• Social Services
• Medical and Public Health

Health and Sanitation- Medical and Public Health

Improvement in health status of the people is one of the crucial areas in social development of a community. This can be achieved by improving the access to health services especially for the underprivileged people. Kerala has achieved a good health status compared to other States in India. Easy accessibility and coverage of medical care facilities, apart from other social factors such as a high literacy rate, well-functioning public distribution system, less exploitation of the workers due to the presence of workers organisations etc. have played a leading role in influencing the health system in Kerala. The Peoples Campaign for Decentralised Planning initiated in 1996 helped improve infrastructure and service in primary and secondary healthcare institutions and widened healthcare delivery. In Kerala, both modern medicine and AYUSH systems play a crucial role in providing universal access and availability to the poorer sections of society.

Kerala has made significant gains in health indices such as high life expectancy, low infant mortality rate, birth rate, and death rate, etc. The State must ensure that it sustains the gains achieved. Further, the State is also facing problems of Life Style Diseases (Non Communicable Diseases) like Diabetes, Hypertension, Coronary Heart Disease, Cancer and geriatric problems. Increasing incidences of Communicable Diseases like Chikungunya, Dengue, Leptospirosis, Swine Flu etc. are also major concerns. Other than these, there are new threats to the health scenario of the State, like mental health problems, suicide, substance abuse and alcoholism, adolescent health issues and rising number of road traffic accidents. The health status of the marginalised communities like adivasis, fisher folk etc. is also poor compared to the general population. To tackle these, concerted and committed efforts with proper inter sectoral co-ordination is essential.

Health Indicators of Kerala

Comparative figures of major health and demographic indicators at State and National level are given in Table 4.2.1.

Working Groups on Health Sector for 13th Five-Year Plan

The State Planning Board had constituted separate Working Groups for Medical and Public Health and Ayush for the 13th Five-Year Plan Period. The Working Groups identified priority areas in health sector for the 13th Five-Year Plan and the reports have been submitted and published. The recommendations of the Committee are being incorporated in the schemes of the health sector.

Major Recommendations of Working Group

I.Ayush

Indian Systems of Medicine (ISM)

• Developing ISM institutions to Indian Public.
• Health/Kerala Accreditation Standards for Hospital standards.
• Providing Specialty service in district and taluk hospitals.
• Formation of Ayurveda tourism consortium to tap tourism potency of Ayurveda.

Directorate of Ayurveda Medical Education (DAME)

• Develop Government Ayurveda college hospitals as tertiary specialty care centres.
• Establish New Ayurveda colleges.
• Establish State Research Institute for revalidating Ayurveda to evidence based medicine.
• Implement e-Health programme

Homoeopathy

• Implement e-Health programme.
• Develop HOMCO (The Kerala State Homoeopathic Co-operative Pharmacy Ltd).
• Establish Drug Control Wing for Homoeopathy.
• Establish Directorate of Homoeopathic Medical Education.

II. Medical and Public Health

• Implement Aardram Mission
• Develop Primary Health Centres into Family Health Centres
• Standardisation of the District and Taluk Level hospitals
• Implement e-Health programme to create centralised database of healthcare information and for close monitoring of public health problems and for speedy implementation of control measures
• Establish Public Health Cadre
• Implement a Human Resource Development Planning in health sector for the State

Approach for the 13th Five-Year Plan

• Provide the best possible preventive, curative, and palliative care in the public sector.
  • Expand insurance coverage.
  • Achieve total sanitation, waste disposal and mosquito eradication.
  • Improve infrastructure in public sector.
• Make Aardram Mission a success by
  • Making Primary Health Centres as Family Health Centres.
  • Providing quality treatment services at secondary level.
  • Creating a Patient Friendly Environment in government hospitals.
• Promote study and research in different branches of Ayurveda.

