V Mohanan Naira,b, Althaf Aa,c, Benny PVa,d, Muhammed Shaffia,e, S Vasudevana,f, K Rajamohanan Pillaia,g, VP Pailya,h, Sreejith N Kumara, SS Lala,i, Muhammed Asheela, Sandeep Ka, Zuhail Sainudeena, Santhosh Kumar GRa, Asha KPa,j, Mini SSa,k, Libu GKa,c

a. Indian Medical Association; b. Former Director Indian Institute of Diabetes, Trivandrum; c. Department of Community Medicine, Medical College; d. Department of Community Medicine, Sree Gokulam Medical College, Trivandrum; e. Global Institute of Public Health, Ananthapuri Hospitals, Thiruvananthapuram; f. Kerala Medical Journal & Department of Urology, Medical College, Trivandrum; g. Department of Pediatrics, Medical College, Trivandrum; h. Rajagiri Hospital, Aluva; i. Global HIV & TB Program, PATH, Washington DC; j. Department of Community Medicine, Alappuzha; k. Department of Community Medicine, Medical College, Parippally, Kollam*

Corresponding Author: Dr Muhammed Shaffi, Assistant Professor, Global Institute of Public Health, Ananthapuri Hospitals, Thiruvananthapuram. Email: fmshaffi@gmail.com   

ABSTRACT

The Preamble to the Constitution of the World Health Organization, as adopted by the International Health Conference, 1946; defines Health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.
Kerala has achieved good health indicators compared to other Indian states and even some of the developed countries. However Kerala’s performance lags behind many countries in terms of reducing MMR and IMR. While the IMR of Kerala is better than most Indian states, the reduction in the rate has stagnated for the last two decades. The health sector in Kerala is now facing many challenges, which are driven by declining investments in the public health sector and inadequate attention to the social determinants of health.
On 8th November 2014, at its 57th Annual Conference at Kovalam, Trivandrum India, the Indian Medical Association Kerala State branch accepted adopted and proclaimed a Citizens Health Charter along with ‘Kerala Health: 2025 – A Road Map’ specifying the goals and effective strategies to achieve them by 2025. The charter calls for an acceptable level of health care for all, which can be attained by the year 2025 through an optimal use of the existing and available resources, an evidence based State health policy, accepting the role of social determinants of health and to ensure the provision of safe drinking water and sanitation; safe and healthy food; nutrition and housing; healthy working and environmental conditions; health education and information and gender equality.
The charter reiterates that State has the responsibility to mobilize additional resources that may well be devoted to health and social development of the state.

Introduction

Kerala has achieved good health indicators compared to most other Indian states.1 The state unequivocally enjoys the highest male and female literacy rates, life expectancy at birth, lowest rates of infant and maternal mortality and malnutrition. Female literacy, geographical factors such as availability of water, agriculture and food grain production, and accessibility to health care for all its citizens at the time of its formation laid the foundation. However, Kerala’s performance lags behind many countries in terms of MMR and IMR. While the IMR of Kerala is better than most Indian states, the rate has stagnated for the last two decades. The decline in IMR in Kerala has almost ceased by the 1990s. For several years, IMR has remained around 12−14 per 1,000 live births, with virtually no change.2

The health sector in Kerala is now facing many challenges, which are driven by declining investments in the public health sector and inadequate attention to the social determinants of health.

It is facing increasing burden of emerging and re-emerging communicable diseases along with problems resulting from the epidemiological and demographic transition. Issues related to gender and with shifting family structures, an ageing population and health issues of elderly, inappropriate health system infrastructure and inefficiency and descends in quality of the health care delivery system, neglected public health and primary health care and increasing social inequity and health issues of the marginalized population are all exacerbating the situation.

The rising burden of diseases is partly attributed to changes in life style, deteriorating environmental conditions, includes environmental degradation driven by urbanization and interference with biodiversity, as well as harmful agricultural practices, and the mismanagement of solid and liquid waste.

