Editing Kerala model (section)

=== 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" />