortality Ratio

On the basis of the reports of Directorate of Health Services, the number of deliveries during 2013-14 was 4,93,534 and maternal death reported was 182 and MMR 37 which was higher compared to the maternal death 165 and MMR 33 of 4,95,613 deliveries during 2012-13.Total number of deliveries during 2014-15 was 4,94,479 and maternal death was 158 and MMR 32. Maternal death and MMR has reduced during 2014-15 compared to previous years.Total number of deliveries during 2015-16 was 4,81,388 and the maternal death reported was 161 and MMR 33.

Modern Medicine - Allopathy

Modern medicine services in the state are offered by the Directorate of Health Services (DHS).Directorate of Medical Education (DME) deals with the education aspects of modern medicine.

Health Care Institutions under DHS

At present there are 1281 health institutions with 38,302 beds and 5,335 doctors under Health Services Department consisting of 849 Primary Health Centres, 234 Community Health Centres, 79 Taluk Head Quarters hospitals, 18 District hospitals, 18 General hospitals, 3 mental health hospitals, 8 W and C hospitals, 3 leprosy hospitals, 17 TB clinics, 2 TB hospitals, 5 other specialty hospitals and 45 other hospitals. Primary health centres are institutions providing comprehensive primary care services including preventive care and curative care. CHCs and Taluk level institutions form the basic secondary care institutions. District hospitals, General Hospitals and Maternity Hospitals provide specialty services and some super specialty services. In the 13th Five Year Plan focus will be on the implementation of the specialty cadre in all health care institutions up to the level of community health centres and modernization of the functioning of the PHCs as Family Health Centres.The bed population ratio in Kerala is 872 and the average Doctor Bed Ratio is 7.18. Category wise major medical institutions and beds in Kerala, details of IP, OP cases, major and minor operations conducted and Medical and Para medical personnel under DHS during 2016 are given in Appendix 4.55, Appendix 4.56 and Appendix 4.57.

Financial Protection Against Catastrophic Health Care Expenditure

Rashtriya Swasthya Bima Yojana (RSBY) is a Health Insurance Scheme, sponsored by the Government of India, for providing free and quality inpatient care to the families falling below poverty line (BPL) in the society. The scheme promises inpatient treatment facility upto Rs.30,000/- on paperless, cashless and floater basis to a maximum of five members in a family, for a period of one year through selected public and private hospitals with a prefixed medical and surgical rates for treatment in general ward. RSBY does not cover outpatient treatment cases. Minimum period of 24 hour inpatient treatment is required for getting the benefit under the scheme. More than 1100 surgical procedures with prefixed rates are included in the benefit package.

Government of India pays 75 per cent of the premium and the State pays the rest. Three important features of RSBY are (i) there is no age limit for joining the scheme; (ii) it covers existing diseases; and (iii) a transport allowance of Rs.100 is being paid in cash to thepatient at the time of discharge from the hospital. Maximum transportation allowance payable in a year is restricted to 1,000. It has a component to pay the wages foregone as well.

As the BPL population according to the definition adopted by the State is over and above the Planning Commission estimate by more than 10 lakhs, the State Government formulated its own Scheme for catering to the needs of the additional 10 lakh population. These two schemes are being jointly run under the banner COMPREHENSIVE HEALTH INSURANCE SCHEME (CHIS). A special purpose vehicle by name CHIAK (Comprehensive Health Insurance Agency, Kerala) has been formed and entrusted with the task of running the schemes.

Government of India extended the scheme to cover families of the participants of Mahatma Gandhi National Rural Employment Guarantee Scheme who have worked for more than 15 days in the previous year, street vendors, and domestic workers. Overall, workers in the unorganised sector are being covered by the scheme in increasing numbers. The State has been trying to bring other categories of population into the CHIS net. In 2014-15, the Government sought to bring the members of the various welfare fund boards and its pensioners, all Scheduled Caste and Scheduled Tribe population, and families engaged in fishing and workers of various unorganized sectors. The two schemes together cover a sizeable proportion of the population in the State. The progress of the scheme is presented in Table 4.12. The number of families covered has steadily increased to reach 32.54 lakh by 2016-17.

