Editing Kerala model (section)

==Public health==
[[File:Calicut medical college view from inside.jpg|thumb|right|250px|[[Calicut Medical College]] in [[Kozhikode]]. Kerala has around 9,491 government and private medical institutions in the state, with a Population Bed ratio of 879, one of the highest in the country.<ref name=":6">{{Cite web |title=Hospitals in the Country |url=http://pib.gov.in/Pressreleaseshare.aspx?PRID=1539877 |access-date=2021-09-14 |website=pib.gov.in}}</ref>]]
[[File:Medical college Gate Thiruvananthapuram.jpg|thumb|Government Medical College, Thiruvananthapuram. Founded in 1951, it is the oldest Medical College in Kerala and one of the largest tertiary care hospitals in the state. During the 1950s Asian flu pandemic, it was the principal institute to isolate and research the virus.<ref>{{Cite web|title=Government Medical College, Thiruvananthapuram|url=https://tmc.kerala.gov.in/tmc/about|access-date=2021-09-14|website=tmc.kerala.gov.in}}</ref>]]

=== History ===
Kerala's improved public health relative to other Indian states and countries with similar economic circumstances is founded on a long history of successful health-focused policies.<ref name=":18">{{Cite web |last1=Madore |first1=Amy |last2=Rosenberg |first2=Julie |last3=Dreisbach |first3=Tristan |last4=Weintraub |first4=Rebecca |date=2018 |title=Positive Outlier: Health Outcomes in Kerala, India over Time |url=http://www.globalhealthdelivery.org/publications/positive-outlier-health-outcomes-kerala-india-over-time |access-date=2022-05-01 |website=www.globalhealthdelivery.org}}</ref><ref name=":19">{{Cite web |date=2015-09-18 |title=Kerala, India: Decentralized governance and community engagement strengthen primary care |url=https://improvingphc.org/promising-practices/kerala |access-date=2022-05-01 |website=PHCPI}}</ref>

One of the first key strategies Kerala implemented was making vaccinations mandatory for public servants, prisoners, and students in 1879 prior to Kerala becoming a state, when it was composed of autonomous territories. Moreover, the efforts of missionaries in setting up hospitals and schools in underserved areas increased access to health and education services.<ref name=":18" /><ref name=":20">{{Cite journal |last=Kutty |first=V R. |date=2000-03-01 |title=Historical analysis of the development of health care facilities in Kerala State, India |journal=Health Policy and Planning |volume=15 |issue=1 |pages=103–109 |doi=10.1093/heapol/15.1.103|pmid=10731241 |doi-access=free }}</ref> Though class and [[Caste system in India|caste]] divisions were rigid and oppressive, a rise in subnationalism in the 1890s resulted in the development of a shared identity across class and caste groups and support for public welfare. Simultaneously, the growth in agriculture and trade in Kerala also stimulated government investment in transportation infrastructure. Thus, leaders in Kerala began increasing spending on health, education, and public transportation, establishing progressive social policies. By the 1950s, Kerala had a significantly higher life expectancy than neighboring states as well as the highest literacy rate in India.<ref name=":18" /><ref>{{Citation |last=Singh |first=Prerna |title=How Subnationalism promotes Social Development |url=http://dx.doi.org/10.1017/cbo9781107707177.004 |work=How Solidarity Works for Welfare |year=2015 |pages=112–147 |place=Cambridge |publisher=Cambridge University Press |doi=10.1017/cbo9781107707177.004 |isbn=9781107707177 |access-date=2022-05-01|url-access=subscription }}</ref>

