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How Kerala became a public health model

Part of Kerala's success in achieving near-developed-world levels of basic health indicators results from a rapid expansion of medical facilities.

Another part derives from the development of public health and disease prevention programmes by enlightened maharajahs, starting with the princely state of Travancore in the late-19th century, later extended into the other areas that became Kerala. With the creation of large numbers of trained doctors and nurses, extensive networks of hospitals, and a primary health centre (PHC) in every village, Kerala had achieved the status of a health model.

More recently, although Kerala's people remained generally far healthier and continued to have better access to health services than most populations of the less-developed world, diseases such as malaria, once nearly conquered, began staging a comeback. New diseases that followed on the earlier successes in extending lifespans began to strain the healthcare system - these included cancer, heart disease, hypertension and arthritis.

Government health facilities began to deteriorate. By the early-1990s, only 30% of even the poorest groups sought help from public sector hospitals, and PHCs in many communities were dilapidated and underutilised. Both safe drinking water and sanitary latrines remained inaccessible to significant sections of the population. A rapid growth of private hospitals appears to correlate with excessive use of sophisticated equipment.

The Kerala People's Campaign for Decentralised Planning was launched in August 1996 with a government commitment to devolve 35- 40% of the plan or development budget to local communities. The campaign evolved through several stages. G ram sabhas were organised in every ward of Kerala's 990 gram panchayats . Similar assemblies were held in urban neighbourhoods. Following this, a group from all the ward assemblies in a village organised to gather local data and draft a local panchayat development report (PDR). Every one of Kerala's 1,212 local communities produced and disseminated such a report, each with a chapter on health.

Lists of project areas were generated using the PDRs. The elected panchayat councils then selected the priority list of projects, and implementation and monitoring committees were set up. Projects in health had to compete with projects for roads, schools, childcare centres, housing, and all other development tasks undertaken at the local level.

The 60-65% of the plan budget not devolved went largely into major infrastructure, electricity generation and industrial development - that is, into projects deemed inappropriate for local assemblies or councils to undertake.

In the first year of the campaign, fiscal 1997-98, there were 67,766 locally devised projects across Kerala, using Rs 7,490 million of devolved funds.

Overall, Kerala's devolution appears to have resulted in a more effective functional division of responsibilities and a set of desirable spending priorities in health.

The prioritisation of projects basically followed the priorities identified by the people. Through the five years of the campaign, PHCs were improved in hundreds of localities. Physicians and community activists worked together. One of the most important areas of improvement was the taluk a hospitals where block panchayats put in equipment and local committees provided volunteer labour.

Though medicines, staff responsibility and bed adequacy were of great concern to people, the decentralisation programme has not yet evolved mechanisms or provided resources for local communities to directly attack these problems. Another shortcoming related to the greater need for technical expertise in medical and health projects.

The May 2001, Kerala state assembly elections were won by a Congress-led coalition that replaced the Communist Party of India-Marxist-led coalition that had launched the People's Campaign. However, people's planning remains largely intact in Kerala. The challenge is to maintain the achievements and fine-tune the process to maximise public participation within the new political context.

Three projects in public health and healthcare were particularly noteworthy: the Koyilandy biological mosquito control project http://chss.montclair.edu/anthro/Koyilandi.htm , the Thrikkakkara cooperative hospital http://chss.montclair.edu/anthro/Thrikkakkara.htm ), and the Erattupettah 'healthy village' project. http://chss.montclair.edu/anthro/Erattupettah.pdf . Also, following the change of ministries in 2001, health activists regrouped around a new project in Mararikulam www.mararidevelopment.org .

(Extracted from Joy Elamon, Richard W Franke, B Ekbal, 'Decentralisation of Health Services: The Kerala People's Campaign'. International Journal of Health Services, 34; 4: 681-708)

InfoChange News & Features, June 2005