Demographic and epidemiological transition

At present the percentage of population above 60 in Kerala is 17 % and is expected to cross 25% by the year 2025. With an ageing population, tackling geriatric diseases has become a crucial issue in Kerala.3 450 people per 10,000 of the total population is mentally disabled in Kerala, which is the highest amongst all the states in India. The corresponding national rate is 220 per 10,000. Highest rates of suicide worldwide are reported in Kerala. The State contributes to 10.1% of all the suicides occurring in India though our population constitutes only 3.4%. The suicide rate in Kerala for the year 2012 is 25.4 per lakh.4

Data on Incidence of Road Traffic Accidents and deaths due to RTAs trend through 2001 to 2013 shows that though the incidence of road traffic crashes has declined, the mortality due to RTAs did not show a proportionate decline.4 This may be due to change in characteristics of RTAs as well as Poor health system preparedness for increasing need for emergency trauma care.

An estimated 52 per cent of all deaths due to non-communicable diseases are among people in the 30-60 years age group. Over 30 per cent of people in Kerala are suffering from hypertension. 27% of adult males and 19 % of adult females are diabetic in the state, thus Kerala is rightly becoming the diabetic capital of India.  According to the Kerala ACS (Acute Coronary Syndrome) Registry, STEMI, a more serious kind of heart attack involving large portions of the heart muscle, was the most common ACS admission, with highest in-hospital mortality rate.5 STEMI patients are more likely to reach hospitals more than six hours after onset of symptoms.In a study conducted in Trivandrum district shows the catastrophic health expenditures were experienced by 84 per cent of participants as a consequence of treating Acute Coronary Syndrome.

The number of new cancer patients registered has increased from 11,173 in 2006−07 to 13,040 in 2009−10, while existing number of cancer patients has increased from 1,29,974 to 1,67,628 during the same period.6

Health Determinants

Only 29.3 per cent of the houses in the State are serviced by the water supply network and just 23.4 per cent get treated water this percentage is lower than the neighboring states Karnataka at 66.1 per cent and Tamilnadu at 79.8 per cent and lower than the national average at 43.5 per cent. 62 per cent of Kerala’s household water demand is met by open wells.3

Kerala had the highest rural and urban inequality among the largest 15 Indian states in 2004-05.7 The state has shown consistently high levels of inequality since NSSO began conducting large-scale “thick” expenditure surveys in 1973-74. In the latest 2009-10 thick NSSO expenditure survey, Kerala tops the list of states ranked by per capita expenditures in both rural and urban areas. Private expenditures on health dwarf public expenditures: In 2004-05, whereas public expenditures amounted to just 0.9% of GSDP, private expenditures was a gigantic 8.2%. The corresponding India-wide figures were 0.9 and 3.6% of GDP, respectively.In Kerala the percentage of the hospitalized patients who became indebted due to medical costs is about 17 percent. Direct and indirect medical costs together push the patients and their households into poverty. This is the reality, so to conclude people don’t have access to care and those who access care are impoverished. So, these are the reasons why we need to protect the poor in the community.

Infant and maternal mortality

Regarding IMR, > 60% of infant deaths is reporting from three districts Malappuram, Kasargode and Palakkad.  1200 out of 6500 Infant deaths in the state occur in one district (Malappuram) where there is no maternity hospital or a new borne ICU under public sector. IMR is unacceptably high among tribal population, 5% of the total Infant deaths are in the tribal area; 80 percent of it are due to preventable causes like malnourishment and infections.

The percent of women aged 15 to 49 with anemia in 1998−99 was 22.7 per cent in Kerala. This number has increased to 34 per cent in 2005−06.8 It also finds increase in anemia amongst children in Kerala between 1998−00 and 2005−06. More than 70% of our Primary Health Centers do not have a simple laboratory where hemoglobin of ANC mothers can be tested without much delay or cost.

Quality of health care

It is made through identifying the importance of health promotion and disease prevention in the process of providing good quality health care and improving the quality of life of our citizens. A new health strategy requires participation by all: public, communities, and government.  Health care costs need to be brought down and out-of-pocket expenditures to be reduced.

