HISTORY OF THE PUBLIC HEALTH

ADMINISTRATION IN KERALA:
PROBLEMS AND PERSPECTIVES

THESIS SUBMITTED TO THE UNIVERSITY OF KERALA

FOR THE AWARD OF THE DEGREE OF
DOCTOR OF PHILOSOPHY
INHISTORY

BY

SANDHYA.J.NAIR

Under the supervision o f

Dr. M.NOORJAM BEEVI

Associate Professor & Head (Rtd)
Department of History
University College
Thiruvananthapuram

UNIVERSITY LIBRAY
UNIVERSITY OF KERALA
THIRUVANANTHAPURAM
AUGUST 2018
 LNTRODUCTiON

M odem Societies are m ore concerned about the studies on public o n en ted

subjects in connection w ith the society as a w hole. B efore the 18'^ century there was

no m uch m ore serious studies in this regard w ere started. A ccording to Foucault, all

such areas o f studies w ere started as a result o f the concentration o f pow er under the

control o f the E uropeans. T he Europeans alw ays believed that they are superior to

any other nation o r civilization m the world. So they started a pow er on en ted

adm inistration. T his m ethod w as started in all realm s o f aam im stration. This

adm inistration introduced changes or developm ents in all fields o f know ledge and

adm inistration. F oucault states that as result o f the developm ents that w ere occurred

in the 18'^ century, health becam e an im portant aspect o f know ledge. H ealth is also

such a lleld o f study.

A ccording to F oucault ’'W estern m edicine w as originated as a collective

practice, and w hich was endow ed by certain m agico-religious institutions w ith its

social character and gradually dism antled through the subsequent organisation o f

private clienteles, the extension o f a netw ork o f personnel offering qualified m edical

attention, the grow th o f individual and fam ily dem and for health care, the em ergence

o f a clinical m edicine strongly centred on individual exam ination, diagnosis and

therapy, the explicitly m oral and scientific- and secretly econom ic- exaltation o f

■private consultation', in short the progressive em placem ent o f w hat w as io becom e

the great m edical edifice o f the nineteenth century, cannot be divorcee from the

co n cu rren t organisation o f a politics o f health, the consideration o f disease as a

political and econom ic problem for social collectivities w hich they m ust seek to

resolve as a m atter o f overall policy, 'P rivate' and 'socialised' m edicine, in their
reciprocal support and opposition, both derive from a com m on global strategy. No

doubt there is no society w hich does not practice som e kind o f 'noso-politics'; the

eighteenth century didn't invent this. B ut it prescribed new rules, and above all

transposed the practice on to an explicit, concerted level o f analysis such as had been

previously unknow n. At this point the age is entered not so m uch o f social m edicine

as o f a considered noso-politics.“ ‘ B y noso politics F oucault described about the

politics o f diseases and roles played by governm ents lo generate conviction am ong

pop ulation or public.

T h e ideas forw arded b y F oucault is applicable to the studies o f public health

adm inistration. In addition to the view s o f Foucault. Partha C hatterjee explains this

problem in a different m anner in his book. ‘Politics o f the G overned R eflections on

popular Politics in m ost o f the W orld' also describes that all the questions o f public

w ere started as a result o f the m odernization o f the m iddle class society by the

colonial governm ents. In the issues o f public health, education and other such issues,

m ainly involved w ere the m iddle class group o f the society. T his w as as a result o f

the m odernization o f the m iddle class or their inclination o f being m odernized. In the

case o f India, m odernization o f all public issues w ere happened m ore o r less in a sam e

w ay. It w as as a result o f their need to becom e cultured people or groups.

H ealth is a fundam ental right as w ell as a public right. B ut P ublic H ealth is a

m ulti professional discipline. U is a state o f total effective physiologic and

psychological functioning, Public H ealth is the “science and art o f preventing disease,

prolonging in life and prom oting hum an health through organized efforts and

inform ed choices o f society, organisations, public and private com m unities and

individuals*'" It is an integral part o f social developm ent and creates w ealth. Public

health is dedicated to the com m on attainm ent o f the highest level o f physical m entai

and social w ell-being and longevity consistent w ith available know ledge and

resources at a given tim e and place. It hold this goal as its contribution to the m ost

effective total developm ent and life o f the individual and his society. A ll those who

are involved in developing program m es and services to tackle the causes o f the m ost

com m on diseases need to have a public health perspective. Public health program m es

are considered as. M ass vaccination and treatm ent. N utrition, Fertility, Environm ental

health; w ater, sanitation, v ecto r control etc., K IV /A ID S and sexually transm itted

infections, T obacco and drugs. P ublic health deals w ith the health o f the w hole

population. Public health professionals have a responsibility to im prove the health o f

the w hole population not ju s t to those m em bers o f the m ost visible population, those

w ho com e to the health facilities. W orld H ealth O rganization in its constitution

defines public h ealth as H ealth is a state o f com plete physical m ental and social w ell-

being and not m erely the absence o f disease o r infirm ity. T he aim o f public health is

to p rovide the best possible health services for everyone and everyw here.

T he term public health becam e so popular during the 19th century. Public

health alw ays tries to increase the quality o f life by introducing different preventive

m easures, eradication program m es etc. It alw ays aim s not only physical health, but

m ental health also. It is concerned w ith threats to the overall health o f a com m unity

based on population health analysis. P ublic health is m ultifaceted area o f study. It

includes as m any sub fields, but typically include the interdisciplinary categories o f

epidem iology, biostatics and health service. Environm ent health, com m unity health,

behavioral and o ccupation health are also im portant realm s o f public health.^ T he

focus o f public h ealth interventions is to prevent and m anage diseases, injuries and

o th er health conditions through surveillance o f cases and the prom otion o f healthy

behaviours, com m unities and environm ent. Its principal aim is to prevent health

problem s. P ublic health m easures alw ays trying to avoid reoccurring o f diseases by

im plem enting educational program m es, developing policies, adm inistrating services

and conducting research etc. T reating diseases or controlling a pathogen is v ital in the

health status o f a society. V accination program m es are exam ples o f com m on

preventive m easures o f public health. Public health also lakes various actions to lim it

the health disparities betw een different areas o f the country. O ne issue is the access

o f individuals and com m unities to health care, in term s o f financial, geographical or

socio cultural constraints in access to the use o f services. Due to various policies and

actions, a public health strategy w as developed in the tw entieth century, and

w itnessed a decrease o f m ortality rates in infants and children and continual increase

in life expectancy."*

H ealth care is the diagnosis, treatm ent and prevention o f disease, illness,

injury and other physical and m ental im pairm ents in hum ans. P ractitioners in

m edicine, dentistry, nursing, pharm acy, allied health and other health care providers

d eliver health care. It refers to the w ork done in providing prim ary care, secondary

care and tertiary care as w ell as in public health. H ealth care system s are

organizations established to m eet the health needs o f target populations. H ealth care

can form a significant part o f a c o u n try 's econom y. H ealth care is conventionally
regarded as an im portant determ inant in prom oting the general health and w ellbeing

o f p eoples around the w orld

Public health care is based on fo u r principles o f E quitable D istribution,

C om m unity participation, Inter-sector coordination and A ppropriate Technology.^

E quitable distribution to all people is the first strategy o f health service irrespective o f

their ability to pay w hether they belongs to urban o r rural disparity. T he social

injustice due to inaccessibility o f m edical facilities w as redressed by shifting the

centre o f gravity o f health care system from cities to the rural poor as near peo p le’s

hom e as possible. C om m unity participation includes the involvem ent o f individuals,

fam ilies and com m unicates in prom otion o f their ow n health and w elfare including

self-care. T he com m unity should participate in the planning im plem entation and

m aintenance o f health services o f a state is necessary for the prom otion o f health care

system . Inter S ector coordination refers to a strong political support and that support

will translate values into actions. By proper planning w ith sectors other than health,

such as agriculture, anim al husbandry, food, industry, education, housing public

w orks, com m unications etc. will boost the health care system s. A ppropriate

T echnology is anoth er necessary tool for im proving the level o f health care system .

T echnology m eans, “ scientifically sound, adaptable to local needs, and acceptable to

those w ho apply it and for those w hom it is used, and that can be m aintained by the

p eo ple them selves in keeping w ith the principle o f self-reliance w ith the resources the

com m unity and country can afford."^

P u rp o s e o f th e stu d y

Public health in India as a v'hole. is not only the result o f the colonial

intervention. In the book S cience and Raj, A Study o f B ritish R aj, D eepak K um ar

states that before the colonial intervention itself, India possessed its ow n m ethods o f

treatm ent and m edical practices. T he sam e was the case o f K erala also.

T h e purp o se o r the relevance o f the study is to explore the developm ent o f the
public health adm inistration in K erala and its im pact on society through a historical

perspective. Even before the introduction o f m odem system s o f m edical care the land

w as in touch w ith different fom is o f m edical oractices. L ater only, the elem ents o f

public health w ere started. T he study is trying to explore the significance o f practices
existed in this land and chronologically trying to explore the introduction o f oublic

health and the im portance given b y the people and the governm ents w hether they are

royal, colonial o r dem ocratic. T he study exploring the health policies o f the various

governm ents and p roper m edical aids given to the people not only physical but also

m ental w ellbeing. It also trying to give details o f the activities and m easures started

by the central and state governm ents after m dependence o f the nation and form ation

o f the state respectively, P ublic health is a universal term and it the duty o f any

governm ent to o ffer am ple space for public health T he health conditions o f a state

alw ays determ ine the other elem ents o f social and com m unity life o f a society.

T he colonial intervention in the field o f health subversively altered the

condition and brought a new situation in w hich m odem m edicine affordable and

accessible to a sizeable section o f the people. T he focus o f the public health

inteiT ention is to prevent and m anage diseases, injuries and other health conditions

th rough surveillance o f cases and prom otion o f healthy behaviours, com m unities and

environm ent. Public health plays a prom inent role in the prevention o f diseases. In

addition to preventing m ethods, it the duty o f all govenm ients to introduce steps to

eradicate the problem s those are existing. A s far as K erala, is concerned, as slated

earlier, there existed an aw areness o f being good in term s o f health. T he life pattern

explains it. Later, as a result o f colonialism and introduction o f m odem m edical

cares, the conditions o f the state developed far m ore.

A re a o f S tu d y

In the field o f public health. K erala has com pleted a long w ay as com pared to

the country as a w hole. T he uniqueness o f the achievem ents, K erala stand out not

only from the rest o f India, but also in the w orld. K erala provides, a vivid

dem onstration o f the real cost o f health care instrum ents w hich all countries can

em ulate, w hether rich o r poor. For exam ple, K erala is the first baby friendly state, the

first polio eradicated place, no fem ale infanticide, has the low est death rate in India.

T his w as largely due to the interventions m ade by the governm ent b y declaring public

h ealth as a state subject along w ith a view that it is the right o f people, not a single

m atter but so m any social refo m i m ovem ents and other socio-econom ic determ ining

factors, private undertaking, increased rate o f literacy, nutritional program m es etc. are
responsible for K erala s developm ent in the particular area. Even though such

achievem ents w ere gained, certain cardinal issues are pertaining to the reputation
achieved.

C onceptual F ram ew ork

C ertain key concepts are used for the present study as significant. T hey are

the follow ing;-

P u b iic H ealth

Public health is defined as the state o f com plete harm ony o f body, m m d and

spirit. It is not the stage o f absence o t diseases, but it is the state aw ay from the

disabilities o f body and m ental distraction, A gain it is the social, econom ic and other

securities and surroundings o f a society to keep the society healthy. A s far the state o f

K erala possess such a situation and circum stances.

D evelopm en t

D evelopm ent is the use o f scientific and technical know ledge in the process o f

social and econom ic transform ations from one condition to a better condition. It is a

process o f m aking im provem ents in the existing situations. In the field o f public

h ealth o f K erala, developm ent has happened as a result o f continuous and steady

process through different phases.

S o d a ! Security

Social security is the situation w hen a society is w ell balancing w ith incom e,

social status and other hum an rights w hen tne governm ent is ready to ensure all these.

In the case o f India, it is the fundam ental nght. The idea o f public health belong to

the category o f social security and it is the duty o f the state to provide the condition.

In India, therefore, public health is a fundam ental right and governm ent is alw ays

supporting the health care m easures o f her states.

P erspectives

Perspectives is the understanding o f influential m atters by ju d g in g ana

analyzing them . In this thesis perspectives m ainly used to indicate about the factors

influencing the public health sector o f the state. So m any factors such as socio­
econom ic factors, environm ental circum siances are affecting the health status o f me
state.

T heories A pplied

T he present w ork has been m odeled on the pattern o f a historical narrative,

B ased on econom ic factors and its influence on society it can be stated that an

econom ic based perspective w riting is follow ed, As M arxist thought envisages,

society is existing in connection w ith econom ic standards. In health sector econom ic

conditions plays a prom inent role than social conditions. It is clearly established in

the thesis. W hen a society is econom ically perfect the society can create social

security on its health sector In the field o f health it is evidenced that econom.ic

standards o f an individual affects his and his surroundings* health conditions largely.

M eth odology

T h e present w ork has been m odeled on the structure o f historical narration

focusing the society as a w hole. D etails and facts have been presented

chronologically. Public health adm inistration o f K erala is the nucleus and all other

m atters are discussed in relation to it. A Sequential pattern has been followed,

O bjectives o f th e Study

T h e study is undertaken w ith the follow ing objectives;

• K erala p ossess d ivergen t form s o f m edical practices and health care

m easures from an cien t p eriod itself.

T he study tries to find out the tradition o f m edical practices and m easures

existed in K erala. It tries to reveal the process o f health care m easures and

significant progress m ade from earlier tim es to till the period o f neo liberal

policies.

• C olon ial intervention and public health m easures

T he study attem pting to explain the introduction o f colonial m easures on

public h ealth sector. It tries to clarify the m ethods introduced by the colonial

people in the three different regions o f Travancore, C ochin and M alabar. It

describes how colonial intervention restructured health as a public subject.

• P olicies o f th e C e n tr a l a n d S ta te G o v e rn m e n ts

By portraying different P olicies introduced to im prove the general condition o f

people, to prom ote active and healthy life o f population, to reduce death rates

etc. by the C entral and State G overnm ents, the study seeking to establish

general health and public health adm inistration are state subjects.

• P ro b le m s a n d P e rsp e c tiv e s

H ealth is the result o f com bination o f different elem ents. I f any o f such

elem ent is absent o r m issing, the total situation m ight be affect. T hereby, the

study exam ines the problem s affecting the public health sector o f K erala and

trying to supplem ent certain instrum ents to be adopt to reduce the problem s.

H y p o th esis

D evelopm ent o f the P ublic health sector o f K erala is a legacy o f the traditional

m edicinal practices and m easures. T he m edical system s and practices existed here

w ere m ainly based on traditional know ledge and indigenous m edical care along w ith a

purified life m anner.

C om ing o f the E uropeans and C olonial intervention subversively altered the

con dition and brought a new situation through w hich m odem m edical facilities w ere

reached this land w hich w as affordable and accessible to a sizeable section o f the

people. C olonial intervention in the health sphere w as prim an ly engineered by the

m issionaries, w hich attracted a num ber o f people to the new m edical system s. T he

introduction o f vaccination, sanitation and other m odem m edical aiim enis becam e

easy th a t’s why. Som e o f the practices existed and the m odem interventions

com m enced here aw arded and accom plished an adm irable position in the realm o f

public health sector. It w as prim arily fo r their benefits, but gradually created positive

results in the society.

T he E conom ic situation o f a state alw ays determ ines its health and hygiene. It

is case o f K erala also. T he determ inant factors o f health such as econom ic, social and

oth er factors supported K erala to achieve good health status in India. T he public

health adm inistration o f K erala occupies a nice standard due to the m ixing up o f

existing m edical care, treatm ent etc. along w ith m odem m edical facilities.
 T he processes involved by the state and central governm ents in the field o f

health sector provided am ble space to achieve the position o f K erala m odel o f

developm ent.

Even though developm ent has been achieved, it lacks o r facing serious

challenges and problem s. T he issues aroused as a result o the negligence show ed

tow ards life pattern, environm ent and traditional know ledge.

A new m odel o f developm ent is necessary for tackling the situation by

assim ilating the form er m odes o f life and traditional know ledge along w ith m o d em

ones fo r the future developm ents.

R eview o f Laterature

T he thesis is com pleted based on both prim ary sources and secondary sources.

Prim ary sources are collected from different sections. T he archival sources w ere

collected form the N ational archives N ew D elhi, T am il N adu State A rchives C hennai,

C entral A rchives T hiruvananthapuram , R egional A rchives at C ochin and C alicut.

C over files, public records, confidential files, tour reports o f the officials o f M adras

G overnm ent, adm inistration reports. T ellichery factory reports, various m edical

registers, R ecords o f M edical C ivil M edical C ode etc. collected from the archives. In

addition, oth er prim ary records w ere collected from N ational L ibrary at K olkata,

K C H R L ibrary T hiruvananthapuram , K erala L egislative A ssem bly L ibrary, Sree

C hithira T hirunal L ibrary at V anchiyoor, P alace L ibrary at K aw adiar, P ublic H ealth

D epartm ent O ffice L ibrary at T hiruvananthapuram , U niversity L ibrary at

T h iruvananthapuram and from Library o f C entre for D evelopm ent Studies,

Thiruvananthapuram . T h e A dm inistrative R eports o f T ravancore C ochin and M alabar

and the G overnm ent o f K erala are w idely used. F or the re construction o f the period

before the state form ation the data collected in a large extent. B ut due to the
p eriodization o f the w ork those data used w ithin a clear speculation. T he T o u r

R eports and T ellichery F actory R eports helped in the reconstruction o f the health

status and m edicinal practices w hich w ere used in the northern regions o f K erala

before state form ation. T he different tour reports especially B uccanan’s is used in the

thesis w idely. It supported to get av/areness about the descriptions o f the diseases and

m odes o f treatm ents that existed during those periods. B efore the state form ation, in
the regions o f T ravancore and C ochin the A dm inistration R eports supplied w ide range

o f in fo n n atio n regarding the concerned area.