Aardram Mission

Government has identified 170 PHCs covering all 14 districts for developing into Family Health Centers in 2017-18. Additional posts of one Medical Officer, two staff nurses and one lab technicians each were created and postings were done with the result that there will be a minimum of 3 doctors and 4 nurses in the Primary Health Centres. 29 Family Health Centres are already inaugurated and made functional and another 26 is ready for inauguration. Transformation of the PHCs into Family Health Centers is very well accepted by the society and the community response is found to be very encouraging. Service delivery of these institutions in terms of clinical care and public health activities have been augmented and outpatient care is provided in the afternoon upto 6.00 PM. Through the implementation of e-Health project it is expected to further develop individual patient care Plan and family health Plan based on family health register data. Registration procedure for e-Health services has already been initiated.Ward and Panchayath level health Plan focusing on preventive, promotive and rehabilitative health care services would be developed in association with Panchayaths and with public participation. A new health volunteer system called Arogyasena is being launched as part of Aardram mission. Public health interventions focusing on the reorganisation of the primary health care system based on the epidemiological needs of the Kerala society especially of non-communicable diseases is a focus area of the programme. Treatment guidelines for 53 common medical conditions to be managed at PHC level have been prepared and made available for Medical Officers. Revised job responsibilities and Family Health Care transformation guidelines have already been prepared and module based trainings have been initiated for major categories of staff.

Considering the fact that medical college hospitals and district level hospitals are larger institutions providing outpatient care for so many thousands of patients every day, patient friendly transformation of the outpatient wings of these hospitals were taken as a priority item under Aardram Mission. Outpatient transformation with adequate OP registration counter, patient waiting area, adequate seating facility, token system with other patient amenities like drinking water, toilet facilities, public address system, information education and communication arrangements and signage systems are being incorporated. Support of patient care coordinators for larger institutions on a temporary basis would also be provided. For ensuring quality medical care, OP computerisation, providing adequate facilities in the consultation rooms and a guideline based case management are planned. Civil modification works have been initiated in Government medical college hospitals and work will be started soon at district level hospitals.

e-Health Project

The e-Health Project targets to link health institutions all over Kerala. The project aims to build a database of individual medical records easily accessible to the medical practitioners. It includes unique patient identification in different settings and exchange of data between different health care delivery units at primary, secondary and tertiary level across State. This could avoid the repeated medical tests and can thereby reduce rush in clinics and labs and out of pocket expenses. The scheme is envisaged to be implemented in seven districts of Kerala with Thiruvananthapuram as the pilot district.

National Health Policy 2017

India has drafted the National Health Policy twice, once in 1983 and in 2002, which has guided the approach towards the health sector in Five-Year Plans. Fourteen years later, a revised National Health Policy has been formulated in 2017. It addresses the issues of universal health coverage, reduction in maternal mortality and infant mortality, access to free drugs and diagnosis and changes in laws to make them more relevant. The primary aim of the National Health Policy, 2017, is to strengthen and prioritise the role of the Government in shaping health systems in all its dimensions-investments in health, organisation of healthcare services, prevention of diseases and promotion of good health through cross sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance. Salient features of the National Health Policy 2017 are;

• Increase health expenditure by Government from the existing 1.15 per cent of GDP to 2.5 per cent of GDP by 2025.
• Increase State sector health spending to more than 8 per cent of their budget by 2020.
• Decrease in proportion of households facing catastrophic health expenditure by 25 per cent, by 2025.
• Ensure District-level electronic database of information on health system components by 2020.
• Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
• Increase Life Expectancy at birth from 67.5 to 70 by 2025.
• Reduce under-five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
• Reduce infant mortality rate to 28 by 2019.
• Reduce neo-natal mortality to 16 and still birth rate to single digit by 2025.
• Increase utilisation of public health facilities by 50 per cent from current levels by 2025.
• More than 90 per cent of the newborn are fully immunised by one year of age by 2025.
• Relative reduction in prevalence of current tobacco use by 15 per cent by 2020 and 30 per cent by 2025.

State Health Policy

The Government constituted a 17-member panel headed by Dr B Ekbal, Member, State Planning Board to draft a new health policy for the State. The Committee held sittings in different districts to get the opinions and suggestions from the common man regarding their needs in the health sector and held consultations with all the experts, professionals and people who are closely associated with the health sector before finalising the draft. The committee laid emphasis on strengthening the primary health sector of the State which would play a pivotal role in detection of the diseases and the need for strengthening disease surveillance at the grass root level to prevent the spreading of epidemics. Apart from strengthening the treatment facilities, the committee looked into the need for giving thrust for disease prevention. The policy envisages establishing a publicly funded, free, universal and comprehensive health care system, bringing infant, child and maternal mortality to levels in developed countries and to increase the healthy life expectancy of the population. The draft report is submitted to the government for further action.