IMA’s citizens’ health charter

Box 1. Goals and Strategies in IMA Citizens’ Health Charter

Box 1. Goals and Strategies in IMA Citizens’ Health Charter

On 8th November 2014, at its 57th Annual Conference at Kovalam, Trivandrum India, the Indian Medical Association Kerala State branch accepted adopted and proclaimed a Citizens’ Health Charter along with ‘Kerala Health: 2025 – A Road Map’ specifying the goals and effective strategies to achieve them by 2025. The charter calls for an acceptable level of health care for all, which can be attained by the year 2025 through an optimal use of the existing and available resources, an evidence based State health policy, accepting the role of social determinants of health and to ensure the provision of safe drinking water and sanitation; safe and healthy food; nutrition and housing; healthy working and environmental conditions; health education and information and gender equality.

Thus the general approach should be to adopt a synergistic approach by relating health to determinants of good health viz. nutrition, sanitation, hygiene, safe drinking water and other environmental conditions. The overall goal should be to improve the availability of and access to good quality health care to the people, especially the poor and marginalized, for those residing in rural and remote areas, the tribal community, the urban poor, women and children and the elderly. Proposed goals and strategies in the Citizens’ health charter are given in Box 1. Hope that the charter will be widely accepted and adopted by policy makers and political entities as a guiding document while shaping the health policy for the state

End Note

Author Information

  1. V Mohanan Nair, Former Director Indian Institute of Diabetes, Trivandrum.
  2. Althaf A, Associate Professor, Department of Community Medicine, Medical College
    Trivandrum.
  3. Benny PV, Associate Professor of Community Medicine, Sree Gokulam Medical College,
    Venjaramoodu, Trivandrum.
  4. Muhammed Shaffi, Assistant Professor, Global Institute of Public Health, Ananthapuri Hospitals, Thiruvananthapuram.
  5. S Vasudevan, Associate Editor, IMA, Kerala Medical Journal & Professor of Urology, Medical College, Trivandrum.
  6. K Rajamohanan Pillai, Professor,
    Department of Pediatrics, Medical College Trivandrum.
  7. VP Paily S, Senior Gynaecologist,
    Rajagiri Hospital, Aluva
  8. Sreejith N Kumar, President, IMA, Kerala State Branch.
  9. SS Lal, TB Director, Global HIV & TB Program, PATH, Washington DC.
  10. Muhammed Asheel, Indian Medical Association
  11. Sandeep K, Indian Medical Association
  12. Zuhail Sainudeen, Indian Medical Association
  13. Santhosh Kumar GR, Convenor, IMA Film Club.
  14. Asha KP,  Assistant Professor, Department of Community Medicine
    TMC Alappuzha.
  15. Mini SS, Assistant Professor, Department of Community Medicine, Government Medical College, Parippally, Kollam
  16. Libu GK, Assistant Professor Community Medicine Medical College Trivandrum.

All Members of IMA Drafting Committee on Citizen’s Charter 2014    

Conflict of Interest: None declared

Editor’s Remarks: This charter was adopted to set standards in the Health sector. IMA assumes responsibility to set these standards.

References

  1. Thankappan KR, Valiathan MS. Health at low cost: the Kerala model. Lancet. 1998;351:1274–5.
    [Source]
  2. State Planning Board (2014). Report of the Expert Committeeon Health.Online. Twelfth Five Year Plan (2012-2017). Government of Kerala.
    [Source]
  3. Registrar General, I. (2011). Census of India 2011: provisional population totals-India data sheet. Office of the Registrar General Census Commissioner, India. Indian Census Bureau.
    [Source]
  4. National Crime Records Bureau (2006). Government of India.Online.
    [Source]
  5. Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J. 2013 Jan;34(2):121–9.
    [Pubmed] | [Crossref]
  6. RCC Trivandrum. Kerala Cancer Registry. Accessed on 10 May 2014.
    [Source]
  7. National Sample Survey Organization (2006). Ministry of Statistics & Program Implementation, Government of India. Employment and Unemployment Situation in India, Part 1, NSS 61st round, (July 2004 – June 2005), Report No. 515(61/10/1).
    [Source]
  8. International Institute for Population Sciences (IIPS) and Macro International (2007). National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.
    [Source]