T h e sources such as handbooks, annual reports and souvenirs published by

the D epartm ent o f Public H ealth o f K erala are used to know about diseases reported,

m easures adopted to solve the problem s, new initiatives o f the G overrm ient on

particu lar issues etc. It also gave good and enough su p p o n ed to calculate the am ount

o f expenditure, n um ber o f hospitals or clinics in the state, prim ary, secondary and

tertiary m edical centres, num ber o f beds in hospitals, etc It also gave inform ation

regarding the officials, staffs o f the departm ents. B ut the ratio regarding the officials

o r staffs are not used and referred in this w ork, as it is connected w ith the m easures

out o f it.

T he C ensus R eports, E conom ic R eview s and E conom ic Surveys o f the C entral

and state governm ents planning b o aras gave details o f population, D ifferent ratios o f

population such as sex ratio, fem ale literacy rate, infant m ortality rate, m orbidity and

m ortality rates o f the state o f various years. It supported to handle the ideas

regarding the expenditure statem ents included in the Five Y ear Plans on health sector

also. A nother im portant sources are, different district gazetteers o f published.

For the construction o f the them es o f individual, public, population, nationalism

and issues crept in the adm inistration o f public health, and establishing facts, the

books o f M ichael F oucault, Partha C hatterjee, B ipan C handra etc. are used. T he

influence o f pow er on the spheres o f life and know ledge concepts o f F oucault

supported a lot. Public health and creation o f clinics or hospitals are due to the

em ergence o f individualism o f the society, instead o f the concept o f state as a w hole

individuals got due im portance in the m odem period,

N ationalism and concept o f a single oriented life is m odelled in the book edited by
B ipan C handra, In d ia a f te r In d e p e n d e n c e . In this book C handra states, nationalism

and concepts o f m odern ideologies are the contributions o f the colonial governm ents,

and firstly they used for their benefits. Later it provided a platform for the

developm ent o f the colonial states. In India also, the elem ents o r branches o f public

h ealth w as the contribution o f the colonial governm ents. H e also states, the public

h ealth m easures m ainly centred in the urban areas, and the rural areas w ere kept alo o f
from the m ain stream s o f public health. But, as in any other circum stances, chances

o f m odernity w ill crept into the nearby areas. T hus, in India, the rural areas got in

touch w ith m odern perceptions. T h a t's w hy the C onstitution gave public health such

an outstanding position.

B ut in the book. P o litics o f th e G o v e rn e d R eftectaons on p o p u k r P o iitics Im

m o st o f th e W o rld , P artha C hatterjee states, as a result o f m odernization and thirst

fo r culturally ideal m iddle class society w as responsible for the so called m odem

im provem ents em erged in the colonized nations. T h at’s w hy, m odern societies

p roduced legislatures and other regulations o r law s for the new ly developed idea

h ealth as a right o f the public o r population. It is sim ilar in the case o f India also.

T he concepts o f form er C hilean P resident S alvador A llende’s w ritings are

u sed to analyse the role o f econom ic factors that are determ ining the individual life

an d thereby its influences o v er the nation as a whole. H e forw arded his ideas o n the

b asis o f the factors o f the L atin A m erican countries. B ut the concept is m ore o r less

effective in the cases o f the T hird W orld C ountries. O nce he stated that the capitalist

im perialism , particularly the m ultinational corporations that extracted profit from

natural resources and inexpensive labour. H e tried to establish and tried to im prove

the h ealth care system , as a p opular governm ent m ust end capitalist exploitation. In

his ides h e considered m edical problem s include m aternal and infant m ortality,

tuberculosis, venereal diseases, other com m unicable diseases, em otional disturbances

and occupation illness. H e observed that m aternal and infant m ortality rates generally

w ere m uch low er in developed than in underdeveloped countries. C auses o f death,

according to him are m al nutrition, p o o r sanitation and other factors. A ddiction

another issue noted by A llende in the health policies. H e states any type o f addiction

cause harm s to the society. H e is considering the addiction are causing m ainly due to

econom ic, social and psychological issues. E ven h e stated all facts in the case o f C hile

in particular, it is applicable in the case o f India and K erala in general.

E liot F ried so n ’s A S tu d y o f th e S ociology o f A p p lie d K n o w le d g e discuss the

in troduction o f w estern m edicine and the profession o f m edicine as a challenging one.

T he ideas presen ted are stim ulating and thought provoking. T he book gives the
expanding dom ain o f w hat illness and the contention o f physician about their rights as
professionals. In his book, he expertise the m ask o f privilege w earing by the

p rofessionals and explains about their dogm as in the form o f pow er.

Fraser B rock ing ton’s W orld H e a lth describes the m eaning o f health and public

h ealth and the m aintenance o f health. A s a practitioner o f social and preventive

m edicine and historian explained about colonial activities on public health. H e states

m alnutrition causes diseases and it m ust take care o f the children to m ake public

h ealth a classical one.

C olon ialism , C u ltu re and R esistan ce w ritten by D r.K .N .P anikkar is a book

bestow ing ideas regarding the facts o f cultural resistance m the colonial period. In the

book the author describes in detail that about the different types o f resistances w ere

occurred in the regions. A ccording to the w riter, one such resistance can see in the

field o f indigenous health sector,

N eshat Q uaiser’s book. H ealth , M edicin e and E m pire (perspectives on

C olon ial India) is a collection o f essays on the particular areas. O ne o f such essays,

P olitics, C u ltu re and C olon ialism -U n a n i's D ebate w ith D octory, explains m odem

m edicine w hich cam e to be intricately linked w ith colonialism , and w hich is

com m only know n as ‘D octory’ in the Indian subcontinent. T he doctor and ilai-

m o d em m edical treatm ent em erged as pow erful sym bols o f colonialism and the

colonial state. T h e doctor w as one o f the visible representatives o f E uropean

know ledge. A doctor according to the w riter sym bolized the m odem m edicine. In

fact, being visited by a doctor becam e a sym bol o f high status and m odernity.

Scien ce and th e Raj: A Study o f B ritish India, w ritten by D eepak K um ar

explains how far the colonial m le interm pted in the indigenous m edical practices o f

India. T h e book supported to locate the developm ents o f science in India. T he book

d escribes about the role o f colonial governm ents in the field o f sanitation, vaccination

and other elem ents. B ut to certain extent the book conveys that here existed a strong

and enough m edical practicing system even m the absence o f m odem paradigm s o f

h ealth and hygiene. T he book provided adequate support for the reconstruction o f

colonial interventions in th e field o f public health.

R adhika R am asubban’s book. P ublic health and M edical R esearch in In d ia ;

T heir origins under th e im p act o f B ritish colonial policy exam ined about the
12
process o f researches started during the tim e o f colonial periods. T his book explains

how India passed into the passage o f the introduction o f vaccination. It explains, fear

about different diseases, forced generations to be vaccinated. D ifferent vaccination

policies, process, and sanitation m easures becam e a necessary under the colonial rule

in India is stating by R adhika R am asubban.

A s com paring to the w ork o f R adhika R am asubban, a w ork w ritten by V inin

Perara, Forgotten E pisode o f H istory is translated to M alayalam by K .V .Sivaprasad

titling, C h arith rath in te M arup u ram give an inform ation that India used h er ow n

style o f vaccination in this land and w hich w as reached to the m iddle east through

travelers even b efo re the invention o f vaccination by E dw ard Jenner.

A m ong the M anuals, M alabar M anual o f W illiam Logan, T ravan core State

M anual V ol. I, II and III o f V. N agam A iya, T ravan core State Mamsaii o f T.K.

V elu Pillai, C ochin S tate M anuals o f P.A chutha M enon and P.Sankunni M enon

supplied proficient know ledge for getting aw areness about the respective areas.

Rev. Sam uel M ateer's book N ative life T ravan core explains the life and culture

o f the people o f Travancore. T he book provides basic aw areness about the issues

faced by the com m on people and aboriginal groups o f K erala. T he book describes the

u pper class com m unity enjoyed high status even m the health and m edical care sector

also. W hile the com m on or the others did not have enough provisions o f good

conditions o f life and it gradually led them in the verge o f diseases and disorders.

K .P .P adm anabha M enon’s H istory o f K erla, Vol.1,11 and,H I supported to get

aw areness about the local term s used to indicate the diseases in Kerala. A nother

notable books is K erala M ahach arith ram w ritten by K uruppum V eetil N .G opala

Pillai. It explained about traditional practices and m edicines used in the earlier period

in all o ver K erala. T he B uddhist and Jain centres o f m edical practicing is described in
the book. Elam kulam K unjan P illai’s Sam sarath in te N azhikakkallukal and

C ollected w ork s o f E lam ku lam gave ideas on term s used to indicate physicians o f

an cient period. It inform that ’v elan ’ w as the term used to indicate the local vaidyans

o f the 7'^ to 10'^ centuries and practicing m edicine is referred as Welan veriy attu ’ A

S reedhara M en on’s A S u rvey o f K erala H istory, C ultural H istory o f K erala and

oth er books rendered general indications about indigenous health facilities prevailed
in the state. K D am odaran’s fam ous w ork K e ra la C h a r ith r a m m entions about the

m edicinal practices o f Sangam period. It also clarifies the life o f people, and gives

special references o f term s o f that period. D uring the Sangam period, people

belonging to the w orking com m unities practiced m edicine and it m ay b e later

developed into the style o f “nattuvaidyam " is stated by K .D am odaran. He also states

that there w e can see distinctions in the choice and selection o f m edicines and

treatm ents according to the standard o f living o f the people.

D r.M .R .R aghava V arrier's w ork on A yurveda, The R ed isco v ery of

A y u rv e d a - th e S to ry o f A ry a v a id y a s a la inspired to recollect the history o f

A yurveda and the history o f K ottakkal A rya V aidya sala in propagating A yurveda.

N .V .K rishnankutty V arrier's book A y u rv e d a C h a r ith r a m is perfectly

supported to restructure the history o f A yurveda. T he author clearly exam ines the

p en o d s o f A yurveda by explaining that it w as passed through different stages, that

before the period o f Sanskit, S anskrit period and after. In his book the author is

ready to explain alm ost all areas connected w ith A yurveda and its im pact on the

society o f Kerala. He explains K erala occupies an honorable position in the practice

o f A yurveda, even it is considering the m edicine o f the entire country.

In the reconstruction o f the m edicinal books on A yurveda, the book

K riy a k a u m u d i needs special attention. It is a text using as reference to treat

poisonous bites. T he book contains notable inform ation on herbs, m edicines etc. are

using in the treatm ent along w ith its treatm ent m ethods.

T he book, M e d ic in e in S o u th In d ia - A H isto ric a l A p p ro a c h (-u p to 16*^

C e n tu ry A .D ) by Dr. R. N iranja D evi is a valuable resource for the p resen t study.

T h e book m ade enough and prom pt support in the reconstruction o f different branches

o f m edicinal practices existed in K erala. T he book created an assistance to cover

different tim elines w ith o th er supporting docum ents. Inform ation regarding

S iddhavaidyam and other native m edicinal practices are explained in the b o o k in

detail.

D R .K .K .N . K u ru p 's book, L eg acy o f Islam - A S tu d y o f M a p p ila s o f

K e ra la gave evidences about the health problem s such as diseases, hygienic issues
etc.faced by the m appilas o f M alabar, in the book, he described about their issues

steps taken to solve it are described.

K e ra la F ifty y e a rs a n d b ey o n d w ritten by C.C. K artha, explains the

achievem ents and problem s, prospects o f the health sector. It give detailed

inform ation about developm ent process o f health sector in K erala. M .C. G u p ta’s

book H e a lth a n d L aw provided m easurable findings on how to im prove health and

the considered effort o f m edical profession. A nother w ork used in the study is the

book w ritten by K andoor K rishna Pillai. In his book T ra v a n c o r e a n d Us R u le rs he

explains how public health organization w as started in T ravancore and explains the

role played by the T ravancore royal fam ily in the prom otion o f public health sector.

E v o lu tio n o f M o d e rn M e d ic in e in K e ra la -B io g ra p h ic a l S k e tc h e s of

p io n e e rs in M ed icin e , m e m o rie s o f M ed ica l T e a c h e r, is the w ork o f Prof. K.

R ajasekharan N air. T his b o o k supplem ented the inform ation about the pioneer docs

and practitioners o f T ravancore and issues faced by them ; also give details regarding

th eir experiences and practices-

K e ra la D e v e lo p m e n t th ro u g h R a d ic a l R e fo rm s w ritten by R ichard W .

Franke and B arbara H. C haisan described about the policies and program m es in the

health sector o f K erala. T his book supported docum ents m coim ection w ith the

problem s facing in the developm ent policies o f housing, sanitation, hygiene, good

drinking w ater and hurdles in the w ay o f developm ent.

V arious studies conducted by the K erala Sastra Sahitya P arishad are

extensively used for the com pletion o f the study. T he sm dies done by Dr. V.

R am ankutty, Dr. K .P.A ravindan, D r.K.P. K annan, K .R .T hankappan etc. deserves

special m ention. T heir studies especially in the field o f paradoxes o f the health sector

supported a lot in the construction o f the work. So m any problem s w ere elucidated

through the ideas and inform ation put forw arded by them . T heir studies are valuable

and needs special m ention w hen the w ork is com pleted. T he prom inent w orks o f

Sastra S ahithya P arishad consulted for the study are; H ealth and D evelopm ent in

R ural K erala, H ealth Status o f K erala, Erupatham N oottandode E llavarkkum

A rogyam , K erala A rogya M athruka, H ealth T ransition in Rural K erala 1987-1996, A

S napshot o f K erala -L if e and thoughts o f the M alayalee People.

15
 T h e K erala m odel developm ent is described in the study and the book L im its

to K e ra la M o d el D e v elo p m e n t w ritten by K.K. G eorge tells the financial crisis faced

by the public sector in general and gives a vivid description about the financial

p roblem existing in the health sector in particular. In addition the articles w ritten by

N obel laureate Dr. A m artya Sen supported to find the issues faced in the K erala

m odel o f D evelopm ent. D ifferent articles on the particular issue is consulted for

fram ing o f the problem Just like m odem health sector facing various issues in

connection w ith life culture o f the people. For the com pletion o f the study, different

books, new spapers, e-joum als etc. are consulted. So m any w orking papers o f CDS

are also consulted for the com pletion o f the study. U n published Phd T heses o f Dr.

M .O .K oshy on T he D utch P ow er in K erala 1729-1758, Dr. M .N oorjam B eev i’s ,

E volution o f the L and T enure system in T ravancore (1810-1949), A. A so k a n 's on

S elf-R eported M orbidity, Im patient and O utpatient C are and U tilisation H ealth C are

Services in Rural K erala., N. A jith K u m ar's Entry B arriers to M edical E ducation in

K erala, a R esearch Project etc. have b een consulted.

Interview s also provided probable evidences for the com pletion o f the study.

Interview w ith Dr. K .K .N . K urup on the role o f D utch in K erala and about the

nattuvaidyans o f K erala. T he influence o f colonial m edicine on indigenous m edicm e

and practices w ere also supplem ented in that interview . Interview w ith

V aidyabhooshanam R aghavan T hirum ulpad provided different inform ation regarding

A yurveda.

For getting a solid inform ation regarding nattuvaidyam o r grihavaidayam

repeated interview s and talks w ith the em inent A yurvedic practitioner, scholar ana

saint Sw am y N irm alanda G iri M aharaj helped a lot. S w am iji presented a plenty o f

sources in the study by supplem enting ideas, philosophies and view points regarding

the concept o f health and m edicine through his experiences and findings. H e w as a

living exam ple in the particular field w ho used various conclusions to cure a disease.

D esign o f th e stu d y

For the co nvenience o f study, the period o f study is fixed w ith 1956 to 2000

even though it is not specified in the title. T he periodization covers the first forty four

years after the state form ation. T he period ending on 2000 is so im portant in the

16
health stream o f the w orld itself is concerned. So the study selected its ending tim e to

2000. B ecause, all the international, national and state agencies and governm ents

w ished the y ear 2000 w ill be the successful year w hen every nation w ill achieve the

goal o f ‘'health for all.” It w as the m otto propounded by the W H O in 1970s and m ade

arrangem ents to achieve that goal universally. T he stale o f K erala, contm uously

charted out different program m es for achieving the goal o f health for all. B ut in

course o f tim e, the state realized that it w as not an easy task as w ished by the popular

agencies. From there all agencies w ere ready to accept it failure in that particular aim.

E ven the agencies and governm ents introduced different m odes o f practices for

eradicating com m unicable diseases and other diseases, they realized that it w as futile,

w hen the diseases cam e b ac k w ith variations. Follow ed by this, em ergence o f new

d iseases ow ing to transform ation o f living styles and environm ental changes created

hurdles on the w ay o f achieving the goal o f health for all on 2000. M aking it evident,

d ata up to 2006 has b een collected and arranged. So the periodization becam e fruitful

in the com pletion o f the w ork. T he entire study is m ainly arranged into five chapters

excluding the Introduction and C onclusion,

T h e first chapter is entitled as A N O V E R V IE W O F T H E H E A L T H C A R E

S Y S T E M O F ‘K E R A L A ’ B E F O R E 1956. T his chapter m ainly deals w ith the

m edicinal system s existed in this land o r the different types o f indigenous m edical

practices. T his chapter clearly describm g that the even before the introduction o f

colonial m edicine here existed a sound and ideal p aitem o f m edical and m edicinal

practices, hi the history o f K erala, it is believed that there w ere strong ties o f casteism

w as existed. B ut in the case o f treating diseases, no m uch m ore evidences o f

stringency o f caste system can b e seen. D ifferent com m unities possessed and

practiced th eir ow n styles o f treatm ent. T his chapter clearly and thoroughly

d iscussing about the adm inistrative m easures introduced in the native states o f

T ravancore, C ochin and in the regions o f M alabar. T his chapter briefly describing the

introduction o f m o dem o r E uropean m edicines in this land. B ut after the introduction

o f m o dem m edicine, the land w as/is ready to blending the tw o types o f m edicinal

practices.

