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close this bookKerala: Radical Reform as Development in an Indian State (FF, 1994, 140 p.)
View the document(introduction...)
View the documentAcknowledgments
View the document1. Introduction to the 1994 printing
View the document2. The land of coconuts
View the document3. Kerala's achievements
View the document4. Behind Kerala's success
View the document5. Food for all
View the document6. Health
View the document7. Education
View the document8. Land reform
View the document9. Helping workers
View the document10. Overcoming caste
View the document11. Women and the Kerala reforms
View the document12. Lessons from Kerala
View the documentNotes
View the documentNotes to the introduction
View the documentBibliography
View the documentInstitute publications
View the documentAbout the institute

6. Health

Following the provision of food, perhaps nothing is more crucial to human life and welfare than conditions for basic health. These include at least two major components: public health and sanitation programs to prevent illness, and adequate health care when illness occurs. Kerala has made major accomplishments in both of these areas. At the same time, we would emphasize that gains in health are not the product of health programs alone, but result from the combined effects of the various reform programs discussed throughout this report.

Public Health Programs in Kerala

Kerala's public health efforts center on four areas, housing, sanitation, water, and vaccination programs. We shall briefly survey the accomplishments and problems in each area.


Poor housing can be a major source of disease. Dirt floors and palm roofs attract bacteria and mosquitoes. Overcrowding exacerbates the spread of infections and parasites. The Indian census of 1971 found that 20 to 25 percent of housing in Kerala was "not fit for human habitation."49

Improvement in housing has thus been a major need in the state even in recent times. Kerala responded by adopting and expanding a national government program to build housing for landless laborers. The Kerala plan is known as the One Lakh Houses Scheme after the Indian word lakh, meaning 100,000. In each of Kerala's 960 village units or panchayats, 100 such houses were to be built for a total of 96,000 units. Each was to have 250 square feet of floor space, with three rooms, a hard foundation, cement floor, sun-dried brick walls, and a the roof on beams taken from hard wood in the state's forests. Although the plan was not fully successful and cost far more than originally envisioned, 57,000 houses had been built by 1978. In addition, several tens of thousands of low-income families had houses built or improved under various supplementary programs undertaken by the state government. In 1971 Kerala had the best rooms-to-people ratio and was seventh out of fifteen Indian states with 46 percent of its housing described as "reasonably good." The all-India average was 38 percent. In 1986-1987 over 8,000 houses were built and another 85,000 plus were renovated.50 The improvement in housing conditions has thus affected a large portion of Kerala's poorer families in the last fifteen to twenty years. Despite these changes, housing conditions remain critical for Kerala's rural workers and small landowners. The Left Democratic Front government elected in 1987 has proposed rehabilitating 50,000 such houses in 19881989, along with a 50 percent increase in expenditures per house over the older plan.51


Improving sanitation has been an activity of the government of Travancore (southern Kerala) since the late nineteenth century, when Town Improvement Committees and Rural Conservancy Establishments were set up to disinfect wells and water tanks, remove feces from public roads, gravel the roads, and supervise health conditions at markets and religious festivals. Construction of safe latrines was also set as a goal, but progress has been much slower. Many rural families still use open-air sites for human waste disposal. Current budget allotments for these latrines and for sewage appear insufficient to meet the state's ambitious target of safe waste disposal in 80 to 100 percent of urban areas and 25 percent of rural areas by the end of the 1980s.52 The dispersed rural settlement pattern in Kerala, however, offers a built-in advantage in sanitation. Since houses in the villages are not crowded together as in many other parts of India, transmission of infectious diseases may be a less serious problem.

Safe Water

Of all the sanitation measures, provision of safe drinking water is probably the most significant in curbing the spread of parasites and infections. International data indicate that for thirty-three countries with the highest infant mortality rates, only 21 percent of rural people have access to safe drinking water. Another thirty poor countries with slightly better rates have an average of only 33 percent of rural people with access to safe water. India member of this second group-claims 47 percent for rural areas, 80 percent for urban areas, and 54 percent overall.