Sustainable Development Goal: Targets Set by Kerala

The Government of Kerala has declared the short and medium term targets to be achieved by the State in the health sector. The Sustainable Development Goals (SDG) Framework specifically SDG no. 3, set by the United Nations, was chosen as the reference frame for these goals so that targets finalised by Kerala would be aligned to national and international targets. Targets announced by the UN were examined by the Working Groups for their relevance to the State and were adapted to suit the State’s current epidemiological status and capacity. In addition to the targets listed in the UN documents, Kerala has included targets in Dental, Ophthalmic and Palliative care as they were considered important in the State. The working groups also recommended key strategies to achieve these targets. A survey will evaluate the performance of the State in 2021 to assess the baseline values against which to measure progress towards achievement of the targets.

Health Sector Financing During Plan Periods

Health has been a major area of allocation in the State Budget in the past years. Government healthcare expenditure has been showing a steady increase in recent years. Even then, Kerala invests less than five per cent of its total State Plan outlay on health care excluding the contribution of LSG and other line Departments. The outlay earmarked for the implementation of schemes during 12th Five-Year Plan was 331,888.00 lakh (BE). The total expenditure reported during the Plan period was 300,600.50 lakh (90.57 per cent). During the first year of 13th Five-Year Plan (2017-18), 131,495 lakh had been allotted for Health Sector. Of which 26.88 per cent was expended upto September 2017. Department-wise Plan outlay and expenditure during the last four Annual Plan period and total outlay and expenditure upto September 2017 (2017-18) is given in Table 4.2.2.

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, Chikungunya, Leptospirosis, Malaria, Hepatitis, H1N1, in recent years has led to considerable morbidity and mortality. Instances of vector borne diseases like Dengue, Malaria, Japanese encephalitis, scrub typhus etc. have seen a marked increase in many districts. Water borne infections like different kinds of diarrhoeal diseases, Typhoid and Hepatitis are showing persistence in many districts. Cholera has surfaced in many districts after few years of relative low incidence. Vaccine preventable diseases like diphtheria and whooping cough are yet to be eliminated despite years of effort. Deaths due to many of these diseases are now drawing attention of national and international organisations to our State, which once was considered a model for many national programs.

Dengue

Dengue fever, which surfaced in Kerala as early as 1998, has now become the single largest cause of vector borne diseases. Till 2015, the disease was more prevalent in districts like Thiruvananthapuram, Kollam, Kottayam, Pathanamthitta, Kozhikode and Malappuram. But in 2017, all the Districts reported Dengue in large numbers. No District was spared. Districts located at higher altitudes were having low prevalence, but all others showed high incidence. The main reason for this wide spread distribution is believed to be due to the changes in the environmental factors causing proliferation of the Dengue vector-Aedes mosquitoes. These mosquitos, which in the earlier days were seen more in rural settings has now spread to both rural and urban areas. The underlying causes for this spread are changes in human behaviour, clubbed with changes in bionomics of the mosquito and climatic changes.

Leptospirosis

Leptospirosis is another emerging public health challenge faced by the State. Considered as a rare disease in the early 80’s, it has now spread to all districts. In 2012-13 a major epidemic of the disease occurred, affecting most of the northern districts, following which the disease has become endemic in Kerala. The disease is initially a rodent borne infection, spread through urine of the infected rodents, and the consequent contamination of the environment is the factor responsible for the disease. Over the years, the disease has been reported in many domestic animals like cows, dogs, pigs etc. and thus has become an occupational risk for those engaged in agriculture works. People, who have been involved in cleaning of stagnant canals and drains were reported to have contracted the disease. More recently the mortality due to Leptospirosis is also on the rise, and joint efforts of Veterinary and Animal Husbandry departments are essential for effective control of this disease.

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. In 2015, there were 666 cases and 15 deaths reported. Number of patients treated in 2016-17 was 967 and death reported was 25 which are slightly higher compared to previous years. Total number of cases reported in 2017-18 (up to July 2017) was 848 and death reported was 11. The details of district wise patients treated for leptospirosis and death reported during 2016-17 and 2017-18 (up to July 2017) are given in the Appendix 4.2.1.

Chikungunya

Chikungunya is a newcomer among the vector borne infections. This disease believed to have originated in the remote islands in Arabian Sea during 2005-06 period, spread rapidly over whole of Kerala within the next two years, affecting more than 80 per cent of our population. Fortunately, the disease is fading out, and has resulted in life long immunity for the affected population, a blessing in disguise. The past two years have seen only sporadic cases in Kerala, annual total being less than 200 cases and no deaths. Here again the vector responsible for disease transmission is the Aedes mosquitoes. Since both dengue and chikungunya are transmitted by same mosquito, and also since the same mosquitoes are responsible for transmission of the potential threat of Zika virus disease and Yellow fever, the State should be vigilant in future.

