I live in Bangalore which has a few super-speciality hospitals. I have access to a reasonable medical/health insurance as part of the compensation for my job. However, I do like to go to Kerala – my home state – whenever there is a need for medical treatment for myself or other members of my family.
This may be partly due to the social capital that I have there. This can be part of my Obsessive Compulsive Disorder, as my daughter would say. However the features of the health-care system of Kerala which encourage me to go there cannot be neglected. Let me note down these key features.
The public or governmental health-care system, which includes a set of speciality hospitals, medical colleges, district hospitals and others in Taluk and block towns, functions reasonably well. There has been a gradual improvement in their quality, thanks to public pressure and the efforts made by successive governments. To be frank, I may not use one of these hospitals but this is an important option for those who cannot afford private health-care. Or let me put it in this way. The option that is available for the poor and the lower middle-class is a reasonable one. It is also serving as a not-so-bad `exit’ option (the one that can be used if something goes wrong) for the middle class. Though there may be similar government hospitals in state capitals or metropolitan cities in other states of India, those in the district and sub-district towns may not have adequate facilities compared to such hospitals in Kerala.
However, public health-care is only one part of the story. Many people may not know that the dependence on private hospitals is much higher in Kerala not only during recent decades which have witnessed a decline in the share of public investments and an increasing trend towards privatisation. Even in the mid-eighties, nearly 66 percent of all visits to a medical facility in the state was to a private hospital/clinic. There is a diverse set of private health-care facilities with a few super-speciality hospitals, a good number of general hospitals, and hundreds of small hospitals. These are located not only in cities and district towns but also in small municipalities and village centres. Who are the owners of these private hospitals? There may be a few corporate types but there are several others owned by trusts, church and other religious groups, cooperatives (including those controlled by political parties), and individuals. There are hospitals owned by individuals and families which have been functioning in specific locations for decades, and they have built reputation and a set of loyal clients.
The third pillar of the health-care system of Kerala is those private clinics operated by individual doctors. Most of these doctors have post-graduate qualifications. One or more of them can be located in each and every panchayath in the state and they too are interested in acquiring reputation and loyal clients. Some of them serve as de-facto family physicians.
The interaction between the private and public healthcare in Kerala is very important. The number of private providers and their presence all over the state make the competition within the private sector intense. Since the public option is not that `horrible’ (and even sections of people belonging to the middle class may opt for government hospitals) private health-care providers have to be much more reasonable if they want to get clients. Or there is an implicit competition between public and private hospitals. The collusion between public and private hospitals is not that easy, though this is possible between different private hospitals. This `double’ competition encourages most private hospitals to provide health-care services at a reasonable cost. I know a number of cases wherein the cost of a medical service in Kerala is one-third or one-fourth of what one may have to pay for the same service in Bangalore.
There are two other aspects which make the health-care affordable and reasonable in Kerala. The network of rural roads in the state makes these hospital facilities easily accessible to most people. Then there is the presence of a competitive and alert media. Even a small issue arising out of the maltreatment in a public or private hospital is likely to be reported in one or other media and that is an important way to keep up public pressure on all kinds of health-care facilities. Media attention may have gone to the other extreme: reporting cases without knowing the real facts of a medical case and prompting popular anger against hospitals and doctors sometimes unjustifiably. Private hospitals/clinics which are interested in their reputation do not want to have negative stories about them in the media.
There has been a shift in government policies and expenditure in Kerala recently. Though the social-security schemes which have focussed on the provision of food or pensions to a major section of the population continue, newer schemes are those aimed at meeting the cost of health-care. People can get financial support for treating severe illnesses, and there are different schemes to provide medicines freely or at a highly subsidised price.
This is not to say that everything is perfect in the health-care of Kerala. There is scope for significant improvement in the functioning of government hospitals. Though successive governments cannot neglect investments for this purpose, fiscal deficits and those general problems associated with the implementation of government programs are barriers in this regard. Some of the settlements of the Scheduled Tribes are far away from a reasonably functioning government hospital. Sections of employees of government hospitals may not behave nicely to patients, especially to those coming from socially and economically vulnerable groups, though the complaints of this nature have become fewer lately. The tendency to depend on a few super-speciality corporate hospitals (even for not so serious illnesses) has gone up and that may increase the cost of medical care. This may be a wasteful expenditure. There are occasional cases where the ignorance of patients is exploited by one or other private hospital to enhance profits. However my impression is that such cases are fewer in Kerala compared to similar ones in other states including those in cities like Bangalore.
Lessons from Kerala
One can draw important lessons from the health-care system of Kerala since affordable health-care is a serious issue not only in developing countries but also in the developed world. The extensive presence of the combination of public and private medical facilities, the implicit competition between the public and the private, and the explicit competition between different private facilities make the health-care system accessible and affordable in Kerala.
Such a combination is better than an exclusive dependence on one type. A greater focus on private hospitals can be problematic even with adequate health insurance. Though such insurance is good to pool the risk among the population, it is well known that the inevitable information problems make exclusive dependence on insurance-based health-care costly even in the developed countries. This is evident from the experience of the USA. Moreover, a substantial share of the population in countries like India may not be able to pay the required insurance-premium to cover different kinds of diseases which may affect them.
Similarly, an exclusive dependence on public hospitals may not be desirable. There will be a shortage of financial resources on the part of governments, and hence what is provided in public hospitals may not be adequate to meet the requirements of society. There could be long delays in getting needed medical treatment, as evident from a few developed countries which depend solely/mainly on public health-care. (Sections of people from there may go to other countries to get medical treatment quickly but that may not be affordable to the majority). On the other hand, the extensive presence of a combination of public and private healthcare facilities reduces the pressure on the public system and also the burden on governments. That would also reduce the delays in getting the required treatment.
When we compare the situation of Kerala with other Indian states, one can see that the widespread availability of quality medical care in a society is also reflection of its human development (including improvements in education). There are poorer parts of India (say, Sundarbans in West Bengal) where most of the medical services is provided by unqualified practitioners (or quacks). In states where there are medical colleges and super-speciality hospitals in the capital and a few other cities, small towns and rural areas suffer from the absence of quality medical care. It is the availability and use of education facilities by the majority, and the possibility of a relatively better quality of life even in villages, that have created a situation where qualified doctors are available in most parts of Kerala.
The improvements in Kerala’s healthcare system are part of the organic human development of the state. The social and political mobilisation of almost all sections of the society and the policies pursued by different governments mostly under public pressure (and shaped by an intensely competitive politics) have facilitated improvements in different aspects of human development (including education and public-health). These have also enabled a substantial section of the population to use employment opportunities wherever these are available (if not within the state). All these have led to the increase in the demand for, the availability of people who are trained and the provision of, health-care all over the state. The experience of Kerala demonstrates the inter-connections between the spread of education, healthcare and other dimensions of human development.
 Kannan, KP; KR Thankappan; V Ramankutty, and KP Aravindan (1991) Health and development in rural Kerala: A study of the linkages between socioeconomic status and health status, Kerala Sastra Sahitya Parishad, Trivandrum