In Kerala in 1980-1981,29 percent of the rural population and 72 percent of urban dwellers had potable water, but by 1985 the figure for rural people had risen to 41 percent as against the all-India average of 56 percent. By 1988, 82 percent of Kerala's urban population had protected drinking water. Despite the impressive gains, Kerala does not appear to stand out among Indian states in terms of access to safe water, and gastrointestinal infections causing diarrhea remain a problem. At the same time, villages with serious water supply problems are among the lowest in India, at only 1 percent, placing Kerala among the group of eight states with extremely low numbers of problem villages.53

Another type of water problem facing Kerala in the 1980s has been the onset of prolonged droughts in a region that once had no shortage of water. Kerala is served by two monsoons: a major one from June to September and a smaller one that comes in October and November. The longest dry spell is from January to the end of May. Average rainfall has declined from the 1960s through the 1980s. Many observers attribute this decline to the severe deforestacion of the Western Ghat Mountains. In 1905, 44 percent of Kerala was forested. By 1965 this had dropped to 27 percent, in 1973 to 17 percent, and by 1983 to only 7 to 10 percent. Soil studies seem to confirm severe erosion in the Ghats, and it may be that Kerala's once-abundant water supply is threatened by human destructiveness.54

If rainfall is truly declining in the long run, Kerala's rural people could face a major public health crisis. Even now, wells in the upland areas run dry in the late dry season and women can be seen walking several miles per day to kill water containers for use in cooking and washing back home. Govemment programs to combat this problem include the short-term measure of drilling deep motor-driven wells in affected villages and the longer-term massive reforestation projects that are currently in the planning stage.


Preventive immunization and vaccination are Kerala's most impressive public health programs. Smallpox vaccination in Travancore began in 1879. It was first made available to government workers and then to the urban and rural populations in general. By 1935, 59 percent of the people of southern Kerala were protected and by the following year nearly the entire population.55 Similar programs were undertaken to eradicate cholera and malaria. The latter disease required the cleaning up of mosquito breeding areas more difficult task than vaccination.

Sanitation and vaccination programs combined with the widespread access to professional health care in Kerala to produce dramatic reductions in several major diseases associated with underdevelopment. Table 7 gives a picture of the decline for the princely state of Travancore, which became the southern part of Kerala when the state was formed in 1956.

By 1970 smallpox was entirely eradicated, making Kerala the first state in India to achieve that goal. Malaria has also been wiped out and has not reappeared in Kerala as it has in many other parts of India. In 1976 Kerala's malaria rate per thousand was zero, compared to the all-India average of eleven, with the high-income state of Haryana having the highest rate at sixty-six.56

TABLE 7: Deaths by Diseases in Travancore, 1900 1940 (per Thousand)
















Fevers (including malaria)





Dysentery/ diarrhea





SOURCE: Panikar and Soman 1984:33.

Of all the age groups in Kerala, children show the most dramatic effects of the health programs. As already discussed, Kerala's infant mortality rate is very low (see tables 1 and 2). In addition, children under five fare much better in general than in the rest of India. In 1968-1970 (the latest period for which we could locate an appropriate comparison), Kerala recorded only twenty-four deaths per thousand children in that age group, far better than any other Indian state and nearly three times below the all-India average of sixty two. Although the death rate for these children is separate from the infant mortality rate, it is a statistical component of Kerala's higher life expectancy as indicated in tables 1 and 2. UNICEF has recently proposed that the under five child survival rate be considered the single most informative development indicator.57

Health Care

Along with public health measures, Kerala has provided the most extensive set of medical treatment facilities of any Indian state. In 1982 there were nearly four times as many hospitals and nearly twice the number of hospital beds per 100,000 people as the all-India average. The ratio of doctors to patients was also 18 percent above the average for the country as a whole. In 1982 Kerala spent 35 percent more per capita on health care than the all-India average.58 Data in table 8 indicate Kerala's superiority in the delivery of health treatment to its rural population as compared with the rest of India.

TABLE 8: Comparison of Health Services, 1979-1980a




Hospital beds (per 100,000)







Average area served per health center (square kms.)

Primary center



Health center



Family welfare



Persons per










SOURCE: Zachariah 1983:13.

(a) A detailed map showing the nearly even distribution of health facilities is included in UN 1975. We may note also that in 1983, 24 percent of Kerala's doctors and 98 percent of its nurses were women (GOK 1984:77). We have not located a comparable all-India figure. Additional comparative hospital statistics are given in ICSSR 1983:108.

From this table we can see the unique features of Kerala's health delivery system. Services are available throughout and across the state to both urban and rural areas. Rural hospital beds are much closer to prospective patients in Kerala than in the rest of India. This helps explain why since 1965, 80 percent of all patients treated were able to get to hospitals and not just to less wellequipped primary health centers. This was far above even the nearest competitor state of Tamil Nadu, which has a 54 percent hospital treatment rate.59

In 1973 Kerala had 90 beds per 100,000 compared to the all-India average of 56. In 1981 Kerala could claim 125 beds compared to the all-India average of 70. In 1988 the number of beds was up to 127. By 1981 Kerala had 46 doctors and 3.5 hospitals per 100,000 persons compared with India's 39 doctors and one hospital for the same number.60 From table 3 earlier in this report we can see how much more accessible are all levels of health facilities in Kerala compared with other Indian states.