In 2011, while 58 chikungunya cases were reported in Kerala, it increased to 169 cases during 2013. Among the districts, highest number of cases was reported in Thiruvananthapuram (149) and lowest in Idukki (11). In 2014, out of the 139 cases of Chikungunya reported, 106 were from Thiruvananthapuram. In 2015, 104 cases were reported and 99 were from Thiruvananthapuram district alone, while it was 90 and 67 respectively during 2016-17. It was 63 and 48 respectively during 2017-18. A total of 2,046,455 viral fever cases were reported in Kerala in 2014, 1,925,690 cases in 2015, 1,541,441 cases in 2016-17, and 2,149,204 in 2017-18.

The details of district wise patients treated for Chikungunya and viral fever in 2016-17 and 2017-18 (up to July) are given in Appendix 4.2.2.

Malaria

Malaria, another vector borne disease, transmitted by Anopheles mosquitoes has been a public health challenge for our country for the past many decades. Various national programmes targeting its elimination was met with limited success. Though Kerala eliminated the disease in early 70s, Malaria is now re-emerging as a public health challenge. The problem is recently aggravated due to the presence of large scale population movement from malaria endemic States. Proportion of Falciparum Malaria, the more severe form of the disease is also slowly on the rise in Kerala. Though elimination of indigenous form of Malaria has been included in the SDG targets by the State, the issues in its fulfillment are many. Rapid urbanisation, extensive infrastructure development in many districts, uncontrolled construction works in urban area, and climate related changes in life cycle of mosquitoes are all big hurdles in the attainment of the SDG goal. Annual cases of Malaria in Kerala are less than 2000 and deaths reported are also very low, but the major issue here is the increase in foci of indigenous Malaria. Thiruvananthapuram, Kollam, Kozhikode, Malappuram, and Kannur districts have pockets of indigenous Malaria over the past few years. Kasargod district is persistently having high number of Malaria, over many years, because of its proximity to the highly endemic districts of Karnataka. Movement of fishermen along the western coast of our State is a potential threat for spread of Malaria along the coastal Districts.

Japanese Encephalitis

This is a form of encephalitis, an inflammatory disease of brain and its coverings, and is also a mosquito borne infection. Due to the presence of large paddy fields, Kerala is also at risk of this disease, as the virus responsible for the disease is spread by Culex mosquitos, which are bred abundantly in water logged areas like paddy fields. The peculiar nature of the culex mosquito to breed in contaminated water also, increases the potential threat in other areas as well. Role of migratory birds in transmission of Japanese Encephalitis (JE) is an extra risk for Kerala, because our State has many attractive sanctuaries for migratory birds. But since there is an effective vaccine against JE, we can be optimistic in its control programme, by strengthening the JE vaccination.

Water-Borne Diseases

There was a decrease in acute diarrhoeal diseases (ADD) in 2017 compared to previous years. There was a considerable decrease in both Hepatitis A and Typhoid in 2017, but death due to suspected Hepatitis increased. This year incidence of ADD was more in Malappuram, Thrissur, Kozhikkode, Palakkad, Thiruvananthapuram and Kannur.Hepatitis A was more in Malappuram, Kozhikkode, Wayanad, Ernakulam, Kollam, Thrissur and Pathanamthitta. Confirmed cases of Typhoid was more in Palakkad district.

The main reason for waterborne diseases is attributed to the unavailability of safe drinking water in many parts of the district especially in tribal and coastal areas. Unhygienic drinking water sources like wells, pump houses, water supplied through tanker lorry, leaks in public water supply pipes and the consequent mixing of foul water with drinking water, dumping of wastes including sewage in water sources, use of commercial ice in preparation of cool drinks, habit of unsafe water in preparation of welcome drinks etc are some reasons for spread of water borne diseases. For prevention and control of communicable diseases, Health Department has formulated a yearlong action Plan called “Jagratha” which will be implemented from November 2017 to December 2018.

HIV/AIDS

It is estimated that around 2.4 million people in India are currently living with HIV source. Kerala State Aids Control Society is the pioneer organisation 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. The society 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 behavior and their sexual partners.

Prevalence of Major Communicable Diseases

A comparative analysis of the prevalence of major communicable diseases is given in Table 4.2.3.