Once Kerala became a state in 1956, public scrutiny of schools and health care facilities continued to increase, along with residents' literacy and awareness of the necessity of access health services. Gradually, health and education became top priorities, which was unique to Kerala according to a local public health researcher.<ref name=":18" /><ref>{{Cite journal |last1=Bollini |first1=P. |last2=Venkateswaran |first2=C. |last3=Sureshkumar |first3=K. |date=2004 |title=Palliative Care in Kerala, India: A Model for Resource-Poor Settings |url=https://www.karger.com/Article/FullText/76902 |journal=Oncology Research and Treatment |language=en |volume=27 |issue=2 |pages=138–142 |doi=10.1159/000076902 |pmid=15138345 |s2cid=3018086 |issn=2296-5270|url-access=subscription }}</ref> The state's high minimum wages, road expansion, strong trade and labor unions, land reforms, and investment in clean water, sanitation, housing, access to food, public health infrastructure, and education all contributed to the relative success of Kerala's public health system.<ref name=":18" /><ref name=":21">{{Cite book |last=Board. |first=Kerala (India). Bureau of Economic Studies. Kerala (India). Bureau of Economics and Statistics. Kerala (India). State Planning |url=http://worldcat.org/oclc/1779459 |title=Kerala; an economic review. |publisher=[Printed at the Govt. Press] |oclc=1779459}}</ref> In fact, declining mortality rates during this time period doubled the state's population,<ref name=":18" /><ref>{{Cite book |last=body. |first=Kerala (India). State Planning Board, issuing |url=http://worldcat.org/oclc/5974255 |title=Economic review ... |oclc=5974255}}</ref> and immunization services, infectious disease care, health awareness activities, and antenatal and postnatal services became more widely available.<ref name=":18" /><ref name=":21" /> In the 1970s, a decade before India initiated its national immunization program with [[World Health Organization|WHO]], Kerala launched an immunization program for infants and pregnant women.<ref name=":18" /><ref name=":22">{{Cite book |author=Thomas, M. Benson |url=http://worldcat.org/oclc/908377268 |title=Decentralisation and interventions in health sector : a critical inquiry into the experience of local self governments in Kerala |oclc=908377268}}</ref> In addition, smaller private medical institutions complemented the government's efforts to increase access to health services and provided specialized healthcare.<ref name=":18" /><ref name=":23">{{Cite book |last=Commission. |first=India. Planning |url=http://worldcat.org/oclc/154667906 |title=Kerala development report |date=2008 |publisher=Academic Foundation |isbn=978-81-7188-594-7 |oclc=154667906}}</ref> As a result, life expectancy continued to increase in Kerala, though household income remained low.<ref name=":18" /><ref>{{Cite book |last=Board. |first=Kerala (India). State Planning |url=http://worldcat.org/oclc/966447651 |title=Economic review, Kerala. |publisher=State Planning Board, Kerala |oclc=966447651}}</ref> Thus, the concept of the "Kerala model" was coined by development researchers in Kerala in the 1970s and the state received international recognition for its health outcomes despite a relatively low per capita income.<ref name=":18" /><ref>{{Cite book |last=Centre for Development Studies |first=United Nations |url=http://worldcat.org/oclc/875483852 |title=Poverty, unemployment and development policy : a case study of selected issues with reference to Kerala |date=1975 |publisher=United Nations |oclc=875483852}}</ref>

In the mid-1970s to the early 1990s, a fiscal crisis caused the government to reduce spending on health and other social services. Reductions in federal health spending also affected Kerala's health budget.<ref name=":18" /><ref name=":20" /> As a result, the quality and abilities of public healthcare facilities declined and residents protested.<ref name=":18" /><ref>{{Cite web |title=Remittances to Kerala: Impact on the Economy |url=https://www.mei.edu/publications/remittances-kerala-impact-economy |access-date=2022-05-01 |website=Middle East Institute |language=en}}</ref> Eventually, private health services began to take over, enabled by a lack of government regulation. In fact, by the mid-1980s, only 23% of households regularly utilized government health services, and from 1986 to 1996, private-sector growth significantly surpassed public-sector growth.<ref name=":18" /><ref name=":20" /><ref name=":23" />

In 1996, Kerala began to decentralize public healthcare facilities and fiscal responsibilities to local self-governments by implementing the People's Campaign for Decentralized Planning in response to public distrust and national recommendations.<ref name=":18" /><ref name=":19" /><ref name=":22" /> For instance, new budgetary allocations gave local governments control of 35 to 40% of the state budget. Moreover, the campaign emphasized improving care and access, regardless of income level, caste, tribe, or gender, reflecting a goal of not just effective but also equitable coverage.<ref name=":19" /><ref name=":24">{{Cite journal |last1=Elamon |first1=Joy |last2=Franke |first2=Richard W. |last3=Ekbal |first3=B. |date=October 2004 |title=Decentralization of Health Services: The Kerala People's Campaign |url=http://dx.doi.org/10.2190/4l9m-8k7n-g6ac-wehn |journal=International Journal of Health Services |volume=34 |issue=4 |pages=681–708 |doi=10.2190/4l9m-8k7n-g6ac-wehn |pmid=15560430 |s2cid=29112205 |issn=0020-7314|url-access=subscription }}</ref> A three-tier system of self-governance was established, consisting of 900 [[Panchayati raj|panchayats]] (villages), 152 blocks, and 14 districts.<ref name=":19" /><ref name=":25">{{Cite journal |last=Varatharajan |first=D |date=2004-01-01 |title=Assessing the performance of primary health centres under decentralized government in Kerala, India |url=http://dx.doi.org/10.1093/heapol/czh005 |journal=Health Policy and Planning |volume=19 |issue=1 |pages=41–51 |doi=10.1093/heapol/czh005 |pmid=14679284 |issn=1460-2237|url-access=subscription }}</ref> The current healthcare system arose from local self-governments supporting the construction of sub-centers, primary health centers that support five to six sub-centers and serve a village, and community health centers.<ref name=":19" /> The new system also allowed local self-governments to create hospital management committees and purchase necessary equipment.<ref name=":18" /><ref name=":22" />