T h e S econd chapter D E T E R M IN A N T S O F H E A L T H T R A N S IT IO N IN

K E R A L A discuss about the determ inant factors o f health as a w hole and K erala in
17
particular. V arious determ inant factors are alw ays determ ining the health situations

o f any country. It is also sam e in the ease o f K erala. In addition, in the case o f

K erala, there are so m any other factors are also responsible. A s everyone know s,

K erala w itnessed different socio religious refonns m ovem ents. T hose m ovem ents

directly and indirectly shaped K e rala's health scenario. T he second chapter exam m es

the results produced by the socio-religious as well as econom ic reform s in the health

sector o f Kerala.

T h e third chapter P R O C E S S O F H E A L T H C A R E M E A S U R E S A N D STS

IM P A C T O N K E R A L A S O C IE T Y 1956-2000 discuss about the governm ent

interventions and developm ent o f health adm inistration o f the state since 1956. The

ch ap ter explains how the governm ent o f India gave so m uch im portance to public

health by m aking it a state subject and a right o f the population. T he governm ent so

appointed various com m ittees on different occasions to study about the problem s and

solving m easures to b e introduce in India to elevate h er to the positions o f other

nations o f the w orld. T his chapter explains the policies o f the governm ent. It

explains the expenditure incorporated w ith the Five Y ear Plans for the enrichm ent o f

the health care m easures. T he national and state level program m es for the eradication

o f various diseases, sanitation and vaccination policies etc. are chronologically and

periodically discussed in this chapter. T he introduction o f policies o f the W H O ,

U N IC E F etc. are described in this chapter. The population grow th and m easures to

preventing population grow th, m orbidity and m ortality rates etc, exhaustively

described on this chapter. G overnm ent decisions to m ixing up o f different dom ains o f

m edical practices are also explained. Total num ber o f hospitals/clinics, total num ber

o f beds in hospitals etc. are also included in this chapter.

T he fourth chapter is titled as T H E D E V E L O P M E N T O F H E A L T H

SEC TO R : KERA LA M O D EL O F DEV ELO PM EN T. T his ch a p tc r is trying to

exam ine the health m odifications and K erala m odel developm ent. A lthough the

K erala m odel developm ent lacks so im portance now , it m ust b e analysed because o f

the developm ents w hich w ere took place during that tim e. It w as believed that K erala

achieved h igh status in certain areas o f adm inistration, and it w as nam ed as K erala

M odel. T his ch apter analysis w hether it w as a K erala M odel developm ent in the field

o f health adm inistration o r not.

 T he last and final chaptcr K E R A L A H E A L T H S E C T O R : C H A L L E N G E S

A N D P R O S P E C T S review ing about the present health status and the problem s or

challenges facing by to d a y 's society in K erala. T oday lot o f problem s are existing in

the health sector o f K erala. Life style diseases, em ergence o f new diseases and

com ing back o f eradicated ones etc. are explam ed in the chapter in a b rie f way. In

addition this ch ap ter describes the geographical positioning o r environm ental factors

that are deciding the health conditions o f a place. T he geographical positioning

provided a bulw ark against the im port o f diseases m to the region from, outside. A t the

sam e tim e its connections w ith the outside w orld through trade, tourism and pilgrim

m ovem ents, K erala perceiving various infectious and other diseases. T he chapter

describing ab out those issues also.

T h e docum ents are acknow ledged in endnotes by follow ing the C hicago

m anual. 'Ibid* is used to refer ttie sam e page o f the book o f the author and italicized;

*op. c it’. is used to refer w hen an author is subsequently referred. M alayalam o r locai

term s are italicized and are collectively inscribed under the title G lossary. D ifferent

shorts term s are used and arc listed w ith its full nam es under the title o f A bbreviation.

F or the convenience o f the study end notes are used and w ritten by follow ing the

C hicago m anual. B ibliography is also w ritten under the style o f C hicago m anual.

A ppendices are essential docum ents m ainly collected from different archives.
 END NO TES

M ichael F oucault, K now ledge a n d Pow er, C olin G ordon (Ed.), (N ew York;

V intage, 1980), p p .166-190.

C harles W inslow - E dw ard A m ory. T he untitled field o f Public H ealth, M odern

M edicine, 1920), pp. 183-191.

K. Sujit D utta, Sociology (it W ork P lace, (Delhi: Supriya Books, 2010), p .55.

Fraser B rockington, W orld H ealth, II Ed., (London: J& A C hurchil Ltd., 1985),

p .5.

E. N eelakanfa Pillai. P ublic H ealth a n d Sanitation. (Thiruvananthapuram :

2000), p.508.

Ibid.
 CH APTER K

AN OVERVIEW OF THE HEALTH CARE SYSTEM OF

^KERALA’ BEFORE 1956

T raditional m edicine, otherw ise called as local health tradition o r ethno

m edicine is natural health care practiced by all cultures o f hum ankm d form ancient

tim es to the present day. H ealth is state o f total effective physiological and

psychological functioning. P ublic health is dedicated to the com m on attainm ent o f

the highest level o f physical, m ental and social w ellbeing and longevity consistent

w ith available know ledge and resources at a given tim e and place. It holds this goal

as its contribution to the m ost effective total developm ent and life o f the individual

and his society, Public health is a m ulti-professional discipline. All those w ho are

involved in developing program m es and services to tackle the causes o f the m ost

com m on diseases need to have a public health perspective

B efore the form ation o f the state o f K erala, the land never possessed a

unified system o f m edical practice o r treatm ent. For curing diseases, people used to

follow different m ethods. T hose m ethods supported the people to get re lie f from the

p roblem s they had faced. T he prom inent am ong those m ethods w ere N ative m edicine

o r G rihavaidya, T ribal m edicine, Sidhavaidya, A yurveda and Unani. P eople

b elonging to different classes, com m unities or follow ing different occupations

practiced these system s w ithout any differences. D ifferent sources are given lot

evidences about the m edicinal practices and treatm ents. V arious travelogues o f the

past discuss the existence o f such system s o f m edical practices, centres o f treatm ent

and presence o f experienced practitioners, etc., extensively. Al K asm i and M arco

Polo described K ollam as one o f such biggest tow ns o f India and there lived very
efficient m edical practitioners on their w o rk s.’in the d escnptions about M alabar,

B uchanan illustrated about different types o f patients and diseases o f this land.

C holera, sm all pox, elephantiasis, leprosy, plague etc. w ere the m ajor diseases noticed

by Buchanan.^

In India, there existed different branches or types o f m edical treatm ent and

p ractices for curing diseases. E very com m unity in the society irrespective o f their
caste o r creed practiced m edicine o f theirow n. In different areas all these practices are

k now n in different term s. T he practices are term ed as nattiivaidyam , grihovaidyam ,

siddhavaidyom , soothichikista. A yurveda. Unani a n d so on. B ut the science o f

m edicine o f India as a w hole w as called A yurveda o r the V eda o f life. It is a part o f

the H oly Scriptures and is believed to be a direct revelation from the creator. B ut for

the convenience o f the study references about different indigenous m edicinal practices

o f K erala is oriented from nattiivaidyam or grihavaidyam to siddhavaidyam ,

A yurveda and ending w ith the practice o f unani.

D ifferent travelogues and com m enranes, as stated above, expressed that

people o f this land w ere very capable o f curing diseases, w hich w ere prevalent in

those lim es. T he collective know ledge o f those practices can be nam ed as N ative

M edicine o r G h h a Vaidya. In the earliest period, the m edical practitioner o f this

system w as called natively as vaidyan or N attuV aidyan w ho had a sound know ledge

o f all the herbs and m edicinal plants and herbs. It is stated in different sources that

the children o f the past society w ere also possessed extensive know ledge on

taxonom y and in the earliest years, they w ere m ade acquainted w ith the nature o f

plants, and their different properties,^ T hey possessed enough m edicines and

m edicinal herbs in their surroundings. T hose children supported the professionals in

the collection and classification o f herbs and m edicines. T he m edicinal herbs w hich

abundant in the forests and the plains o f this land w ere largely used m the

preparations o f decoctions, m ixtures, electuries, confections, pow ders, pills,

m edicinal ghee and oils.'^ A nim al substances and m ineral preparations w ere also

applied in the process o f m edicine m aking. N ative m edicine w as m ainly com posed

w ith the herbs and plants w hich w ere very near to them K .P.P adm anabhaM enon

gives a detailed study about the uses o f different plants o f that period and explains

how the native people cured their diseases. "V ep or N eem w as m ainly used to cure

different types o f fevers. K odithuva w as used to purify and thin the blood, to expel

gout, leprosy and m alignat fevers and to check different types o f cough. A vanakku

w as used to sw eeten the blood and dissolves the corrupt ju ices, expels w orm s.

U latunvera, the root o f Ulam w as an effectual rem edy for jau n d ice, N elli w as a c h ie f

property and it carries o ff the bile and slim e w hich give rise to m ost o f diseases in

India“'^The native Vaidyan was paid w hen the patient recovered from illness. T he

paym ents w ere in the form o f rice, clothes, fruits etc.

22
 N attuvaidyan n ev er pursued a course o f treatm ent w ithout prescribing a diet.^

T he m ost im portant characteristic feature o f native m edicine was its general diet.

A ccording to the existed beUefs, diet will cure the problem s partially. N agam A iya

states, “ it is un im aginary to an English doctor how a patient can subsist on such low

diet.” A ccording to him “the H indu diet in general, w hich regulates the lives o f

m illions o f the Indian population m ay be ju stifiab le” ^ T he m anner o f diet to be

prescribed depends upon the nature o f disease the patient suffers from and also upon

the strength o f physique that should be m am tained for the m edicine to be

adm inistered. D iseases such as leprosy, rheum atism , chronic ulcers etc. require hard

diet alm ost bordering starvation. T here is rigid rule prescribing as to w hat diet a

patient should observe w hen taking a particular m edicine. Prescription o f diet m ostly

depends upon the digestive pow er o f the patient. I f digestion o f a patient is sound and

unim paired, a h ard diet m ay be convenient as the nature o f the disorder will perm it,

should b e observed. T he severity o f the diet and the strictness o f its observance help

the efficacy o f the m edicine adm inistered T he prescription o f a diet is a m atter solely

to be left to the vaidyan s discretion and not to the p atien t's choice. T here are 5 well

m arked conventional kinds o f diet; hard diet, m ean diet, ordinary diet o r optional diet,

everyday diet, after supper d ie t." ^

Just like nattuvaidym n, thorough know ledge o f treating diseases was prevalent

am ong the tribal society o f Kerala. T he branch o f m edicinal practice am ong the

tribes is popularly know n as tribal m edicine. T here is no specific nam e for the tribal

m edicine. It w as know n in the nam e o f their tribal society like, kani vaidyam.

muthuvciu vaidyam etc. specifies the nam es o f m edicine and their tribal identity.

Tribal m edicines are m ainly specified under the title o f p n m itiv e m edicine and

"w hich studies the d iseases and leading m ethods o f neolithic m an” and "these w ere

m ainly depends upon prayers and b eliefs.”^ T he sources o f prim itive m edicine are

“carved stones, folk-lore, m yths and legends, psycho analytic studies o f the m agic

thought o f prim itive m an and prim itive tribes still in existence today” T he study o f

the diseases, m edicines, pharm acopoeia o f the prim itive tribes helps in the

reconstruction o f the history o f pre-historic m edicine in India. T hese tribes have their

ow n beliefs, and concepts w ith regard to diseases and their rem edies. T hey acquired

these beliefs and concepts through generations b y m eans o f the process o f inheritance.

T hrough this process o f inheritance o f m edical know ledge people w ere proficient on
th eir m edicine and generally they kept it as secrei as they fear that it w ill not w ork i f it

is revealed to anyone else; old people pass on their secret to their children or

trustw orthy student and thus their know ledge has its secrei descent to their

g en e ratio n s". E very tribal society has faith in certain custom ary beliefs. N o society

IS ready to violate their faiths o r beliefs. T hese taboos w ere very strong in the earlier

days. T hey strictly follow ed the taboos to prohibit and avoid problem s. T hese taboos

regulated the life and culture o f tribes. T aboos can be seen in the selection o f food,

health, hygiene, sexual behaviour etc. gave the tribes enough courage to live in the

dense forests. Their custom s and beliefs w ere practiced and checked by their leaders.

T here w ere leaders or experts am ong the tribes to assess their life. O ne o f the experts

am ong the tribes w ho safeguarded their health w as their m edicine m an o r vaidyan or

sham ans. T here w ere m edicine m en in every tribal society. T hey w ere identified as

p n e sts o f sham ans or m agicians. T he sham an used different types o f supernatural

aids for controlling pow ers over spirits in treating a patient. Sham ans tied am ulets

and talism ans on the arm s and necks o f the patients in order to protect them from evil

spirits. T he m edicinal practices and know ledge am ong the tn b es w ere inherited from

th eir ancestors. T he tribes are differing in their practices and treatm em s, B ut w om en

o f every tribe are experienced in m idw ifery.'^ T hese tribes generally regarded all

ailm ents w ith tem perature as fever and they abstain from food for a few days w hen

they suspect a fever.

In south India m ajority o f the tribal people are settled in the upper ranges o f

T am il N adu, K arnataka, A ndhra Pradesh and K erala and that there are about 36 tribal

groups in T am il N adu, 49 in K arnataka. 33 in A ndhra Pradesh and 35 in Kerala.*^ In

K erala, the different groups o f tribes like Velans, M alayans, Kurichyas, P enivannans,

K attunaykkers, K aniyans, U ralikurum ers, Thenkurum ers etc. had thorough

know ledge in treatm ents o f snake bites, gynacaeology, anti-rabies etc. Velans are a
notab le tribal group o f K erala. T he nam e Velans is popularly derived from the nam es

o f 'v e l' or ‘v e la ’.^'^Vel is considered as the w eapon o f Lord M iinirka, and he w as the

lord o f the land o f "kurinji belonging to the Uinais ’ o f the Sangam period. ''V elans

perform ed the practice o f 'xela n v e r iy a ttu ' to find out problem s o f diseases and for its

re m e d ie s'^ A t the sam e tim e velans w ere p n ests as w ell as vaidyans as referred in

T am il g ram m ar w ork Tolkappiiini '.^^Velans expressed a high standard in treatm ents.

T hey have differen t m ethods and styles o f treatm ent. It is believed that the velans
w ere the accom panied group o f people o f soldiers in their w arfare.'^ T he velans w ere

also priests and they possessed know ledge on clim atic conditions and they follow ed a

pure and natural life. T hey are now generally seen living in the districts o f K annur and

K asargod. T ribal m edicine was m ainly based on the m ental treatm ent or

psychotherapy. Sam uel M atteer criticized this m ethod o f treatm ent, because it m ainly
18
follow ed a policy o f pray. It w as declared as devil w orship by him.

A nother form o f m edical treatm ent existed w as Siddha Vaidyam. It is an

an cient m edicine o f India. It w as very popular in South India in T am ilnadu and

southern parts o f T ravancore, especially in Trivandrum , besides the T am il districts o f

M adras P residen cy.’^ It is otherw ise know n as C h in ta m o n yV a id ya m P It is

considered as divine. A gastiar, the G reat D ravidian G uru is considered as the father

o f SidhyaV aidyam . A g a stia r is otherw ise know n as K urum uni, because o f his

dw arfness."' T he exact period o f A g a stia r is in ob scu n ty , yet it is believed that he

settled in South India even though he belonged to the Aryavartham . A a g a stia r is

believed to have adorned the first T am il Sangam held in the South M adurai.

A g a stia r had produced several treatises on M edicine, A strology, philosophy, A lchem y

etc.“^

Siddha vaidyam is a com prehensive and scientific system o f m edicine w hich

accurately diagnosis all types o f hum an ailm ents by gauging the pulses o f dasanadis

o r ten p rincipal n e r v e s . Sidhavaidyam is otherw ise considered as the m edicinai

system o f m ercury based alchem ical ideas relating to longevity o f hum an being.

A lchem y centred around tw o objectives nam ely the transm utation process for

converting b ase m etals into noble m etals and the preparation o f elixir o f life for

attaining immortality.*^ T he m edicines o f the siddha system is popularly know n as the

neetu m aru nnu ka l that m eans m edicines prepared from navalohas o r nine m etals like
m ercury, gold, silver, copper, etc. and 64 poisonous substances o r 64 pashanas?^

Siddha Vaidyam w as treated under m ainly seven heads such as. “salt o f w hich

35 kinds, poisons o f 32 kinds, rasas and uparasas o f 112 kinds, m etals o f 11 kinds,

w aters o f 16 kinds, dried drugs like g inger and etc. o f 16 kinds, herbs and roots o f

412 are m entioned. Thus there are 634 different m edicines” .