Kerala's Low Birth Rate

One of Kerala's most impressive achievements has been the dramatic decline in birth rates. As can be seen from table 1, the 1986 rate is only twenty-two per thousand women of child-bearing age, about one-third lower than the all-India average. In 1987 the rate declined to twenty-one per thousand.61 Some observers have linked this low rate to Kerala's general poverty and high unemployment rate or to changing attitudes towards the birth of sons.62 Various studies show that the state's redistribution of wealth and provision of basic health care are the main explanations, however.

This can be proven in the following way. First, detailed statistical research indicates only a weak connection between income and birth rates both for Indian states and for the various districts of Kerala themselves.63 Second, Kerala's birth rate decline came first in the districts of Travancore and Cochin, where public health measures and access to health care facilities were also earliest to develop.64 A recent comparative study found in one Travancore suburb that 72 percent of all births were attended by medically qualified personnel as compared with only 8.5 percent in a village in the Indian state of Andhra Pradesh.65 Third, comparative data for India and Kerala indicate that the most powerful factors correlating statistically with birth rates are the combined set of literacy, infant mortality, and life expectancy.66 Fourth, higher educational levels increase the relative cost of raising children. This rise in cost, together with the greater expectation of child survival through improved health measures and the expansion of old age security through government pension programs (discussed in chapter 9) has reduced the need and the incentive for poor farmers and farm labor households to have larger numbers of children.67 As Kerala birth rate expert K. C. Zachariah has put it in summing up the determinants of Kerala's dramatic birth control success: "In Kerala, the determinants came in the right order-a reduction in infant and child mortality, followed by or along with an increase in female education, followed by redistributive policies, and finally the official family-planning programme."68

John Ratcliffe has put the issue in broader terms:

Development [in Kerala] was achieved, purely and simply, through implementing development strategies based on equity considerations. The more just and equitable political economy that has resulted serves sharply to distinguish Kerala from other Indian states. And, therefore, so do its demographic characteristics.

The Kerala experience...clearly supports the theoretical perspective that low levels of fertility result from public policies that effectively increase levels of social justice and economic equity throughout society.69

Popular Struggles and Health Care

Kerala's health care is a popular demand that the government is compelled to meet. Anthropologist Joan Mencher, who has worked in Kerala and other parts of India for thirty years, sums up the situation as follows:

In [ the nearby Indian state of ]Tamil Nadu, more than half the times I visited a primary health centre [PHC] one doctor was on leave, another was attending a conference, or one doctor had just been transferred and another was off on some training programme, or had gone to see his or her sick mother, etc. This was not the case in Kerala. When I visited a primary health centre in Kerala, I normally found the two doctors assigned to the post there hard at work and people waiting in a queue for treatment. If a doctor had to take leave, a substitute was normally provided and the doctor was expected to account for leave time very carefully. Furthermore, Kerala doctors on the whole did not regard working in primary health centres as a dead-ened job; rather, it was viewed as preferable to setting up practice on one's own.

Mencher goes on to note that "in Kerala, if a PHC was unmanned for a few days, there would be a massive demonstration at the nearest collectorate [regional government office] led by local leftists, who would demand to be given what they knew they were entitled to".70

Anthropologist Kathleen Gough recounts an incident in 1962 when angry neighbors dragged a physician from a cinema and forced him to go to the hospital to deliver the baby of a woman who was in great pain.71 Another observer notes that Kerala village governments, trade unions, and political parties often submit written demands to higher officials for improved health care facilities. Such demands are widely circulated in the local press. If they are not met, unions may strike or other public agitations may occur. In some cases, officials have been gheraoed, or surrounded by protesters who do not allow them to leave their office until demands have been met.72

A study conducted in the early 1980s confirmed the cultural and administrative effects of Kerala's popular health struggles. Among the many positive features of a Travancore primary health center, the researchers found that all the staff were regularly at work as required, that doctors and nurses came mostly from the caste and gender backgrounds of their patients, that the chief physician made daily visits to the appropriate neighborhood substations, and that medicines were not being stolen and were always available to patients. The center had even more women than were required by law, which made family planning efforts easier to administer. Serious illness could be referred to a fully equipped hospital nearby.73 For people who have not lived in the third world, it may be difficult to appreciate this description. For those who have, it will seem unbelievable. The routine practices at this Kerala health center are something hundreds of millions of people in the underdeveloped nations can at present only dream of.

In Kerala, health care is a right. Ordinary people have struggled for it. They expect it. They demand it. They continue to struggle to maintain, expand, and improve it.