=== Present ===
The basis for the state's health standards is the state-wide infrastructure of primary health centers.<ref name=":4">{{Cite web|title=MISSION AND VISION – dhs|url=https://dhs.kerala.gov.in/mission-and-vision/|access-date=2021-09-14|language=en-GB}}</ref> Under the current system, the primary health centers and  sub-centers were brought under the jurisdiction of local self-governments to respond to local health needs and work more closely with local communities.<ref name=":19" /><ref name=":25" /> As a result, health outcomes and access to healthcare services have improved.<ref name=":19" /><ref name=":24" /> There are over 9,491 government and private medical institutions in the state, which have about 38000 beds for the total population, making the population to bed ratio 879—one of the highest in the country.<ref name=":5" /><ref name=":6" />

There is an active, state-supported nutrition programme for pregnant and new mothers and about 99% of child births are institutional/hospital deliveries,<ref name=":3" /> leading to infant mortality in 2018 being 7 per thousand,<ref name=":7" /> compared to 28 in India, overall<ref name=":8" />  and 18.9 for low- middle income countries generally.<ref>{{Cite web|title=Mortality rate, neonatal (per 1,000 live births) - Low & middle income {{!}} Data|url=https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=XO|access-date=2021-09-14|website=data.worldbank.org}}</ref> The birth rate is 40 percent below that of the national average and almost 60 percent below the rate for impoverished countries in general. Kerala's birth rate is 14.1<ref name=":1" /> (per 1,000 people) and decreasing. India's rate is 17<ref name=":2" /> the rate of the U.S. is 11.4.<ref>{{Cite web|title=Birth rate, crude (per 1,000 people) - United States {{!}} Data|url=https://data.worldbank.org/indicator/SP.DYN.CBRT.IN?locations=US|access-date=2021-09-14|website=data.worldbank.org}}</ref> [[Life expectancy]] at birth in Kerala is 77 years, compared to 70 years in India<ref name=":0" /> and 84 years in Japan,<ref>{{Cite web|title=Countries with highest life expectancy 2019|url=https://www.statista.com/statistics/264725/ranking-of-the-20-countries-with-the-highest-life-expectancy/|access-date=2021-09-14|website=Statista|language=en}}</ref> one of the highest in the world. Female life expectancy in Kerala exceeds that of the male, similar to that in developed countries.<ref name="deepu">{{cite news
|url=http://www.ashanet.org/library/articles/kerala.199803.html
|publisher=Bill McKibben
|title=Kerala: A case study
}}</ref> Kerala's maternal mortality ratio is the lowest in India at 53 deaths per 100,000 live births.<ref name=":0" />

According to the [[India State Hunger Index]], in 2009, Kerala was one of the four states where hunger was only moderate. The hunger index score of Kerala was 17.66 and was second only to Punjab, the state with the lowest hunger index. The nationwide hunger index of India was 23.31.<ref>{{cite web |year=2008 |title=The India State Hunger Index: Comparisons of Hunger Across States |url=http://www.ifpri.org/pubs/cp/ishi08.pdf |url-status=dead |archive-url=https://web.archive.org/web/20090214141710/http://www.ifpri.org/pubs/cp/ishi08.pdf |archive-date=14 February 2009}}</ref> Despite the fact that Kerala has a relatively low dietary intake of 2,200 kilocalories per day, the infant-mortality rate and the percentage of the population facing severe undernutrition in Kerala is far lower than in other Indian states. In early 2000, more than a quarter of the population faced severe undernutrition in three states—Orissa, Uttar Pradesh, and Madhya Pradesh—though they had a higher average dietary intake than Kerala. Kerala's improved nutrition is primarily due to better healthcare access as well as greater equality in food distribution across different income groups and within families.<ref name=":9" />
{| class="wikitable"
|+Public Health Infrastructure<ref name=":5">{{Cite web|last=State Health Profile|first=National Health Authority, Government of India|date=January 2021|title=State Health Profile-Kerala, National Health Authority, Government of India|url=https://pmjay.gov.in/sites/default/files/2021-01/Kerala-State-Health-Profile.pdf|website=pmjay.gov.in/}}</ref>
|Medical Colleges
|34
|-
|Hospitals
|1280
|-
|Community Health Centres<ref name=":6" />
|229
|-
|Primary Health Centres<ref name=":6" />
|933
|-
|Sub Centres
|5380
|-
|AYUSH Hospitals/Dispensary
|162/1473
|-
|Total Beds
|38004
|-
|Blood Banks
|169
|}