Siddha vaidyam classifies the diseases into three categories. T hey are,

Sadhvam - diseases w hich can b e cured easily, klishtasaadhyam - disease can b e cured
w ith tw o to three y ea rs' treatm ent, asadhyam - disease im possible to cure these

diseases." T here are sixteen different form s in w hich m edicines are adm inistered to

the patients. T hey are B hasm am o r calx, sindhiiram or pow ders, M atra or pills,

Giilika o r pills, Vataka , cakes or lozenges, rasayam i or elixir, Chiirna o r pow ders,

lekhya o r electuary, A savam o r tinctures, K iizhampii o r ointm ent, L apa o r plaster,

Taila o r oil, G hrila or ghee, R asa o r essence, D ravaka or acid and kashaya or

d ecotion.“^ Siddha system gave utm ost im portance to individual and they try to treat

the patient not the disease. A fully developed system o f m arm asastra is a unique

feature of the Siddha system . T he m ain slogan o f siddha vaidyam is

"O o(hiyo rO o th a n n th o o n A va n eS id d h a n '\ m eans ‘‘one w ho knew how breathes

entered into hum an body.” ^^So the siddha physicians treated patients by adopting the

p o licy o f O othiyorO otharinthaonA vaneSiddhan and prescribed m edicines.

T he books o f siddha vaidyam are m am ly w ritten m Tam il. Som e im portant

am ong them are N aram am isanool nalayiram , P anchavithaP athivadangal,

M arm aSoothram , Siddha Vaidya Thirattii, O osiM nkam m w m ooru,

3\
A gastiyarparipoornam . A dikkiinilaiB odham , A m rithakalaN janam etc. T his system

o f m edicine was m ainly propagated by the siddhars. Siddhars w ere m en o f highly

cultured, intellectual and spiritual facilities com bined w ith supernatural pow ers.

Siddhars belonged to a school o f great know ledge, T he first eighteen m em bers w ere

k now n as M ulavargasiddhars. T he m oolavargasiddhars w ere, N andhi, A gasthiar,

Thinim ular, P im nakkisar, Pidasthiyar, P unaikkannar Idaikkadar. Bogar,

Pulikkaisar, K arurar, K onkanavar, K alange, A higanni, Agappayan. P am batti,

Theraiyar, K utham bai Sattainathar.^^

T he o th er im portant areas o f siddha system are astronom y, astrology,

lakshanasastra. nadisastra, m rigarogasastra, m ukhalakshanasastra, m antravada,

m agic, m etallurgy, psychology, architecture, necrom ancy etc.^^ Siddha vaidyam w as

the m onopoly o f certain traditional siddha fam ilies o f Tam il N adu and K erala. Siddha

know ledge becam e a secret am ong few traditional fam ilies. It is available only to the

generations from father to sons, they w ould pass o n this rich legacy. P opular m edical

sciences, including m o d em m edicine som etim es fail before certain diseases o f so

called incurable and grave diseases such as asthm a, psoriasis, hypertension, rheum atic

diseases, diabetes, arthritis, epilepsy, ulcer, piles, kidney stone, bladder stone, gynaec
problem s, etc. By adopting appropriate siddha system o f m edicine this diseases can

be cured, Siclclha Vaidyam is popularly know n as 'T h a i V a id ya m ’ the ‘m other o f

m edicine or scien ce’.^'* But, its popularity w aned even in South India now.

A s stated earlier, the science o f m edicine o f India as w hole is called A yurveda

or the V eda o f life. D hanvantari is considered as the presiding deity o f this

m e d i c i n e . I t is based o n R ig-V eda. It relates to the branch o f know ledge o f

m edicine o f R ig V eda. W hile for the branch o f surgery it is based on A tliarva-veda

It is the oldest m edical treatise o f Indians that deals w ith the subject o f life, the

conditions tending to prolong o r shorten it, the nature o f diseases its causes and the

m ethods o f treatm ent. T he rudim ents o f the treatm ent for som e diseases are

m entioned in the early portions o f the R ig Veda. T he V edic hym ns m ention about

several diseases such as jv a ra , kiishta, rajayaksIuncL blindness, deafness, sterility and

b a l d n e s s . I n A tharva V eda a m ore advanced style o f know ledge and treatm ents are

found. A ccording to M .R .R aghavaV arier “ it is the representation o f a m ore developed

phase o f social f o r m a t i o n " . A m ore know ledge o f anatom y, treatm ent to poisoning,

oth er m ental and physical disorders are seen in the A tharva Veda. A yurveda has tw o

divisions Sw astavritliam and A thuravritbam ?^ Sw astavritham teaches how to

continue healthy and A thiiravritham teaches the treatm ents o f living beings w hich are

o c c u m n g illness.'*^ It is a science that treated under eight subdivisions o r departm ents

o f salya o r surgery, salakya or treatm ent o f diseases o f the eye, nose, m outh, ear etc.,

k a y a d u k itsa o r m edicine in general, B hutavidya o r restoration o f the faculties from a

disorganized state induced by dem onical possessions, K aum arabritya o r m anagem ent

o f children com prising the treatm ent o f infants and the diseases they are subject to,

A g a d a or adm inistration o f anti-dotes for poisons o f m in e ra l vegetables and anim als,

R a sayana or treatm ent o f the universal m edicine, that will render health, perm anent

and life perpetual. Vqjikarana o r prom oting the increasing the productive capacity o f

h um an race, by increasing the cirile p o w er and giving tone to the w eakened organs o f

generation."*'

A yurveda, in its essence is a w ay o f life. It is a m ode o f treatm ent. It has two

realm s; scientific know ledge and folk w isdom . A yurveda is based on the principles o f

p ra n a h s, saptadhathus and sh a drasas.^' A yurveda considers hum an body as a

co m b in ation o f five elem ents o f earth, w ater, fire, air and sky. P hysically it is
supposed to be preserved in exact proportions o f the three general elem ents o f rheum ,

bile and phlegm or air, fire and w ater respectively.**^ T he sapthadhathus are m ercury,

blood, flesh, fat, bone, m arrow and semen/*^ T he shadrasas are sw eet, sour, saltiest,

bitter, pugnet and astringent.*^^The earliest reference o f all these are seen in the

B havanopanishad^^ o f Atharvaveda.*^^

T h e earliest evidence o f the existence o f A yurveda in South India can b e seen

m the R ock edicts o f A soka. It specifies the establishm ent o f B uddhist viharas m

south India rendering m edical services to m en and animals.*^® Scholars are o f the

opinion that the spread o f different branches o f A yurveda in South India w as

happened as a result o f the influence o f B uddhism . B uddhist tradition o f the land paid

particular attention to the spread o f A yurvedic m edical education. Viuayapitaka is

o ne o f the principal sources that gives the details o f ayurveda know ledge m the

B uddhist period; it devotes a full chapter to Ayurveda.'^'’ A sh ta n g a h h d a ya m entions

B uddhists influence on A yurveda. B uddhist India contributed m uch to the spread o f

A yurveda. A yurveda took its root in all those countries w here A soka sent his

m issionaries to propagate B uddhism . A yurveda spread along w ith the spreading o f

B uddhism to the regions like C eylon, C hina, and the S outheast A sian countries, T ibet,

C entral A sia and som e areas o f Egypt. A ccording to different sources. A yurveda

reached its zenith w hen it's all branches w ere taught in Taxila,^^ Food culture w as

an o th er reason fo r the spread o f A yurveda during that tim e. T he inhabitants preferred

v egetarian m ode o f food culture and that directly influenced the spread o f A yurveda.

K erala possessed a special kind o f treatm ent o f A yurveda w hile it is

com pared to the other parts o f India. C ontributions m ade by K erala to th e theory and

practice o f A yurveda, the indigenous system o f m edical treatm ent, is substantial.^'

H istory o f the A yurvedic tradition o f K erala is m ainly divided into three phases. They
are pre — Sanskrit period, S anskrit period and m odem p e r i o d . I n considering the

co ndition o f K erala there are so m any differences in the style o f m edicinal practices as

com pared to the other parts o f India. A shtangahridaya system expanded b y V agbhata

w as system atically practiced and developed by the K erala physicians. T raditional and

p o p u lar A yurvedic m edicinal practitioners o f K erala are the eight B rahm in fam ilies,

popularly kn ow n as the A shtavaidyans. T hey are Pulam anthol, Alathur, Kuttcinchery,

Thycad, llayidathu, C hirattam on, V ayaskani and V e llo d P T he m em bers o f A lathoor

is know n as N am bis and others are know n as M o o ss? ‘^ T hey enjoyed and still

enjoying considerable reputation for their skill c f curing diseases. They w ere very

em inent personalities in c u n n g all types o f diseases by the easy application o f

specifics as w ell as by the ju d icio u s prescription o f diet. T heir m edical skill is so

adm irable that they w ere able to produce surgical effects w ithout recourse to surgical

instrum ents^^ T he celebrated A shtavaidyaus w ho belonged to the N am boothiri

com m unity are still active. In addition to the eight B rahm in com m unities other

com m unities also follow ed practicing A yurveda. For exam ple, Itty A cuthan, who

helped the com pilation o f H ortus M alabancus, the fam ous w ork on the m edicinal

plants o f K erala collated by the D utch, belonged to E zhava c o m m u n i t y . S o m e

physicians w ere experts in the special branches such as toxicology, pediatrics and eye
57
treatm ent and diseases like leprosy, diabetes, tuberculosis etc. O bstetrics and

P aediatrics, D em onology are the other m ain branches o f A yurveda, in addition to the

treatm ent fo r hum an beings Ayurv'eda com prises treaim.ent for other creatures. It is

believed that Sage Salihotra com posed A yurveda for horse popularly know n as

A svayu rved a. S age M atanga com posed A yurveda for elephants, w hich is know n as

H a sta yu n'ed a . Surapala, a sage w ho com posed A yurveda for tree m eans.

Vrksayun'edci.''^^AW these branches w ere fam iliar and practiced largely in K erala. It

w as due to the existence and availability o f various herbs. A yurveda practiced in

K erala in a different style. P izhichil, kizbi. dhara.^^arQ the special curative m easures

for rheum atism are very peculiar. T he use o f D h a fm a th a ra m pills, Ilanirkuzham pu,

u se o f coconut etc. are deserv'ing special references. M arm achikiisa to cure certain

parts o f hum an body, and ulichil for m assaging are still popular in K e r a l a . A y u r v e d a

occupied notable poshion in the plural m edical system o f state. But, it w as in 1875.

m ore than half- a century after the opening o f hospitals for w estern m edicine that an

ayuvedic phy sician w as posted in the governm ent service into the biom edical hospital
and the first A yurveda hospital was opened.^' U nder im perialist intervention, state

p o licies in bo th education and the registration o f m edical practitioners also created

h ierarchies w ithin the m edical system o f the land.

A nother peculiar treatm ent that existed in the land from very earlier period

w as the treatm ent to poisonous bites. T his treatm ent is a distinctive branch o f

m edicinal history o f K erala. It is popularly know n as vishachikista and the

practitioners w ere know n as visha/uiris or vishavaidyans. T he know ledge was

confeiTed through generations. T he traditional vaidyans and the tribes w ere strongly

pervaded the know ledge o f the treatm ent for snake bites. D etailed descriptions

regarding poisonous bites and its treatm ent are preserved in the books o f A yurveda

also. A yurveda holds eight segm ents and it is the Agathathcm tra portrays the

treatm ent for snake bites. V ddeesam , Ulpalam. Lakshm anam ritham , N arayaneeyam ,

Pniyogcisaniiichayam , K riyakoum adiSarasam graham are the cardinal m anuals from

w hich the land m astered in it.^“ A sh ta u g a h n d a ya m M ekhala and K alavanchanam are

the other im portant records. R ecords ana m anuscripts m M alayalam , Tam il, Sanskrit

transm itting the sam e issue. A yurveda follow s the Tridosho theory in its practice,

V ishaVidya m eans treatm ent o f poisonous bites b y usm g hym ns o r slokas and

VishaVaidyam is the uses o f m e d ic in e s.^ M ost o f the slokas o r hym ns and textbooks

w ere in Sanskrit language. T hose books and hym ns w ere translated to M alayalam in

course o f tim e. T he textbooks P rayogasam uchaya translated to M alayalam by

K ochunniT ham puran of C ochin, VishaJyotsinika by K aratt N am boothin,

L a kshnam ritham by Sundara Bhattachar>'a, Thantrayukthivicharam by V aidyanatha

or N eelam ekhan. VishaVidya and VishaVaidyam o r Vishapradishetham s are the other

prom inent m anuals used by the practitioners occasionally.^^ Sarvagarala

P ram ochanam by K uttam ath C heriya R am a K urup and Visha Vaidya P raveshika o f

an unknow n au thor show s the m astery o f the practitioners o f K erala m this particular

branch o f m edicine. P am bum m ekkattu Illam is still enjoying prom inent role m

c u n n g snake bites from the earlier tim es. Stone treatm ent and hen treatm ent are the

divergent areas o f treatm ent o f poisonous bites in Kerala. Stone treatm ent w as very

p opular in K erala, N orth India and in Sri Lanka.

A nother bran ch o f m edical treatm ent practiced in K erala w as Unani. It w as

the m edicine o f the A rabs. It cam e to India through trade contacts. T he period from

800 B.C. to about 1000 A .D . is considered as e the G olden age o f Indian M edicine.

It w as during that period m ost o f the m edical sam hitas w ere com piled. Unani

m edicine w hich em erged in India and attained great popularity during the M uslim

period.^^ But, U nani o r the G recia School w as very rare in Kerala.

Introduction o f M od ern or E uropean M edicin e in K erala

B efore the form ation o f stale in 1956, the treatm ent and m edicinal practices

existed in the princely states o f T ravancore and C ochin, and the areas under the
control o f M adras Presidency follow ed different m ethods for eradicating diseases

P eople and m iers o f those areas m ade rem edies on the basis o f the situations

happened. B efore the establishm ent o f the Public H ealth D epartm ent in this land,

there w as no unified code for the assessm ent o f the circum stances, problem s and

d isorders affected the health conditions o f the individuals. T he idea about a

d epartm ent for public health cam e as an influence o f the European ideologies. So it

can divide the process o f public health adm inistration o f this land into four phases.

First one w as the p e n o d before the advent o f the Europeans. Second one starting

from the tim e o f E uropeans existed along w ith the traditional and m digenous system s

o f practice. T hird from C olonial interventions and introduction o f public health

instrum ents in the IS'*’ and 19'*’ centuries. Fourth phase extends from public health

adm inistration after the form ation o f the State o f Kerala. T he last segm ent can again

be divide as ‘K erala m odel dev elo p m en t’ and aften^'ards.

T he introduction o f the public health instrum ents in this land was started in the

18*^ and 19'^ centuries. B efore that, there existed varied com position o f system s and

practices in analyzing diseases. T hose m ethods had to exam ine conditions, problem s

and disorders affected the people. L ater they m ade touch w ith the new European

practices. T his connection helped the people to gel speedy re lie f from their

problem s. T his land w as an affected area o f different types o f epidem ics and

endem ic diseases occasionally. M ajority o f the epidem ics w ere seasonal. Seasons

o f w inter, sum m er, etc, w ere greeted by heterogeneous e p i d e m i c s . F e v e r was

frequently spread all over the land. C holera, sm allpox am ong the epidem ics and

ulcers, anaem ia, dropsy, diarrhoea, leprosy, elephantiasis, scabies, yaw s or farang

w o n n s and dysentery am ong the sporadic w ere found. C holera w’as know n m

different nam es like m ad-de-terre. or mort-de~chien. m ordexim, morexi, m erederxy,

m odachi etc., in K onkani, In M arathi it w as nam ed as m odashi o r m odw ashi m eans to

sink or to collapse. T he people o f K erala called it N irkom ban. T he Portuguese called

it by m ordexim .’’'^ T h e earliest description about this disease w as found in 1543 A .D /^

It attacked stom ach, and it im m ediately produced the sym ptom s o f strong poison;

e.g.., vom iting, co n stant desire o f w ater w ith drying o f the stom ach w ith pains that the

p atien t seem ed dead. Sm all pox w as a highly infectious disease m ainly broke out

in the sum m er m onths o f M arch, A pril and M ay. It w as very com m on in the areas o f

T ravancore, C ochin and M alabar and ea rn e d o ff a m uch larger num ber o f victim s
than cholera. D eath rates due to cholera w ere high m ore than 90 percent. M alaria

w as frequently reported in the low land o f the G hats and at WayanadJ"^ B ut it w as not

so strong in the coastal areas. M alaria w as another fever lasts only one day and is

w hich blow s from the G h a t s . L e p r o s y w as a disease m am ly affected to the skin. It

w as m ost prevalent in the areas o f C ochm and M alabar. Som etim es it w as called

M alabar itch.'^ It w as m am ly due to the uncleanliness all over the world. In K erala

the people believed that it was the effect or lack o f sn ak e 's blessings, because the land

had a deep faith in snake w orship. It w as m ainly the thought o f all people especially

valcms and kanakkans, w ho w ere by occupation fisherm en and boatm en had deep

faith in snakes and w ere affected b y this.^^ L ogan and K .P.P adm anabha M enon give

the sam e view that it w as m ainly affected to the people w ho w ere eating the m uddy

fish.’^ B uchanan in his Journey from M adras had noticed leprosy and it was called as
go
D urda. He says it w as very com m on in the po o rer sections o f the people. It was

produced by a m oist clim ate and a diet consisting o f the fish w hich frequent m uddy

places.^' Leprosy was reported from every tohiqs o f Travancore.^" E lephantiasis is an

endem ic disease popularly know n as Cochin teg. due to its high prevalence in the

areas o f Cochin.*^ “It prevails largely in the low- lying w ater logged, sw am py iraits

lying betw een the back — w ater and the sea and to a less extent along the eastern

shores o f the backw ater, but it is hardly seen anyw here in the laterite traits."*'* “It was

very com m on in M alabar, especially am ong M appilas on the coast' ’. P l a g u e was

m uch m ore reported in the northern places o f M alabar. Plague was very m uch

reported in the boundaries o f M alabar like C anara. N ilgin, K utak, M ysore.