Non-Communicable Diseases

Common non–communicable diseases (NCD)causing great threat to life are diabetes, hypertension, cardio vascular diseases, cancer 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. Rampant modernisation and urbanisation, drastic lifestyle changes, heavy dependency on alcohol and tobacco, affinity for white collar jobs, bizarre eating patterns, low priority for physical exertion, high levels of stress in all strata of population are some of the reasons contributing to the prevalence of NCDs in the State.

In India, it is estimated that 42 per cent of total death are due to NCDs. In Kerala, the situation is more serious as more than 52 per cent of the total death between the productive age group of 30 and 59 is due to NCD. Hypertension, diabetes mellitus, cardio vascular diseases, stroke and cancer are the major non communicable diseases seen in Kerala. Studies show that 27 per cent of Kerala adult males are having diabetes mellitus compared to 15 per cent in India. 19 per cent of adult female population is diabetic compared to 11 per cent in India. Genetic predisposition, dietary habits and sedentary lifestyle are considered to be the reason for this phenomenon. 40.6 per cent of adult males and 38.5 per cent of adult females are hypertensive compared to 30.7 per cent and 31.9 per cent in India. Incidents of obesity, hyper lipedemia, heart attack and stroke are also high. Cancer mortality is extremely high in males in Kerala compared to national average.

In a recent survey conducted by Achutha Menon Centre for Health Science Studies, the NCD scenario in the State has further worsened. The survey reveals that one out of three has hypertension and one out of five has diabetes. The study also revealed that the level of normalcy attained for blood sugar and blood pressure even after early detection and management is significantly low compared to the standards. In adults over 18 years of age, on an average, nearly one of three and one of five adults in Kerala had hypertension and diabetes, respectively. Control status of both hypertension (systolic blood pressure less than 140 mm of hg and diastolic blood pressure less than 90 mm of hg) and diabetes (fasting blood sugar less than 126 mg/dl) were alarmingly low at 13 per cent and 16 per cent respectively of the individuals with hypertension and diabetes. While, the control rates in the western population is over 50 per cent. Additionally, among males, one of four adults reported current use of some form of tobacco and over 30 per cent reported current alcohol use. The proportion of population consuming salt above the recommended level of 5 gm/day was 69 per cent. More than three fourth of the study population (77.8 per cent) reported consumption of less than the recommended three servings of vegetables per day and 86 per cent participants reported consumption of less than two servings of fruits per day. Reduction of tobacco use in Kerala by about eight percentage as per the latest Global Adult Tobacco Survey figures is one of the achievements in the State. The extremely low rates of control of hypertension and diabetes need to be addressed urgently. Risk reduction strategies for all the NCD risk factors (tobacco, alcohol, unhealthy diet and physical inactivity) are being implemented through local self-governments and schools. However in order to enhance the control rates of diabetes and hypertension secondary prevention will have to be enhanced.

Cancer

Cancer is a major disease which has affected a major section of population. Every year, 35,000 new cases of cancer are getting detected in Kerala. Nearly 1 lakh people are under treatment for cancer disease annually. Apart from Medical Colleges, Regional Cancer Centre, Malabar Cancer Centre and Cochin Cancer and Research Centre are the major hospitals in Government sector which offer treatment for cancer patients. Apart from these institutions all the major Government medical colleges also provide cancer treatment. Delay in early detection, huge treatment cost, minimal treatment centres and lack of awareness contribute to high mortality of the 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. In 2016-17, a total of 3,971 in patients and 60,834 out patients were treated in Malabar Cancer Centre. The average number of new cases detected every year in the centre is 4,392.

Mental Health

As per the 2011 Census of India, 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. The State Mental Health Policy, 2013 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 1,366. 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 etc. are the major problems noticed. State Government has started 26 day care homes and 506 cured mentally ill patients are being given day care.

District Mental Health Programme

District Mental Health Programme (DMHP) is functioning in all the 14 districts of the State. Thiruvananthapuram district achieved successful integration of Mental Health into Primary Care by 2014. Now Mental Health Clinics are being conducted in all PHCs and CHCs in the district by trained doctors of the concerned institutions and medicines are made available to patients from their nearest PHCs. Efforts are on to scale it up to the whole State. Around 17,000 patients are receiving treatment every month, from DMHPs in the State. Other activities include information education and communication (IEC) activities for general public to create awareness and reduce stigma, training for doctors, nurses, pharmacists and health workers for integration of mental health into primary care and targeted interventions like substance abuse prevention, suicide prevention, geriatric mental health and stress management. Day Care Centres were started for mentally ill in remission under Comprehensive Mental Health Scheme. Now 26 day care centres are functioning in the State under the scheme. School Mental Health Programme is implemented in the State in association with NHM.