'''District-wise Hospital Bed Population Ratio as per the 2011'''<ref>{{Cite web|last=Government of Kerala|first=Health at a Glance 2018|date=2018|title=Health at a Glance, 2018- Department of Health, Government of Kerala|url=https://pmjay.gov.in/sites/default/files/2021-01/Kerala-State-Health-Profile.pdf|website=dhs.kerala.gov.in/}}</ref>
{| class="wikitable sortable"
|-
!District
!Population Census(2011)
!Number of beds
!Population Bed Ratio
|-
|Alappuzha
|2127789
|3424
|621
|-
|Ernakulam
|3282388
|4544
|722
|-
|Idukki
|1108974
|1096
|1012
|-
|Kannur
|2523003
|2990
|844
|-
|Kasaragod
|1307375
|1087
|1203
|-
|Kollam
|2635375
|2388
|1104
|-
|Kottayam
|1974551
|2817
|701
|-
|Kozhikode
|3086293
|2820
|1094
|-
|Malappuram
|4112920
|2503
|1643
|-
|Palakkad
|2809934
|2622
|1072
|-
|Pathanamthitta
|1197412
|1948
|615
|-
|Thiruvananthapuram
|3301427
|4879
|677
|-
|Thrissur
|3121200
|3519
|887
|-
|Wayanad
|817420
|1367
|598
|-
|'''Total'''
|33406061
|38004
|879
|}

The Health Index, ranking the performance of the States and the Union Territories in India in Health sector,  published in June 2019 by the NITI Ayong, Ministry of Health and Family Welfare, Government of India and The World Bank has Kerala on top with an overall score of 74.01.Kerala has already achieved the SDG 2030 targets for Neonatal Mortality Rate, Infant Mortality Rate, Under-5 Mortality rate and Maternal Mortality Ratio.<ref>{{Cite web|last=Report on ranks of States and Union Territories, June 2019|first=Healthy States Progressive India|date=June 2019|title=Healthy States Progressive India- Report on the Ranks of States and Union Territories, June 2019|url=http://social.niti.gov.in/uploads/sample/health_index_report.pdf|website=social.niti.gov.in/}}</ref><ref name="Economist">{{cite web
|url=http://graphics.eiu.com/upload/QOD_main_final_edition_Jul12_toprint.pdf
|title=Kerala: the community model (Page No 24)
|publisher= The Economist
|access-date=25 July 2010}}</ref><ref name="Express">{{cite web
|url=http://newindianexpress.com/cities/thiruvananthapuram/article182738.ece
|archive-url=https://web.archive.org/web/20160304220053/http://www.newindianexpress.com/cities/thiruvananthapuram/article182738.ece
|url-status=dead
|archive-date=4 March 2016
|title='The Economist' hails Kerala model
|publisher=The New Indian Express
|access-date=25 July 2010}}</ref>

The Economist has recognized the Kerala government for providing palliative care policy (it is the only Indian state with such a policy) and funding for community-based care programmes. Kerala pioneered [[universal health care]] through extensive public health services.<ref>{{Cite web|url=http://www.theguardian.com/society/2015/jan/06/-sp-universal-healthcare-the-affordable-dream-amartya-sen|title=Universal healthcare: the affordable dream|date=6 January 2015|website=The Guardian}}</ref><ref>{{Cite web|url=https://www.theatlantic.com/magazine/archive/1998/09/poor-but-prosperous/377206/|title=Poor but Prosperous|first=Akash|last=Kapur|date=1 September 1998|website=The Atlantic}}</ref> [[Hans Rosling]] also highlighted this when he said Kerala matches U.S. in health but not in economy and took the example of [[Washington, D.C.]] which is much richer but less healthy compared to Kerala.<ref>{{Cite web|url=https://www.ted.com/talks/hans_rosling_asia_s_rise_how_and_when/transcript|title=Transcript of "Asia's rise -- how and when"|first=Hans|last=Rosling|website=www.ted.com}}</ref><ref>{{Cite web|url=https://www.utne.com/community/theenigmaofkerala/|title=The Enigma of Kerala|date=9 October 2007 }}</ref>