Koiambatore^^. F rom T halassery, C alicut and C annanore it was reported. B ut m

C o ch in there w ere a few im ported c a s e s . T h e r e w ere so m any other im portant

diseases w hich w ere described in the H istory o f K erala, but m ore or less the diseases

specified are sam e as a whole,

T he talk about the relationship betw een w estern and Indian system s o f

m edicine specifies that it had passed through different stages. It is m ainly divided

into five s t a g e s . T h e first stage w as from the earliest voyages o f the Portuguese

until around 1670 w as characterized by a w illingness to learn from Indian m edical

system s, w hich w ere in som e respects, seen to be on a par w ith the learned m edicine
o f the ancients.**^ B oth Europeans and Indians shared a sim ilar view o f the hum an
body as being com posed o f elem ents o r hum ours -tne exact num ber depending on the

system s- w hich displayed qualities o f m oisture, w arm th, cold, dryness and so forth.

T he second phase is spread up to the period from 1670 to around 1770. D u n n g

this phase the gap betw een European and Indian m edical system s becam e w ider. l\

reflected the expansion o f form al m edical education at the universities o f L eiden and

Edinburgh and the im pact upon m edicine o f N e w to n 's m echanics.^’ T he dem ise o f

hum oral m edicine in E urope m eant that any debts ow ed to Indian system s o f m edicine

w ere overw helm ingly em pirical and therapeutic; European m edicm e appeared to be

su perior in every other departm ent.^^ D uring this phase, there developed a thought

that the W estern m edicine w as scientific and it is based on reason and observation,

w hereas the Indian system s o f m edicm e is seem ed slavishly to follow tradition and

w ere interm ingled w ith priest craft and superstition. B ut this conceptual g u lf aroused

betw een w estern and Indian M edical system s did not lead Europeans to abandon the

dialogue betw een them selves and Indian practitioners. Indeed the third phase from

around 1770 to around 1820 brought out the first attem pts to record system atically

indigenous m edical practices. It w as as a result o f the direct consequence o f terntorial

expansion and the consolidation o f im perial rule. T hese efforts w ere supported by the

labours o f orientalists, som e o f w’hom had m edical training and had begun to translate

the treatises o f H indu and Islam ic m edicine for the first time.^^ T his led som e

E uropeans to develop a great respect fo r the achievem ents o f Indian physicians in

form er ages. But, the discovery o f India’s G olden Age on all spheres o f life and

culture served only to accentuate the ‘d egeneracy’ o f the present. By allow'ing

unm ediated access to ancient m edical texts, the orientalists also lessened the need for

E uropean physicians to rely directly upon indigenous practitioners for know ledge o f

m edical plants. T he sam e w as true o f large scale scientific studies o f Indian

pharm acopoeia sponsored by the E ast India C om pany. It w as an attem pt to reduce its

reliance on im ported drugs. T hus in m edicine, as in other spheres o f colonial

know ledge, a trend tow ards m ore system atic collection o f inform ation during the

1820s and 1830s w as happened. T he period after 1820 this trend intensified and

personal contact betw'een indigenous practitioners and Europeans appears to have

played a far less im portant role m the form ation o f m edical know ledge than in the

past.
 T he Portuguese w ere the first E uropean pow ers who cam e to India in the 15‘^

century. T hey started a sm all treatm ent centre in late 1490s/’‘* B ut the Portuguese

fleet und er Francisco de A lbuquerque airived at here created changes in the field o f

treatments.^^ A fter realizing the need for a hospital to treat their sick soldiers and

officers a w ell - equipped hospital w'as set up in C ochin inl506.^^ It was called the

S anta C ruz hospital {Holy C ross Hospital).^^ B ut another reference states that the first

E uropean hospital in India w as probably established at G oa in 1510 A.D.^^It was

started by A lfonzo de A lbuquerque, the C aptain G eneral from 1509 - 1515.^'’ He

captured G oa in 1510 and started this hospital. It w’as know n as the H ospital Real

(R oyal H ospital). Follow'ing this m any hospitals w ere established at C annannore,

C haul and Goa.'*^'^The hospital w as m aintained by the Portuguese king and donations

from w ell-w ishers. T he physician o f the hospital used to consult the native physicians

and they had com m unicated the different view s and m ethods o f treatm ent each other.

It is believed that till the period o f 1650“s the black apothecaries (native vaidyans)

used palanquins and they adorned a highest position in society. B ut after an

announcem ent the Portuguese govt, denied the using o f the palanquins by black

vaidyans and issued a certificate for the treatm ent o f patients. T hey w ere denied to

treat patients w ithout a certificate from the G oan G o v e r n m e n t . L a t e r it introduced

into other places as a practice. D uring this tim e Indological studies and research w ere

started by the E uropean sch o lars.’^ G arcia da O rt's w ork on the m edicinal plants o f
105
India is one o f the earliest studies on such subject.

T he D utch w ere the next foreigners who influenced the life and culture o f the

Indians. T he D utch E ast India C om pany w as established in India on 1592. B ut the

suprem acy o f the D utch in K erala becam e strong only after their capture o f C ochin in

1663.'^^ T he D utch evolved a sound system o f adm inistration for the territories under

their jurisdiction . T he D utch pow er m ade interest on every field o f their

adm inistration. It resulted in the establishm ent o f a court o f justice, a political

council, a court o f orphans, a court o f petty and m atrim onial affairs, w ar and fire

com m ittee, church com m ittee, a board o f education, a board o f guardians, an

orphanage, a hospital and a leper a s y l u m . I n s t e a d o f these, they m aintained an

efficient m edical service and took steps for the treatm ent and eradication o f leprosy in
I Qg

the coastal areas w hich cam e w ithin their sphere o f influence.

 T he D utch also contributed to the m edicinal w orld o f K erala. A fter the encounters

and w ars w ith native rulers the D utch soldiers faced a setback due to the lack o f

m edicines. T hey used m edicines from N etherlands and there w ere alw ays a delay in

gettm g m edicines on these situations"^^ T hey w ere inefficient to treat their fellow

beings because o f the lack o f enough m edicinal accessories. So they tried to fm d a

solution. T hey w ere forced to follow the m edical treatm ent and practices o f this land

to m ake it safe for their fellow s. At that tim e the D utch residents tried to fm d an

alternate m edicine useful to them . It resulted in the com pilation o f the fam ous H ortus

M alabaricus, com piled by the fam ous D utch G overnor V an R heed w ith the support o f

C arm elite m onk M athaeus. Itty A chuthan and the B hatt b ro th ers.’*®It show s the

interest o f the D utch in m aking solution to the existing problem s they had faced.

T he m ajor disease interrupted am ong the D utch w as leprosy. T hey m ainly

stationed on the coastal regions and these regions w ere heavily affected b y this

disease. To solve that issue largely, they m aintained a leper asylum at Pallipuram on

the V ypen Island.*" W hen the disease began to spread they m ade effective steps and

annual m edical inspection w as introduced. A perm anent order was issued to m ake the

peop le appear before the upper surgeon o f the D utch hospital and m edical

exam ination w as c o n d u c t e d . * T h e tow n becam e free o f lepers in due course. 'T h e

lep er house w as m aintained by special fund. It w as placed under a special trustee.

T h e predecessor o f M oens placed it under the m anagem ent o f the D eacons w hen

m anaged it efficiently by good and careful supervision, T he eradication o f leprosy

from the tow n o f C ochin w as a praisew orthy contribution o f the D utch East India

C om pany. B ut the D utch did not extend this type o f health services beyond the

confines o f C o chin.”

R ole o f M issionaries in P lacin g M odern M edicine in K erala society

By follow ing the colonial intervention for territory expansions, Europeans sent

different groups o f m issionaries to spread C hristianity upon the new ly encroached

areas. T hose m issionaries played a vital role m the m odernization o f the native states

in the lines o f the E uropean style. T hey m odernized the society through different

w ays. T he m issionaries o f different sections played a very prom inent role in the

educational, m edical and social lives o f the new ly explored areas. T hey w ere alw ays

engaged in giving m edical aid and educational facilities to the low er sections o f the
society, T he L ondon M ission Society at N agercoil had played a notable role in those

areas. It tried to m ix the system s o f m odem m edicine and the traditional m edicines-

European m edicine offered by the m issionanes cured the diseases far faster than the

traditional m cdicines o f the natives. In addition to the speedy recovery and survival

o f European m edicine, the traditional m edicines w ere hardly easy to follow. T his

influenced the w ide spreading o f m odem m edicine. People quickly attracted to this

new system and they began to use the m edicines offered by the m issionaries. T his

m ove w as also supported b y the colonial pow ers. For spreading m edical support to

the natives, m issionary societies started hospitals in various places. T he m issionary

hospital at N eyyoor in S outh T ravancore is the oldest private institution in the state

w as started about 1852, by Dr. Leitch. Dr. L eitch w as the successor, o f R evd. Mr.

M ead, w ho w as the pioneer o f the E nglish education in Travancore. ‘ A fter the death

o f Dr. Leitch, Revd. B aylis and Revd. John Low e continued the w orks for the poor.

Dr. John L ow e established a m edical class, and he w as succeeded by Dr. T hom oson.

H e w as follow ed by Dr. Fry. Dr. Fry, who built a new hospital, form ed a new

m edical class and established a L eoer A sylum . Dr. Fells and Dr. B entall tried all

possible w ays for the popularization o f E uropean M edicine in this land, especially in

T rav an co re."^

T he C hurch M issionary Society, another m issionary sect, started a L eper

A sylum in 1871 at A lleppey T he R om an C atholic A rchbishop o f V erapoly started a

hospital. A dispensary w as started at M anjum m ei and it received governm ent grants.

T he other im portant hospitals and d isp en san es started by the C M S m issionaries o f

special attention w ere the Z enana M ission D ispensary at Trivandrum , the Planters'

D ispensaries at D evikulam and A sham boo and the Local Fund D ispensary at

B odainaikanur. H ospitals and dispensaries got m ore attention because these

institutions alw ays tried to help the coolies and planters o f that period. ’

In C ochin no serious m issionary activities w ere happened as it is com pared to

T ravancore and rest o f south India. T he first im portant step in m aking a hospital by a

m issionary in C ochin w as happened in 1818. T his hospital was started by Rev .J.

D aw son at M a tta n c h e ry ." ’ B ut it w as a failure. A fter its failure, private hospitals

w ith the C hristianized nam es w ere started in C ochin in a later period. In 1848, the
first g o veram ent hospital w as started at C ochin by the influence o f D iw an Sankara

W arrier."^

T he Basel M edical M ission, another m issionary group started its w ork in

C alicut in 1886 w ith Dr. L eibenderfor, as their first m edical m issionary. O w m g to

his ill health, he had to retire in 1895. F ollow ing him . Dr. W. Stokes M B & C M ,

E dinburgh took charge o f the w ork. T he usefulness and p o p u lan ty o f this institution

increased enorm ously. S ubsequently alterations and extensions w ere m ade. A

hospital contains 12 beds for w om en and 12 for m en. one operation room , and one

hall w ith tw o room s for dressings the O P 's D epartm ent w as started frequently.

G ynaecological and labour cases w ere treated in a separate build in g .‘^ V n o th e r

im portant step taken by the B asel m ission w as m aintaining a leper asylum , w hich was

started by the C alicut m unicipality. T he m ission to lepers in India and E ast w hich

w orked as an auxiliary to other m issions. It m ade responsible for the upkeep and

m aintenance o f the asylum and the Basel M edical M issionary w as responsible for the

im m ediate governm ent intervention. T he C alicut m unicipality at that tim e w as unable

to m aintain th eir old leper asylum any longer. T hey passed a resolution on 17'^ June

1894 deciding to com ply w ith the request o f the S uperintendent o f the Basel M edical

M ission and decided to hand over their asylum to the m issio n .'"' G overnm ent

approved C o u n c il's proposal and the institution w as handed over by certain

conditions to function it as an asylum .*"

In the long run, the old asylum in C alicut near the beach w as insufficient to

m eet the adm ission seeking lepers and therefore w ith the help o f the M unicipality and

the C ollector o f M alabar, another centre w as m ade at C hevayoor w ith fifteen acres o f

land. T he w hole expenses w ere m et partially by the m unicipality and partially b y the

m ission. T h e w hole property w as registered in the nam e o f the L eper M ission Trust

A ssociation incorporated under Act. X X I o f 1860 in D ublin o n the condition that it

should be carried on as an asylum .'^^Tw o new buildings o f one for m en and another

for w om en w ith a capacity to adm it 20 patients w ere established in 1903. O ne

separate hall for severe cases and an isolation w ard for bad cases was also constructed

there

Thus, by the 18t‘" century there w as the developm ent o f W estern M edicine in

K erala to a w id er extent. U nder the B n tish , T ravancore and M alabar got chances for
im proving w estern m edicine. C ochin also cam e under the purview o f introducm g

m odern m edicine not directly by the British; it was an indirect influence. In course o f

tim e B ritish governm ent started the Indian M edical Service. T he Indian M edical

S ervice w hich w as initially a m ilitary service w hich form ed the backbone o f m edical

adm inistration und er the B ritish. W hile m any sanitary and m edical provisions

stem m ed from the need to preserve the health o f the arm y. T he sanitary condition o f

the area has not b een altogether favourable in regard to the civil population and w ide

spread tracts o f the land. F or creating better sanitation and m edical aid for the

m ilitary m en, the governm ent introduced the departm ents o f vaccination, sanitation

and statistical analysis o f health conditions. It som etim es supported the other areas o f

the land w here there w ere no m ilitary m en w ere stationed. T hereby the governm ent

created a tendency to concentrate m edical and sanitary expenditure in colonial

enclaves. B ut m ajority o f their m easures w ere for the needs o f Europeans and for the

m ilitary affairs.

C olon ial Intervention and universalization o f M odern M edicine in K eraia

T he colonial governm ent took initiatives to establish the public health system

in the land. In this effort various laws and regulations w ere enacted. T he m ost

im portant one w as the Indian E vidence A ct o f 1872. By w hich, a M edical C ouncil

w as established in the M adras Presidency. T he council consisted o f fifteen m em bers.

T h e m em bers w ere elected from various departm ents. A m ong the panel o f m em bers,

m em bers belonged to the faculty o f m edicine and other different teaching departm ents

from am ong various universities under the presidency. M em bers w ere elected from

am ong the m em bers o f the Faculty o f M edicine o f M adras U niversity. Som e other

from m em bers w ere elected from the faculty o f m edicine o f A ndhra U niversity. T he

oth er m em bers w ere elected from the o ff the M edical C ollege at M adras, from am ong

the m em bers and sta ff o f the M edical C ollege at V izagapatam and S anley M edical

C ollege at M adras. Seven m em bers w ere elected by the registered practitioners and
three m em bers w ere nom inated by the Provisional G o v e r n m e n t . T h e P resident and

V ice-P resident w ere elected from am ong the council m em bers. O nly registered

practitioners w ere eligible for the election. N o person w as eligible to the election as

a m em ber if he w as not a registered practitioner. It w as for a term o f five years from

the date o f election. A R egistrar w as also appointed and he w as probably the

secretary o f the C ouncil. A register o f the m edical practitioners w as kept by the

reg istrar and the register had revised from time to tim e and published it in the

prescribed m anner. It w as based on the Indian E vidence A ct o f 1872.“"^

In 1914. the M adras M edical R egistration A ct w as passed for the registration

o f M edical practitioners by the then G overnor o f Fort. St. G eorge o f M adras. It w as

applicable to the w hole o f the Presidency o f M adras. L ater this A ct was am ended m

1929, 1932 and 1938.'"^ T his A ct gave som e privileges to the registered practitioners.

T hey w ere exem pted from having certificates. T hey got the privilege that except w ith

the special sanction o f the G overnor in C ouncil no one other than registered

p ractitioners shall be com petent to hold any appointm ents as P hysician, S urgeon or

o th er M edical O fficer in any H ospital. A sylum , Infirm ary, and D ispensary Lying in

H ospital not supported entirely by voluntary contributions o r as M edical O fficer o f

health.

Side by side w ith this, a n u m ber o f steps such as introduction o f vaccination,

sanitary m easures, registration o f birth and death, eradication program m es o f

epidem ics, introduction o f health education etc. w ere taken into consideration.

T he later decades o f the 18'^ century and the 19'^ century w itnessed the

passing o f various regulations and rules in this regard, T he Public H ealth Law o f the

T ravancore state was passed and it w as based on the Epidem ic D iseases R egulations

o f the B ritish G overnm ent. T he first o f its kind w as the Epidem ic D isease R egulation

II o f 1898 to control the epidem ic diseases such as plague, sm all pox, cholera and

typhoid fever. A num ber o f R ules w ere passed on 17’^ M ay 1898 to regulate the

procedure for the m edical officers, m agistrates and police in regard to the

transm ission o f substances for exam ination to the C hem ical Exam iner. In 1902 a

R egulation w as passed w hich provided for the segregation and m edical treatm ent o f

pau p er lepers and control o f lepers pursuing certain callings. T hese regulations,

prov ided the lepers to stay w ithin the tow ns, should personally prepare food and they

should not sale any article o f food o r drinks o r any drugs or clothing intended for

hum an consum ption o r use. T hey should not w ash o r bath in the public w ell, tank,

fountain o r any sources o f w ater supply except stream s and rivers. D riving, conduct

or ride in any public conveyance plying for hire other than a railw ay carriage,

attending public m eetings or public m arkets, exercise the posts o f advocate,

schoolm aster, m edical practitioner, m idw ife, w asher m an. barber etc w ere also

a b o l i s h e d . O n the basis o f the circum stances existed, on 1904, a Lunatic A ct w as

passed and it provided chances for the reception and detention o f lunatics. A sylum s

w ere established for that purpose and for the care o f the person and estate o f lunatics.