Aswasam: Depression management in Primary Care was started in 170 Family Health Centres across the State. Health workers and staff nurses were trained in screening using PHQ9 and psychological first aid, while doctors were trained in diagnosis and management of depression at Primary Care. Referral Protocol for cases to be seen by DMHP psychiatrist is included in the programme. 4,588 persons have been screened till date, of which 626 were positive for depression. Pharmacotherapy started for 400 and psychosocial intervention for 472.

Modern Medicine

In Kerala modern medical services are offered by the Directorate of Health Services (DHS) and the concerned education sector is dealt by the Directorate of Medical Education (DME).

Health Care Institutions under DHS

At present there are 1,280 health institutions with 38,004 beds and 5,465 doctors under Health Services Department (DHS) consisting 848 Primary Health Centres, 232 Community Health Centres, 81 Taluk Head Quarters hospitals, 18 District hospitals, 18 General hospitals 3 mental health hospitals, 8 W&C Hospitals, 3 leprosy hospitals, 17 TB clinics, 2 TB hospitals, 5 other speciality 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 speciality 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 modernisation of the functioning of the PHCs as Family Health Centres. The bed population ratio is 878 and the average Doctor Bed Ratio is 6.95. Category wise major medical institutions and beds in Kerala, details of IP, OP cases, major and minor surgeries conducted and medical and para-medical personnel under DHS during 2017 are given in Appendix 4.2.3, 4.2.4 and 4.2.5.

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 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 1,100 surgical procedures with prefixed rates are included in the benefit package. Government of India pays 60 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 100 is being paid in cash to the patient 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 lakh, 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 has 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 etc. 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 brought 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 unorganised sectors under CHIS net. The two schemes together cover a sizeable proportion of the population in the State. The progress of the scheme is given in Appendix 4.2.6. The number of families covered has steadily increased to reach 34.83 lakh by 2017-18.

Financial protection in the form of RSBY offered the option of using services of the private sector by all those enrolled in the scheme. Interestingly, instead of the proportion of users of private institutions increasing over the years, the share of the government hospitals in the total has steadily increased. This is given in Appendix 4.2.7.

A new scheme for providing tertiary care treatment with a benefit package of maximum 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 in 2012 by including diseases relating to liver, brain and treatment of accident trauma care.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 357,036 patients till 2016-17 with a total claim of 361.43 crore. This is presented in Appendix 4.2.8.

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. Many among them would appeal for assistance. Perceiving such a need, the State designed a scheme 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 authorisation. 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 3,000 per family. Treatment can be availed at all government hospitals and empaneled private hospitals.

Arogyakiranam

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 expenses were debited. During the period October 2013 to July 2017, this scheme benefited 20,432,275 patients. During 2016-17 alone, the scheme has benefitted 7,642,497 patients.

National Health Mission

The Government of India has launched the National Health Mission (NHM) which includes two sub missions NUHM and NRHM. 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 infrastructure maintenance component,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 total fund has to be given to the NHM 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. There are 83 Urban Primary Health Centres under NHM. Total GOI release to the State in 2014-15 was 224.94 crore, in 2015-16 219.19 crore and in 2016-17 it was 191.94 crore.

Pradhan Manthri Swasthya Suraksha Yojana (PMSSY)

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 in 2017-18.

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 918 students are studying in the Nursing Colleges of SI-MET as on October 2017.

Child Development Centre (CDC)

Child Development Centre (CDC) established by the Government of Kerala is an autonomous 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 and create a generation of prospective and responsive parenthood through healthy children and adolescents. The number of patients treated was 14,174 in 2015-16 and was 19,051 in 2016-17. Only out-patient services are available and there is no facility for admitting patients. Around 434 medical and nursing students got academic training.

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 in 2016-17 are given in Table 4.2.4.