Table 4.12
Progress of RSBY/CHIS

Year Number of Families Enrolled (Lakh) Premium Paid Number of Claims Claims Paid (crore)
2008-10 11.78 51.27 1.64 56.00
2010-11 18.75 80.49 3.65 125.00
2011-12 28.01 205.00 6.99 211.00
2012-13 28.28 310.00 7.00 198.00
2013-14 29.73 219.49 5.57 172.15
2014-15 31.94 235.77 5.87 194.18
2015-16 31.94 216.48 5.25 159.92
2016-17* 32.54 167.03 2.94 81.79

Source: CHIAK
*Upto September 2016

Financial protection in the form of RSBY offered the option of using private sector services by all those enrolled in the scheme. Interestingly, instead of the proportion of users of the private institutions increasing over the years, the share of the government hospitals in the total has steadily increased (Table 4.13).

Table 4.13
Utilisation of CHIS by Sector

Year Claim Settlement by Sector ( Count in lakh and amount in crore)
Govt. Hospitals Pvt. Hospitals Total
Count Amount per cent Count Amount per cent Count Amount
2008-10 0.48 18 40 0.95 27 60 1.43 45
2010-11 1.44 52 46 2.16 61 54 3.60 113
2011-12 3.78 119 56 3.20 93 44 7.00 212
2012-13 4.82 125 70 2.18 56 30 7.00 181
2013-14 4.02 143.13 72 1.56 55.9 28 5.58 199.03
2014-15 4.16 158.7 70 1.7 69.36 30 5.86 228.06
2015-16 3.71 145.32 71 1.53 60.27 29 5.24 205.59
2016-17 1.97 81 64 0.98 45.02 36 2.95 126.02

*Upto September 2016
Source: CHIAK

A new scheme for providing tertiary care treatment with a benefit package of maximum Rs.70,000 for critical illness like cancer, cardiac and renal failure to all the RSBY and CHIS card holder families was designed during 2010-2011. The scheme, named as CHISPLUS, was launched by the middle of February 2011.The Coverage of CHISPLUS has been extended by including diseases relating to Liver, Brain and treatment of Accident Trauma care during 2012.The scheme is implemented through all the five Government Medical Colleges in the State, Regional Cancer Centre, Thiruvananthapuram, Malabar Cancer Centre and all Government District Hospitals, General Hospitals, and Taluk Hospitals. The scheme is monitored by CHIAK with the help of software developed by Keltron. The scheme, implemented through a non-insurance route, has benefited 2,91,812 patients upto September 2016 and the claims have totalled 312.56 crore.

The RSBY benefit package does not cover tertiary care. The CHIS Plus covers limited tertiary care for the population groups registered under the scheme. This leaves out the other groups for whom tertiary care treatment becomes unaffordable. Realising the need for intervention in this area, a new scheme was designed called Karunya Benevolent Fund (KBF) to meet the tertiary care expenditure of deserving individuals. Unlike the CHIS, which is a cashless scheme, the KBF requires a prior authorization. The amount is paid to the hospital which has to submit the utilisation certificate. In addition, there is also provision to provide a one-time assistance of Rs 3,000 per family. Treatment can be availed at all government hospitals and empanelled private hospitals. (Table 4.14)

Table 4.14
Progress of the CHIS Plus Scheme

Year Number of Patients Amount crore
2010-11 158 0.29
2011-12 14453 26.08
2012-13 42228 56.94
2013-14 50945 53.08
2014-15 66738 68.03
2015-16 80017 73.42
2016-17* 37273 34.72

*Upto September 2016
Source: CHIAK


Arogyakiranam was one of the flagship Health programs of the Government of Kerala. The program provides free treatment and related medical services to all patients from birth to 18 years, as an entitlement. Expenses covered by this entitlement include costs incurred for OP registration, investigations, drugs/ implants/ materials used in treatment and procedures. The fund for coverage of treatment expenditure was allotted to districts, to be maintained as corpus fund, from which all said expenses were debited. During the period October 2013- April 2016, this scheme benefited 1, 04, 81,613 patients.