'''Key Health Development indicators-''' '''Kerala & India''' 
{| class="wikitable sortable"
|-
!Health Indicators	
!Kerala
!India
|-
|Life expectancy at birth (Male)<ref name=":0">{{Cite web|title=GBD India Compare {{!}} IHME Viz Hub|url=http://vizhub.healthdata.org/gbd-compare/india|access-date=2021-09-13|website=vizhub.healthdata.org}}</ref>
|74.39
|69.51
|-
|Life expectancy at birth (Female)<ref name=":0" />
|79.98
|72.09
|-
|Life expectancy at birth (Average)<ref name=":0" />
|77.28
|70.77
|-
|Birth rate (per 1,000 population)
|14.1<ref name=":1">{{Cite web|last=Report 2018, Government of Kerala|first=Annual Vital Statistics|date=2019|title=ANNUAL VITAL STATISTICS REPORT – 2018, Vital Statistics Division Department of Economics & Statistics Thiruvananthapuram, Kerala 2019|url=http://www.ecostat.kerala.gov.in/images/pdf/publications/Vital_Statistics/data/vital_statistics_2018.pdf|website=www.ecostat.kerala.gov.in|access-date=17 October 2021|archive-date=2 November 2021|archive-url=https://web.archive.org/web/20211102023933/http://www.ecostat.kerala.gov.in/images/pdf/publications/Vital_Statistics/data/vital_statistics_2018.pdf|url-status=dead}}</ref>
|17.64<ref name=":2">{{Cite web|title=Death rate, crude (per 1,000 people) - India {{!}} Data|url=https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=IN|access-date=2021-09-13|website=data.worldbank.org}}</ref>
|-
|Death rate (per 1,000 population)
|7.47<ref name=":1" />
|7.26<ref name=":2" />
|-
|Infant mortality rate (per 1,000 population)
|7<ref name=":7">{{Cite web|title=Reserve Bank of India - Publications|url=https://m.rbi.org.in/Scripts/PublicationsView.aspx?id=19999|access-date=2021-09-13|website=m.rbi.org.in}}</ref>
|28<ref name=":8">{{Cite web|title=Mortality rate, infant (per 1,000 live births) - India {{!}} Data|url=https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=IN|access-date=2021-09-13|website=data.worldbank.org}}</ref>
|-
|Under 5-Mortality rate(per 1,000 live births)<ref name=":3" />
|10
|36
|-
|Maternal mortality ratio (per lakh live births)<ref name=":0" />
|53.49
|178.35
|-
|}
{| class="wikitable"
|+Other Key SDG 3 Indicators<ref name=":3">{{Cite web|last=PARTNERSHIPS IN THE DECADE OF ACTION|first=SDG INDIA INDEX AND DASHBOARD 2020-2021|date=4 March 2021|title=SDG INDIA INDEX AND DASHBOARD 2020-2021-PARTNERSHIPS IN THE DECADE OF ACTION, NITI AYOG 2021|url=https://www.niti.gov.in/writereaddata/files/SDG_3.0_Final_04.03.2021_Web_Spreads.pdf|website=www.niti.gov.in}}</ref>
!Indicators
!2020
!2019
|-
|Children in the age group 9–11 months Immunised(%)
|92
|
|-
|Notification rate of Tuberculosis per 1,00,000 population
|75
|71
|-
|HIV Incidence per 1,000 uninfected population
|0.02
|0.03
|-
|Suicide rate (per 1,00,000 population)
|24.30
|
|-
|Death rate due to road accidents per 1,00,000 population
|12.42
|
|-
|Institutional deliveries out of the total deliveries reported (%)
|99.90
|74
|-
|Monthly per capita out-of-pocket expenditure on health (%)
|17
|
|-
|Physicians, nurses and midwives per 10,000 population
|115
|112
|}