Medical Education

In Kerala, Medical Education is imparted through 9 Medical Colleges at Thiruvananthapuram, Alappuzha, Kozhikode, Kottayam, Manjeri, Idukki, Ernakulum, 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 also 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 2017-18 are given in Appendices 4.2.9 and Appendix 4.2.10. A comparative analysis of the status of medical college hospitals and attached institutions in 2016-17 and 2017-18 is given in Appendix 4.2.11. The bed strength has increased by 330 in 2017-18 in medical college institutions as compared to the previous year. The number of outpatients and major surgeries conducted has increased during 2016-17. Major achievements of Medical Education Department in 2016-17 include;

• Aardram project started in all Medical Colleges
• Biometric punching system started in all Medical Colleges
• Initiated steps for implementing e-governance
• Heart transplantation surgery successfully done in Medical College, Kottayam.
• Construction of poly trauma building,
• PMSSY project and burns unit completed zin Thiruvananthapuram Medical College
• Burns unit started in Medical College, Thrissur
• 390 posts created in Parippally, Medical College
• First phase construction completed in Medical College, Idukki

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 commenced in academic year 2010-11. The number of institutions affiliated to University is (up to October 2017) 284 with 37 Government colleges, 5 Government Aided Colleges and 242 Self-financing Colleges. The colleges fall under all systems of medicine such as Modern Medicine, Ayurveda, Homoeopathy, Sidha, Unani, Yoga, Naturopathy, Nursing, Pharmaceutical Science and Paramedical courses. The total intake of students is almost 20,000 under various health sciences stream. Details of the Government, Aided, Unaided colleges affiliated under various streams are given in Table 4.2.5.

Indian System of Medicine

Ayurveda is a science dealing not only with treatment of some diseases but also a complete way of life. The Department of Indian System of Medicine renders medical aid to the people through the network of Ayurveda hospitals and dispensaries, grant-in-aid Ayurveda institutions, Sidha, Unani, Visha,Netra and Naturopathy. Specialty hospitals such as Mental Hospital, Panchakarma, Nature cure and Marma are functioning under this Department. At present there are 127 hospitals and 819 dispensaries under the department. The State Medicinal Plants Board co-ordinates matters relating to the cultivation, conservation, research and development and promotion of medicinal plants in the State. List of major institutions and district wise distribution of institutions, beds and patients under ISM department in 2016 and 2017 is given in Appendix 4.2.12.

Special projects were implemented by the ISM Department in 2016-17 in addition to the normal medical treatment. They are Balamukulam, Ritu, Prasadam, Koumarashtoulyam, Drishti, Jeevani, Punarnava, Karalrogamukthi, Snehadhara, Geriatric Care, Yoga, Sports Medicine, Panchakarma, Ksharasutra, Manasikam, Vayoamritham and Bhamini.

AYUSH (Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homoeopathy)

Government of India has set up two regulatory bodies to set standards of medical education. The Central Council of Indian Medicine (CCIM) under Indian Medicine Central Council (IMCC) Act, 1970 regulates educational institutions and practitioners in respect of Ayurveda, Unani and Sidha systems of medicines. The Central Council of Homoeopathy (CCH) under Homoeopathy Central Council Act, 1973 regulates educational institutions and practitioners in respect of Homoeopathy system of medicines. At present Yoga and Naturopathy, being drugless systems, are not regulated.

National AYUSH Mission

Department of AYUSH (Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homoeopathy), Ministry of Health and Family Welfare, Government of India has launched National AYUSH Mission (NAM). The basic objective of NAM is to promote AYUSH medical systems through cost effective AYUSH services, strengthening of educational systems, facilitate the enforcement of quality control of Ayurveda, Siddha, Unani and Homoeopathy drugs and medicinal plants. The funding pattern will be 60:40 by Centre and State. Government of Kerala started the Ayush Department in the State on August 8, 2015. Government of India release in 2016-17 was 858.63 lakh and in 2017-18 (up to September 30, 2017) it was 1,260.82 lakh.

Ayurveda Medicine Manufacturing- OUSHADHI

OUSHADHI is the largest manufacturer of Ayurvedic medicines functioning in India in the public sector. It is one among the few profit making public sector undertakings. Oushadhi is the exclusive supplier of Ayurvedic medicines to government hospitals and dispensaries of Ayurveda Department. In Kerala, Oushadhi supplies medicines to State ISM department at 30 per cent less than the market price and ISM Department supplies this medicine to the poor patients in the State free of cost. The company also caters to the demand of the public through a network of 600 exclusive agencies spread in and outside the State. The sales proceeds of the company in 2016-17 are 95.76 crore and the profit is 13.99 crore.

Ayurveda Colleges

There are 3 Government Ayurveda Colleges situated at Thiruvananthapuram, Thrippunithura and Kannur having bed strength of 1,389. Total number of inpatients treated in 2016 were 6650 and outpatients treated were 523,925. It was 13,100 and 460,595 respectively in 2017 (up to August 2017). Panchakarma hospital and Women and Children hospital are also functioning under the Government Ayurveda College Thiruvananthapuram. There are two aided Ayurveda Colleges, 11 self-financing Ayurveda Colleges, one self-financing Siddha College, one self-financing Unani College and 6 Paramedical self-financing colleges for imparting Medical education in the State. Annual intake of students for UG Degree is 980, PG Degree is 127 and Paramedical Courses is 700.