National Health Mission

National Health Mission (NHM) is the major Centrally Sponsored Schemes on health sector relevant to Kerala. The scheme is categorized as ‘Core Scheme’ with funding pattern 60:40 between Centre and State. This umbrella scheme includes the following schemes

a. National Rural Health Mission

b. National Urban Health Mission

c. Tertiary care Programmes

d. Human Resources in Health and Medical Education

e. National Ayush Mission

NHM has five financing components to the States, namely (i) NRHM/RCH Flexi-pool, (ii) NUHM Flexi-pool(iii) Flexible pool for Communicable Diseases (iv)Flexible pool for Non Communicable Diseases including injury and trauma and (v) Infrastructure Maintenance. Under the component of infrastructure maintenance, support has been given over several Plan periods, to States to meet salary requirement of Schemes viz. Direction and Administration (Family Welfare Bureaus at State and district level), Sub Centres,Urban Family Welfare Centres, Urban Revamping Scheme (Health Posts), ANM/LHV Training Schools, Health and Family Welfare Training Centres, and Training of Multi-Purpose Workers (Male).

NHM is functioning in the State for the development of health institutions with Central Government funding. 40 per cent of the cost has to be borne by the State Government as State share. NHM is supporting the Health Services Department, Directorate of Medical Education and AYUSH Departments. National Rural Health Mission aims to provide accessible, affordable and accountable quality health services to the poorest households in the remote rural regions. Under NRHM, the focus is on a functional health system at all levels, from the village to the district. Total GoI release to the State during 2014-15 was 224.94 crore, in 2015-16 it was 219.19 crore and in 2016-17 it was 163.51 crore (upto October 2016).

Pradhan Manthri Swasthyasuraksha Yojana (PMSY)

Pradhan Manthri Swasthya Suraksha Yojana is a Government of India supported scheme to improve infrastructure facilities and technology in Government Medical College, Thiruvananthapuram (Phase I) and Kozhikode and Alappuzha (Phase III) with a total outlay of 150 crore each of which 30 crore is the State share. The project for Government Medical College, Thiruvananthapuram (Phase I) has already been completed and the rest are ongoing during 2016-17.

State Institute Of Medical Education And Technology (Si-Met)

State Institute of Medical Education and Technology (SI-MET) was established in the State in 2008 to promote medical education and research. There are seven nursing colleges functioning under SI-MET with an annual intake of 340 students. A total of 838 students are studying in the Nursing Colleges of SI-MET as on October 2016.

Child Development Centre (CDC)

Child Development Centre (CDC), an autonomous centre established by the Government of Kerala, is a centre of excellence in Early Child Care and Education, Adolescent Care and Education, Pre-marital Counseling, Women’s Welfare and other related fields to reduce childhood disability through novel scientific initiatives.It aims to create a generation of prospective and responsive parenthood through healthy children and adolescents. The number of patients treated during 2015-16 was 14,174 and 2016-17 (upto October) was 9087.Only Out-patient services are available and there is no facility for admitting patients.

Drugs Control Department

The responsibility of the Drugs Control Department is to ensure the availability of quality drugs to the public and see that the market is free from counterfeit, spurious and substandard drugs and no drugs are sold at a price higher than the retail price marked on the container. The Department has 6 Regional Offices, 11 District Offices, 4 Ayurveda Wing Offices and 2 Drugs Testing Laboratories. Drug testing laboratories are functioning at Thiruvananthapuram and Ernakulam. Major achievements of the department during 2015-16 is given in Table 4.15.

Table 4.15
Major achievements of the Drugs Control Department during 2015-16

Number of Inspections conducted 16844
Number of Prosecutions Initiated 96
Number of sale Licences Suspended as Deterrent Measure 635
Number of Samples Tested 5528
Number of new Manufacturing Licenses Issued (Allopathy and Cosmetics) 25
Number of Price Violations detected and reported to NPPA 50
Number of New Blood Bank Licenses Issued 8

Source: Drugs Control Department

Medical Education

In Kerala, Medical Education is imparted through 11 Medical Colleges at Thiruvananthapuram (2), Alappuzha, Kozhikode, Kottayam, Manjeri, Idukki, Ernakulum, Konni, Kollam and Thrissur districts and Nursing Education through 6 Nursing Colleges in Thiruvananthapuram, Kozhikode, Kottayam, Alappuzha, Ernakulam and Thrissur districts. Five Dental Colleges are functioning at Thiruvananthapuram, Kozhikode, Alappuzha, Thrissur and Kottayam districts. Besides, four colleges of Pharmacy and one Paramedical Institute is functioning under the Department.