T he M unicipal R egulation passed in 1920 consisted o f the necessary rules in

connection w ith the Public H ealth w ork in the several m unicipalities o f the state. T he

T ravancore R egistration o f B irths and D eaths R egulation w as enacted on 1921. T he

g overnm ent introduced m easures and staffs to register birth and deaths. T he Food

A d ulteration R egulation o f 1931 provided chances for the analysis o f articles o f

suspected food to be adulterated and introduced issue o f certificates in connection

w ith them,

T he colonial governm ent m ade aam irab le steps for the developm ent o f public

h ealth adm inistration. B y passing num ber o f rules and regulations they decided to

start P ublic H ealth D epartm ent for properly m anaging health conditions and

situations. In the initial days, the D epartm ent w as not a full-fledged one. It w as due to

the clear aw areness about the idea o f public health m atters. T he natives and its rulers

w ere fully not aw are about such situations. T he general state o f the public health in

every country depends on the m easure o f adjustm ent o f the relations o f the individual

and the race to the environm ent; the m ore com plete and continuous the adjustm ent,

the greater the longevity. T he tendency o f E uropean civilization is to give m an m ore

and m ore com plete control o v er his surroundings, w hereas in India these are actually

and relatively stronger, m ore capricious and unreliable, than in the W est, w hile the

individual is less resistant and adaptable. T hese influences have m olded the m oral

and physical character o f the people and their civilization. A b rie f reference to som e

o f the salient features o f the situation w ill tend to elucidate the vital statistics as w ell

as to explain som e o f the p ecu liar difficulties o f the problem s they disclose. T he

p roblem s disclosed by the E nglish in India w ere, early m arriage, defective nutrition,

influence o f religion and custom s, influence o f rainfall, m fluence o f tem perature,

influence o f the environm ent etc. B ut the colonial governm ent structured the

departm ent o f public health by incorporating the m atters and activities like,

registration o f vital statistics. C ontrol o f com m unicable diseases: - Sm all pox, cholera,

m alaria, typhoid fever, V accination, Plague control m easures, M edical Entom ology,

H ookw orm survey and treatm ent cam paign. Public H ealth L aboratory, H ealth U nits,
R ural sanitation, inspection o f M unicipal Public H ealth w ork, school m edical

inspection and public health education.

T here w as no regular agency for the registration o f vital statistics in

T ravancore. till 1893-94. B ut the village officers kept a record or register o f birtns

and d e a th s,'^ '.it was know n as the Jananm aranakam ikkn}^^ T his w as the “B ook -

keeping o f life.” '^^ T he registration o f births and deaths w ere regularly started in the

tow ns o f T rivandrum , N agercoil. Q uilon, A leppey and K ottayam under the control o f

the T ow n Im provem ent C om m ittee. It was m ade possible after the passing o f the

T ow ns Im provem ent and C onservancy R egulation II o f 1 8 9 3 . A schem e fo r the

registration o f births and deaths throughout the state w as sanctioned w ith effect from

the beginning o f A ugust 1895.'^^. A special D epartm ent o f V accination, V ital

Statistics, and S anitation w as organized and was placed under the charge o f an officer

o f the S anitary Com m issioner.'^'^The registrations o f the vital statistics w as conducted

in the P roverti C utchery by a P ro verti accountant m eans O rdinaly N aivali

A ccountant'^^ T he T ow n Im provem ent and C onservancy R egulation II o f 1894

m ainly concerned w ith the births and deaths o f the tow n w orked m ainly in the tow ns

like T rivandrum , N agercoil, Q uilon, A lleppy and K ottayam and the statistics w ere

collected by the com m ittees w ere subm itted to the Sanitary C om m issioners. T he

program m e o f registration w as m ainly conducted by the m unicipal sta ff in m unicipal

areas, conservancy overseers in p olice conservancy tow ns, p ro verthikars in pa ku th ies,

revenue inspectors in forest areas, and m edical officers and superintendents in the

estates o f the h igh r a n g e s . I n addition to the various officers, various planters'

A ssociations w ere also collected the statistics, a daily V intthikaran w as specially

deputed for each pakiithi.^'^^ln the taluqs o f Tovala and A gastisvaram the village

w atchm an collected the d a ta .”'’’. In prisons and hospitals officers in charge w ere

responsible fo r doing this duty. T he S tatistics collected w ere m ainly consolidated in

the P ublic H ealth D epartm ent and the departm ent received returns quarterly from the

R evenue and M unicipal au th o rities.’‘^“For giving authenticity to the data collected, the

M unicipal R egulation o f 1920 and the T ravancore R egistration o f B irths and D eaths

R egulation o f 1921 w ere passed''^^ D ue to the issues subm itted by the R evenue
departm ent, a m edical officer o f health w as deputed for training in foreign countries.

A fter being trained he w as put in charge o f the vital statistics and E pidem iology in

V ilavancode lalu k for an ex p erien ce."^ As getting positive results from it sim ilar
experim ent w as done in N eyyattinkara. A new Taluk H ealth organization Schem e w as

introduced in the five taluks o f T ravancore viz. T hovala, A gastisw aram , K alkulam ,

V ilavancode, and C henkotta w as the next step in this r e g a r d . O n the basis o f the

statistics subm itted by the departm ent the standard average o f birth - rale for the state

w as estim ated to about 40 per m ile o f the population, the highest birth rate w as

noticed in the C hristian c o m m u n ity .'“^^Male births exceeded fem ale births and in 1937

w as 106:78, death rate for the state w as varied from 18 to 20 per m ille o f the

population,''*^ T he h ighest death rate was noticed in the H indu c o m m u n i t y . T h e

d eath rate in T ravancore w as very m uch low er than that m the B ritish India and the

m ajo r reasons for death w ere cholera, sm all pox, diarrhoea, anaem ia etc. C holera -

9% o f death, sm all pox - 4 . i l % . anaem ia - 5% , and different types o f fevers -

26.15% ., an average num ber o f deaths from suicide w as 65 p er a n n u m . J u s t like

the birth and death rates, the average o f the infant m ortality rales o f T ravancore was

varied from 80 to 100 per 1,000 live births. T his was also very low as it com pared to

B ritish I n d i a . T h e registration o f births and deaths began in C ochin in 1897-98,

registration duties w ere conducted by the P rm r/m -v illa g e officers.'^' T hey had to

co v er an area o f 20 square m iles and its average population w as 19,000.'^"In the

M alabar region the data w ere prim arily collected by the A dhikaris in different

areas.

C om m unicable diseases w ere occurred largely due to unhealthy situations.

Sm all pox, cholera, m alaria, typhoid fever w ere frequent as far as this land w as

concerned. To solve the issues different m easures w ere introduced by the colonial

governm ents- O ne such m easure to prevent sm all pox w as vaccination. Sm all pox

vaccine w as the first successful vaccine. V accination for preventing sm all pox w as

prevalent in India and it w as som etim es conducted by a section am ong the B rahm in

com m unity. It w as calculated that this type o f vaccination w as good as com pared to
the new one because the victim s o f the sm all pox w as low in this type. T he earlier

serum o f sm all pox w as used for the next y ears' vaccination. In 1720s the w ife o f the

then B ritish A m bassador in T urkey gave inform ation about the Indian m ethod o f

vaccination to the outside w o r l d . E d w a r d Jenner started the new vaccination in

1796 and after that the B ritish stopped the earlier Indian vaccination for prom oting the

V accination o f Jenner. It is calculated that in the 19'^ and in the beginning o f the 20'^

centuries, a larg e scale o f the cases o f sm all pox w as happened due to the abolition o f
the traditional system o f In d ia ’^^ V accination was introduced in T ravancore as early

as 1813. It w as started as system o f ‘P reventive M ed icin c’ under the directions o f Cl.

M unroe, the then R esident and D iw an o f T ravancore w ith the help o f Dr. Proven.

V accination w as m ade strict through the Royal Proclam ation on 14’^ A ugust 1878

am ong the public servants, students in all public schools either G overnm ent o r aided,

hospital patients and ja il convicts and law yers who w ere practiced m the courts.

T h e V accination departm ent w as organised as a separate departm ent in i 865-66 under

the ch arge o f m edical o fficer w ith European qualifications. T he first o fficer w as Dr.

Pulney A ndy M .D , w ith tw enty seven vaccinators in five grades w ith fem ale

vaccinators. T he vaccine m aking depot w as established in 1888 for the preparation

and distribution o f vaccine lym ph. “T he average cost o f each successful vaccination

varies from 1 a m a to 10 p a isa to 3as.w hile it w as 3as. 9 pies for 1903-04.” '^^

V accination in C ochin w as started before 1802 w ith six trained vaccinators

and the p eo ple w ere very m uch afraid o f the operation, but after getting the E nglish

education there aroused a positive altitude. T he vaccination departm ent o f C ochin

w as organized in 1886. T he condition o f M alabar w as very m uch different from the

conditions o f T ravancore and C ochin. A s early as 1801 rew ards w ere offered to the

people who successfully practiced vaccination and in 1803 the services o f Sub-

C ollectors w ere utilized for persuading the infected to subm it to vaccination. In the

y ear o f 1884, about 4,902 deaths w ere reported in M alabar and the highest death rate

w as reported in the Ponnani taluk}^'^ In the tour report on 31^' January 1805 the

S ecretaiy directs the R esident to extend vaccination in M ahe and its vicinity.'^^ In

1807, orders w ere m ade to debit the vaccination charges to the M adras governm ent

from the B om bay G overnm ent. T he Secretary o f the M adras governm ent also had

approved the suggestion to debit the expenses o f vaccination in M alabar to the

M adras governm ent and to place the surgeon at Palghat under the control o f the
general superintendent o f vaccination. V accination w as m ade com pulsoiy in the 14

am sam s o f Malabar.'^*^ In 1884 the total num ber o f vaccinations m ade w as 33,201

and in 1885 it w as 45,891.'^^ In 1900-01 56,732 persons w ere vaccinated in the

district excluding the m unicipalities. " in 1906-07, the num ber o f vaccinators has

risen to 112,212 excluding revaccinations. T he vaccination o f infants w as backw ard

d uring that time.

 A n inspector o f vaccination w as appointed and his duty w as to visit each

district at irregular periods and exam ine the returns o f the vaccinations and see that a

p roper supply o f vaccine lym ph was kept up. T he num ber o f vaccine cases in 1034

w as 18.624 and in 1035 w ere 12.777.'^^ V accination w as how ever m ade com pulsory

in C alicut M uncipality in 1914 and in p a n s o f W aynad in 1925. T he m unicipaiity

em ployed its ow n vaccinators. They w orked under the supervision o f the H ealth

O fficer o r C ivil S urgeon o r D istrict Surgeon. T he im portant areas o f the state w ere

divided into three divisions nam ely CaHcut, Palghat and T h a la ss e ry .'^ Each division

w as und er the control o f each D eputy Inspectors. B elow them there w ere about 49

vaccinators. T hey w ere graded as one and two. A person m ust m ake treatm ent to 150

p ersons on a m onth. F or easily getting the lym ph for vaccination in the state o f

T ravancore, King Institute at M adras w orked as a support for that purpose. T his

m ethod w as sam e for the m unicipalities o f M alabar and to the four provinces near to

the K annur m unicipality.'^^ T he rural areas w ere divided into se \’eral ranges for

m aking vaccination an easy process. Each ranges w ere brought under the supervision

o f a H ealth inspector w ho w as under the control o f the D istrict H ealth O fficer.

L ym ph obtained from the K ing Institute at M adras was used for vaccination in all

areas. So m any other organisations, students and institutions also supported im parting

o f know ledge o f vaccination in different areas. F or exam ple, Bindu band, Eliabas,

B anaras and in the other places' colleges or institutions w ere the centres o f im parting

ilie know ledge o f vaccination to the students.

F o r controlling o th er issues such as plague, colonial governm ent w ith the

support o f the native nilers im plem ented different type o f sanitary m easures. It is

assum ed that the lack o f sanitation is m ainly responsible for the issues such as
hookw orm problem , plague etc. Steps w ere taken to introduce different m easures o f

sanitation in the rural and urban areas. R adhika R am a Subban claim ed that the B ritish

had “ lost the historic opportunity for initiating sanitary reform ” and had scuttled all

initiatives put forw ard by the Indians them selves. Instead, she argues “the B ritish

developed a distinctly colonial m ode o f health care, characterized by residential

segregation and neglect o f the civilian indigenous population." T he core o f this

argum ent that colonial m edical policy privileged the needs o f Europeans and the

m ilitary has been accepted by the m ajority o f these who have w ritten on health and

m edicine under the R aj.’^^ T he sanitary conditions o f M adras Presidency, T ravancore

and C ochin w ere not in a good condition till 1860s. T he epidem ics w ere seasonal and,

the hot m onths o f M arch. A pril and M ay w ere alw ays tiireatened by sm all pox. and

the m onths o f June, July, A ugusi and S eptem ber w ere alw ays w elcom ed by the

epidem ics o f C holera and o th er w atery affected epidem ics. T he sanitary conditions o f

the ja ils w ere also the sam e. T he prisoners o f the Presidency had suffered a lot from

the hands o f the lack o f proper sanitation. T he ja ils o f the centre and the N orthern

D ivision w ere m ostly unhealthy. T he great evils o f the jails in the presidency w ere

deficient vaccination, and m any o f them w ere badly constructed.'^^

For im proving sanitary conditions, the T ravancore governm ent introduced the

T ow n Im provem ents C om m ittees and Rural C onservancy E stablishm ents tow ards the

end o f the last century to supervise the sanitary m easures in the rural and urban

a r e a s . T h e T ow n Im provem ent C om m ittees had the responsibility to supervise

scavenging, disposal o f rubbish, street lighting, disinfection o f w ells and tanJcs.

rem oval o f nigh soil from public roads, gravelling o f roads and lanes, control o f

sanitation in m arkets and slaughter houses etc. T he earliest m easure for direct rural

sanitation was the establishm ent o f sm all conservancies in 1889 at the stations such as

Parur, V aikom , C hanganassery, Shenkotta, V arkaia and P adm anabhapuram and at

oth er p la c e s"^ T he S anitary departm ent w as organized in 1895 in T ravancore w ith a

sanitary C om m ission er as its head. T he G overnm ent defined its duties as for easy

w orking o f this D epartm ent, the W hole country is divided into 4 D istricts’ nam ely

T rivandrum , Q uilon. K ottayam and V aikom and an Inspector w as appointed to

inspect the functions o f each district by m aintaining the conditions such as the to

superintend and check the vital statistics throughout the D istrict, to attend to the

sanitation o f all parts o f the D istrict w here the T ow n Im provem ent R egulation is not

in force, to study and report on the state o f P ublic H ealth w ithin his D istrict, to

superintend the vaccination w ork, and to be a sort o f travelling dispensary, actually

conveying m edical aid to the door o f the villager. T he Inspectors w ould be under the

orders o f the S anitary C om m issioner. T he establishm ent o f the Sanitary D epartm ent

o f 1895-96 w ith a view to provide for the registration o f V ital statistics offered itself

as a fitting opportunity for placing the conservancy establishm ents o n an im proved

footing.
 in 1896 S anitary B oards w ere constituted by ihe G overnm ent o f C ochin for

the tow ns o f Ernakulam , M attanchcry and T richur w as follow ed by sim ilar B oards in

K unnam kulam , Irinjalakuda, T ripunithura, N enm ara, and the N elliam patis.' ‘ T he

duties o f the Sanitary B oards w ere to keep the roads and tow ns clean, lightening the

streets, etc. T hey w ere strictly controlled and financed b y the govem m eni.

S anitation w as very w eak in M alabar w hen it is com paring to the conditions

existed in T ravancore and C ochin. T he am ount for starting sanitation W'orks given by

the m unicipalities w as not sufficient to m eet the requirem ents o f the province. T here

w ere able inspectors for the sanitation facilities. T here w as a system that the person

w ho cleans the city o f C alicut m ust cake the w astes o f 70 houses, but the w ork

functioned im proper. T his process w as absent in places other than the m unicipalities.

B ut later K ollangodu and Palghat taluks introduced this system w ith Tahik B oards.

