India - Kerala Health Systems Improvement Program

Overview & Synopsis

Kerala has achieved the Sustainable Development Goal (SDG) 2030 targets according to the National Institute for Transforming India Aayog SDG index, for neonatal (3.4 per 1,000 live births), infant (4.4 per 1,000 live births), under-five mortality (5.2 per 1,000 live births) rates, and maternal mortality (19 per 100,000 live births). According to the National Family Health Survey-5 (NFHS-5), the fertility rate decreased from 2.0 to 1.8 (1992–1993 to 2019–2021), which is well below the replacement level. Kerala’s health gains stem from a sustained emphasis on promoting public health and primary health care (PHC), the improved status of women, and decentralized governance through the Local Self Government (LSG). Kerala’s high literacy rates, particularly in girls’ education, and strong community ownership have contributed to active citizens’ participation in health promotion. New health, demographic, and fiscal challenges may impede Kerala’s excellent performance in human development. The epidemiological transition toward non-communicable diseases (NCDs), a rapidly growing elderly population, increased vulnerability to disease outbreaks, and climate change impacts, place a large section of Kerala’s population at risk. While the state of Kerala has the lowest multidimensional poverty and leads in education and health performance among Indian states, its economic growth has lagged, averaging 5.5 percent between FY12–13 and FY19–20, which is below the national average and that of other major states. Kerala’s capital expenditure is less than 2 percent of gross state domestic product, significantly lower than the national average and other major states. Although the government health budget has increased from INR 71 billion in 2019–2020 to INR 100 billion for 2024–2025 in real terms, there is an increasing role of private health care, especially in treating complications of NCDs. Increased hospital care, with higher out-of-pocket (OOP) costs, severely strains households. The Kerala Health Systems Improvement Program aims to deliver integrated care for NCDs such as hypertension, diabetes, and cancers; comprehensive home based care for the elderly; a multilevel trauma and emergency care system; and multisectoral approaches for addressing disease outbreaks and addressing climate challenges.