Medical and Para medical courses conducted in Government Medical Colleges with annual intake of students, details of clinical and non-clinical personnel in Medical Colleges under DME, during 2015-16 are given in Appendix 4.58 and Appendix 4.59. A comparative analysis of the status of medical college hospitals and attached institutions during 2015 and 2016 is given in Table 4.16.

Table 4.16
Status of Medical College Hospitals and Attached Institutions during 2015 and 16

Medical College Hospitals Beds Inpatients Outpatients Major Operations conducted
2015 2016 2015 2016 2015 2016 2015 2016
Medical College Thiruvananthapuram 2637 2941 89826 116169 1043789 368380 16716 15115
SAT Hospital Thiruvananthapuram 502 502 18127 13143 100201 75373 990 794
Medical College Alappuzha 1125 1051 62398 57134 912092 909174 1743 3180
Medical College Kottayam 1463 1722 73126 74863 769027 871670 5623 14765
ICH Kottayam 203 170 9614 8454 162454 173719 1289 504
Medical College Thrissur 800 1436 35427 37954 193124 277943 15450 7793
ICD Thrissur 475 330 29146 718 325039 8681 Nil NIL
Medical College Kozhikkode 2200 2694 81324 73927 484651 1032065 8671 11788
IMCH Kozhikkode 1200 740 41290 39065 92456 188241 2198 2076
ICD Kozhikkode 140 110 4218 3887 58901 55132 Nil Nil
Medical College Idukki 192 192 7830 20837 139185 88321 928 597
Medical College Ernakulam 500 500 4057 5537 66818 75932 1244 1563
Medical College Manjeri 637 637 29146 29146 116791 828057 6636 3841
Total 12074 13025 485529 480834 4464528 4952688 61488 62016

Source: Directorate of Medical Education

An increase of 951 numbers of beds has increased the bed strength to 13025 during 2016 in Medical College institutions compared to previous year figure of 12074. The number of outpatients and major operations conducted has increased during 2016.Major achievements of Medical Education Department during 2016 include;

  • Successfully fulfilled Heart Transplantation Surgery in Kottayam Medical College
  • Conducted administrative improvement training for 230 faculties
  • Initiated steps for implementing e-governance
  • Completed construction of Poly Trauma Building in Medical College, Trivandrum.
  • Construction of corridor connecting OP Block
  • Burns unit put in motion in Medical Colleges, Trivandrum and Thrissur
  • Construction of Multi-disciplinary research lab in Trivandrum Medical College
  • Started construction of Super Specialty block and administrative block in Medical College, Alappuzha
  • Construction of Clinical Skill Laboratory in H1 and h4 block of Alappuzha Medical College hospital.
  • Construction of Tertiary Cancer Centre in Kozhikode Medical College having estimate of Rs. 45 Crores is carrying on through financial assistance of central government

Kerala University of Health and Allied Sciences

Kerala University of Health Sciences was established as per the Kerala University of Health Science Act 2010 with the aim of ensuring proper and systematic instructions, teaching, training and research in Modern medicine, Homoeopathy and Indian System of Medicine and allied health sciences in Kerala. Academic activities of the University has commenced in academic year 2010-11. The number of institutions affiliated to University is 282 (upto October 2016) with 32 Government colleges, 5 Government Aided Colleges and 245 Self-financing Colleges. The colleges fall under all systems of medicine such as Allopathy, Ayurveda, Homoeopathy, Sidha, Unani, Yoga, Naturopathy, Nursing, Pharmaceutical Science and Paramedical courses. The annual intake of students is almost 20,000 under various health sciences stream. Details of the Government, Aided, Unaided colleges affiliated under various streams is given in Table 4.17.

Table 4.17
Details of the Government, Aided and Unaided colleges affiliated under various streams in number

Stream Government Aided Unaided Total
Medicine 9 0 24 33
Ayurveda Medicine 3 2 11 16
Homoeo Medicine 2 3 0 5
Dental 5 0 20 25
Sidha Medicine 0 0 1 1
Unani Medicine 0 0 1 1
Nursing 5 0 114 119
Paramedical 4 0 36 40
Pharmacy 4 0 37 41
Ayurveda Pharmacy 0 0 1 1
Total 32 5 245 282

Source: Kerala University of Health and Allied Sciences