W ells w ere b uild up by rounded necks w ith the help o f the Taluk B oards for the

w elfare o f the people. D rainage and surface conservancy and the w ater supplies w ere

indifferently protected in m ost o f the places. A s a result, D istn ct M edical officers had

taken great interests m sanitation. T h eir rem arks w hile on inspection tours w ere

copied into a book. T hose notes w ere passed through the local authorities to the

co llector for obseiTations. So that the view s o f all concerned are elicited w ere p u t on

perm anent record and progress or retrogression brought to l i g h t . S a n i t a t i o n was

very low especially am ong the m ukkuvas and m appilas and eye diseases w ere

com m on am ong them m the areas o f M alappuram . V arious skin diseases and deaths

w ere happened f r e q u e n t l y . d i s t r i c t M edical and sanitary officer w as stationed at

C alicut and C ivil surgeons at C annannore, C ochin and T ellichery w ere instructed to

solve and reduce such issues w henever those w ere happened,

Introd u ction o f d ifferen t typ es o f hospitals

In addition to the m easures m entioned above, hospitals and other institutions

w ere established by the colonial governm ent. M ost o f the references clearly explain

that before the introduction o f m odem m edical institutions, m ajor treatm ents w ere

done by the native vaidyans and the traditional A yurveda physicians irrespective o f

their caste and creed. W ith the m fluence o f Jainism and B uddhism they gave

m edicinal aid to the people through their m onasteries. B ut after the decline o f Jainism

and B uddhism , th eir m onasteries w ere added to the H indu tem ples, and the
educational and cultural institutions also began to function as adjuncts to those

tem ples and they w ere know n as 'S a la is'. T he Salais w ere the centres o f know ledge

and provided m edicinal health care. For exam ple a hospital o r a thurasalai w as

functioned in T iruvalla for m edicine and treatm ent o f the stuaents and p n esis attached

to the tem ple, its period was in 10'^ o r 11*^ century A.D., and daily food w as given to

the in patients and persons o f the h o sp ital'^ ^ T he prom inent tem ples o f K erala played

a m ajor role in m edicinal treatm ents. T he people believed, the prasadam s and

theertham s o f tem ples had the capacity o f curing different diseases. In course o f lim e,

the practitioners used to visit the residences o f the patients and gave m edicines and

treatm ents to them . B ut the A shtavaidyans are believed to be the practitioners o f the

p alaces or elevated fam ilies o r n o b l e s . R e f e r e n c e s about m odem type o f hospitals

can be traced back to the period o f the Portugues, w hich is already stated. Instead,

n um ber o f dispensaries and hospitals o r asylum s etc. w ere started in this land on

various occasions and periods.

In T ravancore, in 1837 His H ighness Sw athi T hirunal, started a hospital at

T haikkadu was the earliest dispensary started by the T ravancore royal fam ily. A t the

tim e o f the d eath o f Sw athy T hirunal, there w ere about seven hospitals in

T r a v a n c o r e , A H ospital at T rivandrum w as opened in 1838as a civil hospital and

later it becam e the G eneral H ospital. A nother hospital w as started to treat inpatients

in 1871 at K ollam . For m aking gynecological support to the ladies in K ollam , a

hospital was started in 1870, as a ju b ile e m em orial o f Q ueen V ictoria. In 1900 this

hospital w as separated from the district hospital and it becam e a separate institution.

In 1814 the D ental departm ent w as started in the G eneral hospital. In 1906 an eye

hospital w ith X -ray departm ent w ere started in the G eneral hospital. A special

hospital fo r the so called higher caste w om en w ere started during the period o f His

H ighness A ayilyam T hirunal in 1915. A hospital w as established in Peerm edu during

178
the p erio d o f Sir.T .M adhava R ao for the w elfare o f the planters and coolies there.

T he T ravancore royal fam ily started leper asylum s for the patients o f leprosy. They

started leper asylum in O oianpara n ear T hiruvananthapuram fo r the poorer sections o f

the people. T here the patients w ere given every attention and all possible

accom m odation, clothing, bathing, food exercise and general hygiene. T he L eper

A sylum in T ravancore w as opened in 1897 and the lepers w ere accom m odated in the

C harity H ospital, T aikad m anaged on a good condition and M r.T.A .B ailey, Secretary
to the ‘M ission to L epers in India and the East* visited the asyium and m ade an

excellent com m ent on it

In betw een 1903-1904 a m ental hospital at O olanpara near T rivandrum was

started. A leprosy hospital at N ooranad near A lappuzha was stan ed on 1934. A n

A yurveda and an A llopathy hospitals w ere started m T ravancore on 1932. T here

w ere tw o hospitals in every 33 square m iles. In the hilly regions it w as about 21

square m iles. M aternity and child w elfare services for rural areas o f T ravancore w as

started in 1938. It w as started for the benefits o f sm all tow ns and rural areas lacking

in facilities for m edical and m idw ifery aid. T w o units o f a lady doctors an d five
181
m idw ives w ere posted to take care o f the concerned.

T he first attem pt to introduce the w estern m edical system o f treatm ent through

m edical institutions in C ochin w as m ade by. Rev. J. D aw son. H e w as a m issionary,

w ho opened a D ispensary at M attanchery m 1818 and it existed for a short span o f

18*^
time. " In 1848, D ew an Sankara W a rn e r opened the first governm ent hospital o f

C ochin. It w as nam ed as the C harily H ospital o f E m akulam , w hich later developed as

the G eneral H ospital. In 1852, a room for surgery w as opened for im proving the
183
facilities provided for m edical treatm ent at the district headquarters. T he

governm ent assured that all the police stations m ust have w ork as the centres o f first

aid and they should give all possible helps to the v i c t i m s . H o s p i t a l s w ere opened at

T rich ur on 1875, T ripunithura on 1888, M attanchery on 1890. D ispensaries w ere

1
started at A ndikkadavu and N jarakkal on 1907 and at M attanchery on 1909. An

asylum for lepers w as opened in 1909 in the island o f V enduruthi.'^^ A lunatic

asylum and a L eper A sylum w ere opened on 1892 and 1909 at T richur and V endurithi

respectively. T here w ere separate dispensaries and institutions for w om en and

children in M attanchery, E m akulam , T richur. A m ental hospital at T rissur w ith 14

beds w ere started in 1892.'*^ D uring that tim e leprosy centres w ere started at

P alliport and C hevayoor. In 1872 a m ental hospital w as started at P uthiyathura near

C alicut w ith the capacity to accom m odate about 107 m ales and 36 fem ales.

C ivil hospitals w ere opened at M alabar in the m iddle o f the 19th century. T he

first public hospital w as set up in C alicut in 1844.’^^ W hen M alabar becam e a

m unicipality it b ecam e a hospital under the control o f the C alicut M unicipality. T he

C ivil hospital w as first located in the building o f T rav eller’s bungalow , w hich was
originally a D anish factory and w as acquired b y the governm ent in 1845. T he

hospital w as m aintained by the governm ent until 1863. L ater the public w ere invited

to subscribe tow ards the m aintenance and clothing o f the sick. A s result, a sum o f Rs.

26,500 w as collected. T he institution w as m anaged b y a com m ittee up to A ug.1872,

w hen it w as handed o v er to the m unicipal council. D ue to the lack o f facilities to this

hospital, another building w as com pleted in 1893 at a cost o f R s .l4 , 620. T w o w ards

w ere there and third w ard w as b uilt by Mr. D anjibhoy M aneekjee at his ow n cost for

the m em ory o f his daughter. O p w as built in 1895 in six w ards w ith operation room .

W om en and ch ild ren ’s ’ hospital w as established on A pril 1904.*^^ It w as follow ed by

tw o hospitals at P alghat and C ochin. T he local boards opened hospitals and

d isp ensaries at all T aluk centres and im portant villages. H ospitals got govt, grants for

its functioning and the treatm ent w as free. In the F actory R ecords o f A njego the

P resident from the B om bay G overnm ent directed the R esident o f M adras to indent

B om bay fo r all m edicines.'^® About 1920 a L eper A sylum w as opened at C hevayur by

th e '■mission to L epers.’’^’ In the sam e y ear G overnm ent took over the m anagem ent o f

the H ospital at C alicut w ith a view to im proving the facilities provided for m edical

treatm ent at the district headquarters. T he hospital at M anjeri w as taken o v er b y the

g overnm ent in 1928. A m ental hospital w as opened at Puthiyara, a suburb o f C alicut

in 1872. A hospital for w om en and children was also soon set up at C alicut. T he

M ission T ru st o f S outhern India m aintained a hospital at C alicut and dispensaries at

K ottakkal and C hom bala. T he P alghat m unicipal hospital was opened by the

g overnm ent on the 1^' S eptem ber 1860. In 1866 the m anagem ent o f the hospital w as

transferred to the M unicipal C o u n c i l . I n 1881 in C alicut there w ere a total o f 12

hospitals and dispensaries. A ccording to the census o f 1881 the population o f

M alabar, 2,365,035, the n um ber o f ta lu k w ere 11 and the n um ber o f dispensaries w as

also 13.

A t the close o f 1884, there w ere 299 institutions in existence and during 1885

th ere w as an increase o f 9 and 1closed, and the total w as 307. T he ratio o f

dispensaries w as 1 0 0 0 / 0 . 0 0 5 . Th e dispensaries in M alabar w ere located in

B adagara, C alicut, C annannore, C ochin, C herpalachery, M anantody, M anjery,

N elam bur, P alghat, P alliport L azaretto etto,P onnani, T ellichery, V aiytiri. A m ong

them 8 w ere m unicipal 4 w ere local fund and 1 w as o f G o v t . A hospital was

constructed from the favour o f S ir R am asw am y M udaliar. A nother hospital for

w om en and children in P alghat w ere done by the m u n ic ip a lity .'^ K annoor an

im portant m ilitary station o f M alabar and the G arrison H ospital o f that tim e

designated as G eneral H ospital on 1863, shifted from its original place to a rented

building in B azar N o .3 and on 1900 the old A rtillery B arracks w ere secured for the

hospital,

T he M adras G overnm ent m aintained Police hospitals at C alicut and

M alappuram . T he L azaretto at P alliport w as a legacy from the D utch and w hich had

accom m odated 48 lepers. A dispensary at A ndroth in the Laccadive Islands w as

an o th er contiibu tion o f the D utch. Each M unicipality m aintained a hospital and

Palghat and T ellichery have a branch o f dispensaries. A t P alghat there w as

dispensary for w om en and children only. T he local boards provided seven hospitals

an d eight dispensaries. N early 150,000 patients w ere treated in those hospitals in the

y ear o f 1906-07. S anitation w as practically non-existent there. D iseases w hich had

their origin in dirt and contam inated w ater w ere endem ic in the districts. O utbreaks
108
o f sm all pox and cholera w ere com m on. It is stated that there w as one m edical

institution to 83 square m iles. T he average o f m edical institution w as for T ravancore

b eing one to 129 square m iles and that o f M alabar one to 223 square m iles.

C alicut m unicipality w as unable to m aintain their old leper asylum . H ence,

passed a resolution on 17'*^ June, 1894 as stated earlier in this c h a p t e r . A s p er the

resolution, the superintendent o f the Basel M edical M ission was requested to take

ov er the charge o f the asylum . T he G overnm ent approved the request and the

institution w as taken over b y the superintendent o f the B asel M edical M ission.

A ccordingly, on the condition that it should be carried on as an asylum . T he old

asylum in C alicut n ear the beach w as insufficient to m eet the adm ission seeking

lepers and so w ith the help o f the M unicipality and the C ollector o f M alabar a site at

C h evay oor about 15 a c r e s . M u n i c i p a l i t y and leper asylum each bearing the h a lf the
coast o f acquisition. T he w hole property w as registered in the nam e o f the “ Leper

M ission T ru st Association'* incorporated under A ct o f 1860 in D ublin on the

co n dition that it shall be carried on as an a s y l u m . T w o new buildings w ere erected

in 1903, one for the m en and one for w om en and each had the capacity to carry 20

patients each. T here w as one room for the severe case and an isolation w ard was

for the bad cases.

 C alicut lunatic asylum founded on 28'^ M ay 1872 w as situated in 22 acres.^^'^

W hen it w as founded it had the capacity to accom m odate about 30 patients. U p to the

end o f 1906 the total num ber o f patients treated w as 1,105. T he m axim um num ber o f
205
any one y ear treated w as 184 and the m axim um daily average num ber w as 141.

W hen it w as com pared to the other parts o f India the m ales w ere predom inant in the

asylum and the age w as ranged from 26 and 40.^^^ T his asylum gave accom m odation

to the civil p atients and in the M adras Presidency the only asylum w hich gave
207
accom m odation to the crim inal patients w as in the M adras A sylum . T he poorer

labour sections o f the people w ere the m am inm ates o f the asylum and it w as linked to

the pau p er asylum o f England. T he w ealthy classes w ere rarely used the asylum . T he

inm ates w ere provided w ith suitable occupation insisting upon physical exercise and

m aintaining strict and gentle d i s c i p l i n e .S o m e t i m e s the inm ates w ere taken o u t for

p icnic and the c h ie f industries carried on in the asylum w ere w eaving, gardening,

vegetable gardening and goat rearing and the asylum gave clothing and bedding to all

the hospitals and d ispensaries in South Malabar.^*^^ T he asylum consisted o f a

S uperintendent, a hospital assistant, a stew ard, a storekeeper and 28 w arders and

servants. T he S uperintendent w as also the district m edical and sanitary officer. T he

institution w as also u n d er the supervision o f 10 official visitors.

In C alicut, a hospital fo r w om en and children w as started at the heart o f the city

and it consisted o f series o f w ard in separate blocks for B rahm ins, N airs, E uropeans,

and E urasians and for o th er castes. T here w ere septic shed, an operation room and an

O P and a dispensary. It w as built from public subscriptions as a m em orial o f the

D iam ond ju b ile e o f Q ueen V ictoria at a cost o f 34,079, R aja S ir Savalai

R am asw am y M udaliar gave R s.lO , 000 for its construction. T he C alicut M unicipal

council and M alabar D istrict board gave R s.6000 e a c h .^ '“ T he balance am ount w as

raised through the efforts o f three ladies M rs. M acrae, M rs. H ackett W illiam s and
M rs. W elsh. T h e hospital b ears the nam e o f S ir S avalai R am asw am y M u d aliar?'^

T h e foundation stone o f the hospital w as laid by Lord. A m pthill o n O ctober 1901 and

later it w as handed over to the Municipality.^*^ It w as opened for the public o n A pril

1904 w ith a lady apothecary in charge o f the hospital. It w as freely resorted to all

people, but the w ard for the B rahm ins w ere rarely used.^''^ In 1905 another w ard for
215
the Pancham as w as built.
H e a lth E d u c a tio n

A nother m easure started as a part o f the public health departm ent w as the

introduction o f health education. T he health education proved to be a successful

experim ent started im parting the aw areness on the necessity o f health conditions. The

h ealth educational branch aim s at the creation o f a sound public health conscience,

w hich is the vital requisite for the success o f every pubhc health activity. H ealth

exhibitions, h ealth w eeks and baby show s along w ith public health m odels, posters,

cinem as, lectures on health and hygiene, lantern show s and publication o f press

articles, pam phlets, and bulletins, health plays and dram as, school health processions,

and com petitive essay w riting on questions o f health and hygiene etc., introduced a

vivid picture o f the im portance o f health am ong the public. H ealth com m ittees and

leagues w ere form ed for a b etter health education in the state. T he H ealth E ducation

Schem e o f the T ravancore governm ent w as undertaken through a m iniature o f a

health m useum , w hich w as also there in the central office.

D uring the colonial period m edicine w as an instrum ent o f colonialism . T here

w ere system atic w eederies o f indigenous health care know ledge under nationalism .

The colonial governm ents alw ays tried to professionalizing tendencies of

m odernization by continuing displacing disparate know ledge o f unorganized and

pow erless populace. From the 16'*’ and I?'*’ centuries, E uropean countries had

com petitively colonized m ost o f the tropical world. T he contagious diseases they

brought w ith them frequently indigenous populations. T he existed diseases o f the

colonized areas threatened the invaders. So they tried to introduce colonial sanitation

and m edical care w hich they believed original and designed it to serve in the interest

o f the colonists. B ut after the establishm ent o f their superiority they strongly

recom m ended the w estern m edical science and enhanced incentive to control the

m ajor tropical diseases that w ere interfering w ith the econom ic developm ent o f the
th
colonies. T he situation greatly changed tow ards the end o f the 19 century. T he

developm ent o f nationalism w as accom panied by a cultural aw akening. In the 1890’s

the nationalist began to claim the effectiveness and the superiority o f Indian system s

o f m edicine and a m ovem ent began w hich aim ed at the political authorities

recognition and patronage o f indigenous m edicine. A n A yurveda pa ta sa la w as first

established in 1889 and a system o f grant-in-aid to qualified vaidyans w as also

sanctioned.^'^T he curricula o f studies in A yurveda schools w ere then revised o n up-

to-date scientific basis to suit m odem requirem ents and an A yurveda hospital and

dispensary w as established in Trivandrum . Thus the T ravancore state began to take

an interest in indigenous m edicine from, the late 19*^ century. D evelopm ent o f health

service w as not confined to the provision o f preventive care. Initiatives taken to get

m em bers o f the respective states w ho w ere trained in w estern m edicine into key posts

in the governm ent services. T he appointm ent o f Dr. M ary Punnen L ukose as the

surgeon in the G eneral H ospital o f T ravancore in the early years o f the 20**^ century

w as an exam ple. She w as first w om an to be appointed as surgeon general in an

Indian state, at the tim e w hen w om en doctors w ere rare in E urope and A m erica.

D evelopm ent o f health seiTice w as com plem ented by other parallel initiatives

to p rovide safe drinking w ater and the provision o f state supported prim ary education,

m cluding education for w om en. A nother factor w as the establishm ent o f M ission

hospitals in the rem ote areas under the auspices o f m issionaries. T his w as m ainly

because the m edical activities o f the m issionaries w ere very useful to the state,, In

1889 the A yurvedic School w as opened in T rivandrum w hich w as undoubtedly one

for the earliest institutions o f this kind in India, and after this the state rather

enthusiastically contributed to the developm ent o f indigenous m edicine, W ith

increased m edical facilities an d m edical education there w as an im provem ent in the

public health sector o f K erala.

C o n clu sio n

India possessed w ell oriented and system atic m edicinal practices and caring

from very an cient tim es. A t that tim e, the m edicinal practices and caring m easures

w ere m ainly focused upon the life style o f the people. D iseases w ere seasonal and life

style o f the peop le existed together. W hen the diseases occurred the people w ere

ready to change their life style. T rade relations, travels, pilgrim age etc. also coined

the h ealth sector o f India. In course o f tim e, different form s o f m edicine cam e here

and b ecam e a p art o f the traditional life o f the society. L ater the colonial m edicine

w as introduced here and m ade a com bination o f both, the traditional m edicines and

the n ew ly introduced one. It finally resulted in the total updating o f the m edical care.