HOMOEOPATHY

There are 659 homoeopathic dispensaries, 14 District hospitals, 17 Taluk hospitals, 2 ten-bedded hospitals and one hospital with total bed strength of 100 under Homoeopathy Department in the State. In addition, Kerala State Homoeopathic Co-operative Pharmacy (HOMCO) Alappuzha, a medicine manufacturing unit is also functioning under the Directorate of Homoeopathy. HOMCO is running in profit for the last 20 years. District-wise distribution of institutions, beds and patients treated under Homoeopathic Department in 2016 and 2017 is given in Appendix 4.2.13.

Major Achievements of Homoeopathy Department in 2016-17 and 2017-18

• One Homoeo dispensary in each district was upgraded as model dispensary.
• Clinical lab was set up in Government Homoeo Hospital Kayamkulam.
• Pain and palliative care unit was started in all District Homoeo hospitals.
• AYUSH Holistic centres for prevention and management of lifestyle diseases were started in Thiruvananthapuram, Kollam, Ernakulam, Malapuram and Kozhikkode integrating the merits of Homoeopathy, Ayurveda, Yoga and Naturopathy systems of medicine.
• Seethalayam is a gender based scheme for the multi-level support, welfare and health care service exclusively for the suffering women folk implemented in all District Homoeo Hospitals. De-addiction centres and infertility clinics are also functioning as part of this programme.
• Floating Homoeo Dispensaries were started in the coastal area of Kuttanad in Alappuzha District.
• Endocrine disorder care centre at Idukki, Mother and Child care centre at Kannur, Geriatric care centres at Alappuzha, Kollam, Kozhikkode, Kottayam and Wayanad and speciality mobile clinic at Idukki were started under the scheme “Homoeopathy Speciality Care Centres.”
• 16 Temporary Homoeo Dispensaries were started at various pilgrim centres during festival season.
• 14 Homoeo Dispensaries (one Dispensary in each district) were upgraded as Model Homoeo Dispensaries and existing 56 Model Homoeo Dispensaries across the State were standardised.
• One clinical lab was set up in Government Homoeo Hospital, Pala.
• Regional Medical Stores were started in Kottayam, Malappuram and Kannur
• Adolescent Health Care and Behavioural Management Programme was implemented in all District Homoeo hospitals.
• Second phase expansion of HOMCO was initiated.

Homoeo Medical Education

Homoeo Medical Education is imparted through two Government Homoeopathic Medical Colleges, at Thiruvananthapuram and Kozhikode. In addition to this, 3 aided colleges and one unaided college are functioning under this Department. Total bed strength of the Government Homoeopathic Medical College at Thiruvananthapuram is 118 and the patient treated in 2016-17 in IP was 1,192 and OP was 114,215. Total bed strength of the Government Homoeopathic Medical College at Kozhikode is 100 and the patient treated during 2016-17 in IP was 1678 and OP was 155,903. Annual intake of students and courses in the six Homoeo Medical Colleges are given in Appendix 4.2.14.

Immunisation Coverage

Immunisation is one of the most successful and cost effective health interventions and prevents debilitating illness, disability and death from vaccine preventable diseases such as diphtheria, hepatitis A and B, measles, mumps, pneumococcal disease, polio, rotavirus diarrhea, tetanus etc. The coverage of immunisation programmes in Kerala during five years from 2013-14 is given in Appendix 4.2.15.

Outlook

A healthy society can contribute more significantly and effectively to economic development. Long term illness and expensive illness drive non-poor into poverty. Good health is indispensible for the enjoyment of every phase of life. High levels of education especially among women and greater health consciousness have played a key role in the attainment of good health standards in Kerala. However, the issues to be addressed are the health problems of the tribal population and other marginalised communities, re-emergence of communicable diseases, second generation issues like increasing incidence of non communicable diseases, health problems of the aged especially women and increasing health expenditure etc. These challenges will have to be addressed in the coming years. There are specific issues to be addressed specifically in the areas of general health, rural health, tribal health, women health, mother-child health care, health insurance and medical tourism, etc. in the 13th Five-Year Plan period. The public health care system has to be strengthened further to face these challenges.