The Kerala healthcare model
Healthcare systems of countries, especially the ones first hit by COVID-19 including developed Western European countries, and even the United States are still struggling to keep pace with the spread of the disease, and the steady surge of patients requiring urgent medical attention.
The cases in India are also rising swiftly on a daily basis. The infections and fatalities presently stand at around 110,000 and 3,500 respectively. Ominously, medical and disease modelling experts fear that India is far behind the curve when it comes to the spread of the virus. All India Institute of Medical Sciences (AIIMS) director Dr. Randeep Guleria recently stated that even though there is a constant flattening of the growth curve in India, the cases in the country are expected to peak only by the end of June or in July.
Kerala, my home state, has been one of the outliers during these days of the virus-induced pandemonium. The state that incidentally saw India’s first COVID-19 positive case way back on the 30th of January has been one of the few places anywhere in the world that has managed to keep the exponentially spreading virus reasonably at bay.
The efforts of the mid sized Indian state in containing the virus till now have raised a great deal of interest as well as admiration from many corners of the world. The Kerala healthcare model deservingly warrants a closer examination so that the contributing elements of the success story could be translated to other curious health systems elsewhere.
Nonetheless, right from the early stages of this exercise, one would do well not to overlook that Kerala whose GDP per capita of $ 2,900 (equating to less than 1/20th of the GDP per capita of the US), poor by western standards, always have had development indices that could better most developed countries. The origins of the formation of the much vaunted model could actually be traced way back to the 19th century.
The state that have the deep ancient roots of Ayurveda entrenched in its culture since forever was quick to adapt to the advent of novel medical practices, including the western medical practices that were brought into the region during the colonial times.
In the later stages of the 19th century itself, the princely states of Travancore and Cochin took initiatives in making modern healthcare techniques available to their subjects. A royal proclamation in 1879 made vaccinations compulsory for public servants, prisoners and students.
Kerala has the proud history of the princely state of Travancore appointing Dr. Mary Punnen Lukose who had returned back after medical training from England in the early 20th century as the first surgeon general of the state, at a time when women doctors were a rarity even in the western world. Primary healthcare was one of the top priorities of all the rulers in the state, with the general hospitals in Trivandrum and Cochin districts in Kerala now well over 150 years old.
Since the inception of Kerala state in 1956, every single state Government irrespective of their political affiliations had placed primary education and primary healthcare as their two topmost priorities. The steady growth of local healthcare capacity and facilities till the last mile gram and taluk panchayat levels over a seventy-year time span is a case in point.
The United Nations introduced the Human Development Index (HDI) in 1990, and from the year of starting of the index Kerala had numbers comparable to many developed countries. The India Human Development report prepared in 2011 placed Kerala on top of the index for achieving the highest literacy rate, quality of health services, and the consumption expenditure of the population.
Top notch, dedicated health workers provide the second pillar that holds the Kerala healthcare model on a pedestal. State governments over a period of time had succeeded in creating medical colleges at almost every district in the state, and have sanctioned self financed private medical colleges at an impressive average of more than one per district.
This has been the principal reason for Kerala having 1.5 doctors per 1000 people. This is far above the national average of 0.62, and is comfortably ahead of the WHO mandated 1 for 1000 people. Kerala also have myriad private and public nursing colleges spread across the state, with almost 10,000 nursing graduates registering in the work force every year.
The stories of Malayali nurses working as frontline healthcare warriors with utmost bravery and dedication during the COVID-19 times have come up with the deepest of admiration from many corners of the world. This was hardly surprising news for the Malayalis themselves who have been witnessing their efforts from close quarters for decades.
The state’s willingness to embrace innovative practises is another factor that greatly fortifies the Kerala healthcare model. The engine driving Kerala’s fight against COVID-19 is an open source digital group - ‘The Corona Safe Network’ that comprises of hundreds of Malayali policy makers including senior government officials, health policy experts, innovators, and technocrats from across the world. There is a constant flow of knowledge resources, best practises and solutions within the network; with the ones deemed fit to be executable going to the desks of the relevant policy makers in real time.
Despite success so far in containing the virus, Kerala face unique challenges that would mean that the state would have to remain in high alert in the foreseeable future. Nearly 1/10th of Kerala’s population live outside India. With the economic slowdown and the resultant workforce downsizing becoming a global trend, a massive inflow of Non Resident Keralites (NRKs) back into the state is expected in the coming months. Almost 5 lakh NRIs wishing to return had registered through the NORKA – Roots program just within a week the process started in Kerala.
It would certainly be a difficult task for the financially strapped state to provide the mandatory quarantine facilities for the incoming population, and execute the WHO recommended ‘test, isolate, trace and treat’ process - with little margin for any error. However, if the discipline, solidarity and resilience shown by the Malayalis when the state faced devastating floods the previous two years, and during the COVID-19 days till date is anything to go by, Kerala will overcome these trying times.
Malayalis at large are beaming with pride that the spotlight now shines on the ‘Kerala healthcare model’ as a possible solution while the world grapples its biggest challenge since the days of the Second World War.
The model however is a result of many decades of Government efforts, before and after India’s independence – with all of them placing primary healthcare alongside primary education as their topmost priorities, and creating their budgetary allocations accordingly. They all had made continuous efforts to produce top quality health workers and healthcare centres, and could take them to the last mile, all the while remaining receptive to novel innovative practises. This Kerala healthcare model would be replicated only with sustained effort over long periods of time.
(Anil K. Antony is the Convener of INC-Kerala Digital Media, and the National Coordinator of PIIndia.org, a COVID19 action group. Tweets@anilkantony).