It w as suitable for the developm ent o f health sector in K erala also. K erala is the first

state o f India achieved the status o f good health updating sim ilar to that o f developed
nations o f the w orld. T here w ere so m any factors or reasons for updating the m edical

care and health care sector in K erala. A ll those supporting factors provided the land a

chance to attain the m axim um achievem ents in the health sector.

 END N O TE S

E lam kulam P .N .K unjanP illai, Sam skarathinte nazhikakalhtkal, (M ai),

(K ottayam ; Sahithya Pravarthaka Sahakarana Sangham , 1964), p. 106.

/ 22, A jo u r n e y fr o m M a dras through the countries o f M ysore, C anara a n d

M alabar. F rancis B uchanan .M .D, V ol.L (M adras: G overnm ent o f M adras,

K .P .P adm anabha M enon, H istory o f K erala, V ol. I, (N ew Delhi: A sian

Educational Services, 1995), p .140.

C. A chutha M enon, C ochin State M anual, (E m akulam : C ochin G overnm ent

Press, 1911), p 3 6 8 .

^K .P.Padm anabha M enon, op. cit., p p .141- 149.

V. N agam A iya, Travancore State M anual, Vol. II, (C ochin: K erala B ooks and

Publication Society, 1999). p .558.

7;

pp.568-570.

Francis Lieber, E ncyclopedia o f A m ericana Vol.12, (N ew York: G rolier Inc.,

2006), p. 118.
10
Ibid.
n
Ib id
12
P.V. K uryan., K eralam Innu Innale Nale, (M ai.). (K ottayam : V angard Press.

1976), p.lO
13
Census R eport. 2011. (N ew Delhi: G overnm ent o f India, 2011), p p .231-32.
14
Ibid.
15
E lam kulam K unjan Pil/ai. op. cit., p.49.
16
Ibid.
17
Ibid.
18
N iranjana D evi, M edicine in South India, (C hennai: E sw ar Press, 2006), p .6 1 ,
19
N agam A iya, op. cit., p . 550.
20
V inayachandran K erala C hikilsa C harithram (M ai), (K ottayam ; C urrent

B ooks, 2 0 0 1 ),p p .2 0 0 -2 0 1 .
N iranjana Devi, op. cit., p .107.

A. Shanm ughavelan, Sid d h a r 's Science o f L ongivity a n d K aipa M edicine in

India (I. Ed), (M adras; S akthi N ilayam , 1963), p.40.

P.T. S rinivasa Iyengar, H isto iy o f Tafnils fr o m the earliest to 600 a D,

(M adras, C, C oom arasw am y N aidu & Sons, 1995), p.4

S. M anu V aidyar, Siddha Vaidyam, K erala C alling, (T him vananthapuram :

Public R elations o f K erala, July 2007), pp.32-33.

S.N .Sen, (et.al) A C oncise H istory o f Science in India, (H yderabad: U niversity

Press, 1988), p.309.

Ibid.

N agam Aiya, op. cit., p .557.

M anu V aidyar op. cit.

Ibid.

P. V inayachandran, op. cit.

R. N iranjana Devn, o p .cit.p .1 10,

Ibid, p. 104.

S. M anu V aidyar, op. cit.

Ibid.

M .R .R aghavaV arier, The R ediscovery of A y u n ’eda The sto ry of

A ryavaidyasala K ottakkal, (N ew Delhi: Penguin B ooks, 2002), p .l.

N .V .K rishnan K utti V arricr. A yurveda C harithram . (M ai), 2"^* edition,

(K ottakkal: A rya V aidya Sala, 2009), pp.336-359.

Ib id

Ibid.p.Ti.

K .R aghavan T hirum ulpad, Bhaishyaj'yadarsanam (Mai).

^ h iru v a n a n th a p u ra m : C hintha Publications, 2002), p p .24-33.

Ib id

Ibid.

Ibid, pp.21-22.

Ibid, pp.46-47.
44
R .N iranjana D evi, op. cit., p p . 62-10.
45
Ibid.
46
B havanopanishad is an U panishad w hich belongs to the group o f U panishads

o f A tharva Veda,
47
A bseena J. Salim , A yitn 'ed a m C harithram Sastram chikitsa (M ai),

(T hiruvananthapuram : C hinta Publications, 2007), p. 10.

48
R. N iranjana D evi, op. dr.
49
Ibid.
50
M. R. R aghava V arier, op. cit., p p .9 -\A .
51
Ibid, pp. 1-2.
52
Ibid, p p .1-10-
53
K. R aghavan T hirum ulpad, op. cit., p p .98-101.
54
Ib id
55
N iranjana D evi, op. cit., p .70.
56
A. N. C hidam baran, H orthusum Itti A chutham im , Sathyavum M m idhyayum

(M ai), (T hrissur: K erala S ahithya A cadem y, 2011), p .57.

57
R. N iranjana Devi, op. cit.
58
N .V . K rishankuttyV arrier, op. cit., pp.229-258.
59
Three types o f A y iin ’edic treatm ents using to p u rify hum an body.
60
K uruppum V eetil K.N. G opala Pillai, K erala M aha C haritram (M aL),

(Thiruvananthapuram ; R eddyar and sons, 1948), p p .136-141.

61
A /608, A /609, A /1083, R egional A rchives. Calicut.
62
M aina U m aiban. Vishachikisthsa (M ai), (K ozhikkode: O live Publications,

2007), pp. 12-20.

63
V, M . K uttikrishna M enon, K riyapadhathi, (M ai), (K ottayam : C urrent Books,

1987), p.25.
64
Ib id
65
M aina U m aiban, op.cit.
66
Ib id
 B isam oy Pati and M ark H a m so n (Ed.). Health, m edicine a n d em pire:

P erspectives on colonial India (J). N eshai Q uaiser, Politics, C ulture and

co lo n ia lism -U n a m 's D ebate w ith D octory\ (H yderabad: O rient L ongm an.

2001), p.317-355.
68
Ibid.
69
J / 22 A, Francis B uchanan M.D. Journey fr o m M adras through the countries

o f M ysore. C anara a n d M alabar, Vol. 1. p p .32-33.

70
K. P. P adm anabha M enon, op. cH.. p. 130.
71
Ibid, p .\3 2 .
72
Ibid.
^3
Ibid.
74
I b id p. 134.
75
Ibid.
76
W illiam Logan, M alabar M anual, Vol. I, (re-print), (T hiruvananlhapuram :

M athrubhum i B ooks. 1981), p. 254,

K, D am odaran, K erala C harithram (M ai), (T hiruvananthapuram ; P rabhath

Books. 1998), p .243

78
M, Jayarajan, Sacred G roves o f N orth M alabar, (Thiruvananthauram : C entre

for D evelopm ent Studies. 2004), p .9,

79
W illiam Logan, op. cit.

D urda m eans a type o f fever in connection w ith leprosy existed in the M alabar

region noticed by B uchanan.

Francis. T. B uchanan, .op. cit.

T. K. V elu Pillai, T ravancore State M anual, (T hiruvanthapuram : G overnm ent

o f K eraia, 1996), p.356.

83
C .A chutha M enon, C ochin State M anual, p .365.
84
Ib id
85
W illiam L ogan op. cit., p .254
86
M a la bar D istrict G azetteer III, p p .11-112
87
P. A chutha M enon. op. cit., p .366
 K. N. Panikkar. C olonialism , Culture, a m i R esistance, (N ew D elhi: O xford

U niversity Press, 2011), pp.168-19!,

P. B haskaranuni, P athonpatham noottandile K eralam (M ai), (K ottayam :

K erala Sahitya P ravarthaka S angham , 1988), p .798.

Ibid.
91
D eepak K um ar., Science a n d the Raj: A study o f British India, p .92.
n

93
Ib id
94
R. N iranjana D evi, op. cit., p p .73-75.
95
Ibid.
06
ib id , p.76-
97
Ib id
98
K. R ajasekharan N air, E volution o f M odern M edicine in India- B iographical

Sketches o f P ioneers in M edicine M em ories o f a M edical Teacher,

(T hiruvananthapuram : TB S Publications, 1998), p.2.

99
R. N iranjana D evi, op. cit.
100
Ib id
101
P. B haskaranunni, op. cit.. p p .799-800
102
A speech o f Prof. K. K.N. K urup regarding the contributions o f the D utch in

K erala co n d u cted b y the U niversity o f Kerala, T hiruvananthapuram . 25'^

N ovem ber 2009.

103
Ib id
104
A .N . C hidam baran, op. cit.
105
K.K .N . Kuioip, op. cit.
106
M .O. K oshy, D utch P o w er in K erala 1729-1758. unpublished PhD. Theses,

(T hiruvananthapuram : U niversity o f K erala 1988), p.335.

107

108
Ib id ,p .3 7 0 .
109
Ibid, pp.374-377.
110
Ibid.
 C. A chutha M cnon, op. cit., p.369.

Ibid.
113
Ibid, p.370.
114
K .R ajasekharan N air, op. cii.
115
K .P .P adm anabha M enon. C ochi R ajya C harithram , Vol. / / , (E raakulam :

G overnm ent o f C ochin, 1914), pp.577-578.

116
C. A chutha M enon, op. cit., pp.496-499-
!P
P. S ankunni M enon, op. cit., p .368.
118
D istrict G azetteer, E m akulam , (G overnm ent o f Kerala: 1976), p. 733
1IQ
F irst Tour o f H.E. the R ight Hon. the L o rd P etk in d G overnor o f M adras

C oim batore a n d M alabar, M adras, 1913, p.! 16.

120

121
Ib id
122
Ib id
123
Im p eria l G azetteer o f India G /54 the Indian E m pire Vo. I D escriptive, p. 500,

R egional archives, C alicut

124
Ib id
125
A /1083, R eport on the adm inistration o f the M adras Presidency during the

y ear 1860, M adras, 1861, pp. 140-142, R egional archives, Calicut.

126
Ib id
127
Ib id
128
Ibid.
129
Ib id
130
T. K. V elupiliai, op. cit., p p .761-762.
131
Ib id p. 766.
132
V. N agam A iya, op. cit., p.499.
133
T. K. V elu Pillai, op. cit.
134
Ib id p.767.
135
V. N agam A iya, op. cit.
136
!38
ibid.
139
T. K. V elu P illai, op. ci(., p p .768-769.
140
V. N agam A iya, op. cit., p .500.
HI
Ibid.
142
T. K.. V eiu Pillai, op. cit., p .767.
143
Ibid. p .766-768
!44
Ibid, p.769.
145
Ibid. p770.
146
Ib id p. 771,
147
Ib id
148
Ib id
149
V. N ag am A iya, op. cit., p .504-505.
150
I b i d .p .l l l .
151
P. S ankunni M enon, op. d r.. pp.496-499.
152
Ibid.
153
Im perial G azetteer, op. cit., p .746.
154
K. V. Sivaprasad , C Juinthrathinte M arupuram , (T m s.)(M al) V adakara 2003,

V inin Perera, The other sid e o f H istory, M u m b ai,1985.

155
Ibid.
156
P. Sankum ii M enon, op. cit., p .369,
157
Ibid.
158
A d m inistration R eport, M adras, 1885, R egional A rchives, C alicut, p .l3 .
159
G/5<5,Ko/,/.p.303,Regional A rchives, Calicut.
160
Ibid.
161
Ibid.
162
Ibid.
163
A /1085, R ep o rt on the adm inistration o f the M adras P residency du rin g the

y e a r i8 6 0 , M adras, 1861, p.140-142.

165
M a la b a r Gazetteer. Op. cit., p .134-141,
166
R adha R am asubban, P ublic H ealth am ! m edical R esearch in India; Their

origins a n d D evelopm ent under the Im pact o f British C olonial P olicy.

Stockholm ; SA R EC 1982, p .14.

167
B isw am oy Pati (et.al) H ealth, M edicine, a n d Em pire. P erspectives on

C olonial India, p.3.

168
Ibid.^iA
169
P. G. K. Panikkar, C.R. Som an, H ealth status o f K erala P aradox o f E conom ic

B a c h ^ ’ardness a n d H ealth D evelopm eni. (Thiruvananthapuram : C D S, 1984),

p .50.
170
Ib id .p M 5
171
C. A chutha M enon, op. cit., p p .631-632.
172
A /9 , A nnual report. 1885, p. 126, R egional A rchives, Calicut.
173
D istrict G azetteer M alappuram , C. K. K areem , (C om p.) A door K.

R am achandran N air, (Ed.) (T rivandm m : G overnm ent o f K erala, 1978), p .743,

174
Ibid.
175
R. S ubm m aniyam , H istory o f Indian M edicine, op. cit., p .113.
176
A. Sreedhara M enon, Social a n d C ultural H istory o f K erala, (Sterling:

U niversity o f M ichigan, 1979), p.28L

177
S how case notice 242, State A rchives, T hiruvananthapuram .
178
T. K. V elu Pillai, op. cit., p .212.
179
T. K. V elu Pillai, op. cit., p.SOO.
180
Ib id
181
Ibid, pp,761-762.
182
C .A chutha M enon, op. cit., p .368.
183
R eport on adm inistration o f C ochin 1855- 66 A /642, C ochin, 1866, p .38,

R egional archives Calicut.

184
P. B haskam unni, op. cit., p .801-802.
185
D istrict G azetteer, E m akulam . op. cit.
187
P. Sankunni M enon, op. cit., p .370.
188
C .A .lim es, M a la b a r G azetteer, Vol. II, (T hiruvananthapuram : K C H R ,1997)

P-134
189
IstT o u r R eport, M adras, pp.95-96, R egional A rchives, Calicul.
190
G/86, Guide, p. 103, R egional A rchives, Calicut.
19 !
Ib id

T/26. tour o f H. E. T he R ight Hon. the L ord Petland, M adras, 1914. p.

R egional A rchives, Calicut.

193
C ensus R epo rt o f 1 8 8 L R egional archives. Calicul.
194
A/609. A nnual R eport o f the C ivil H ospital and D ispensaries for th e year

1885, M adras Presidency, O otacam und, 1886, R egional archives, Calicut.

195
Ibid.
196
C .A .Innes, op. cit.
197
Ibid.
198
T/24. T h e fifth tour o f the H on. Sir. A rthur Law ley, G overnor o f M adras

M alabar, M adras, 1907, p.47. R egional A rchives, C alicut

199
C. A chutha M enon, op. cit., p.369.
200
Ib id
201
Ib id
202
Ib id
203
Ibid.
204
T/24, p .91, R egional A rchives, C alicut.
205
Ib id
206
Ibid, p .92.
207
Ibid.
208
Ibid, pp.92-93.
209
Ib id
210
A /608, A nnual report on the C ivil hospitals & dispensaries in the M adras

P residency, M adras, 1884.

 A /609, A nnual report o f on the civil hospitaIs& dispensaries in the M adras

Presidency. 1885.
212
M /167, T he M adras m edical R egister for 1938, pp. 8-18,
2 !3
Ibid.
214
Ibid.
215
Ibid.
216
T. K. V elu Pillai, op. cil., p p .810-812

Ib id
 C H A P T E R I!

DETERMINANTS OF HEALTH TRANSITION IN KERALA

India as a developing country, has a populace o f m ore than 100 crores. V arious

studies show that the general health standard in India is quite low and m ost o f the

people in India have poor health conditions and fall sick quite often. A m ong the m ajor

reasons for p oor health conditions o f the population in this country are lack o f

nutritious diet, inadequate m edical care and unhygienic living conditions. A s m edical

system s becom e costly, m ajority finds it unaffordable. H ospitals are m ainly located in

the urban areas w hich are not at easy to reach to m ost o f the rural population. Y et

there are significant im provem ents in the country since the day o f independence. B ut

certain lim itations are there in the im provem ent o f health conditions o f the nation.

M ajor lim itations o f In d ia's achievem ents in health status are the existence o f w iae

interregional inequality across the states. G enerally, the circum stances in w hich an

individual lives is o f great significance on health situation and reputation o f life

H ealth is enduringly uphold and enhanced through the progress and applying o f health

science. A lso the efforts and intelligent lifestyle choice o f the individual and society

determ ines the health conditions. T here are so m any influencing factors on health

conditions. T h e factors that affect health conditions o f a society are called

determ inants o f health.*

M ajor health determ inant factors are I) genetic pattern, 2) level o f

developm ent, 3) lifestyle, 4) environm ent and 5) health infrastructure. T he health o f

the population is greatly dependent upon genetic constitution o f the respective

population. It includes both the inclination to certain ailm ents and health conditions,

as w ell as the routine behaviours o f individuals are developing through the lifestyle o f

th eir fam ilies." T he second determ inant factor Levels o f D evelopm ent m eans
econom ic and social developm ent, w hich helps to im prove the health status o f a

society. L ifestyle o f people is the third determ inant and it depends upon a so ciety 's

culture and socio-econom ic developm ent. L ife styles are o f different types in

different regions. Sedentary lifestyle is one am ong them , w hich is very com m on in the

w est and is being adopted by m ore and m ore people in the developing co u n tn es also.

S edentary lifestyle, an over am bitious outlook, excessively aggressive consum ption o f

alcoholic beverages and sm oking have brought non -com m unicable disease like

diabetes, hypertension, m yocardial infarction etc. to the forefront as som e

com m unicable diseases have been controlled.^ Environm ent is another im portant

factor m fluencing the health status o f individuals. It includes characteristics o f the

natural environm ent, the b uilt environm ent, and the social environm ent E iem em s

such as clean w ater and air, adequate housing and safe com m unities and roads all

have been found to contribute to good health, especially health o f infants and

children. P oo r environm ental sanitation, inadequate safe drinking w ater, excessive

levels o f atm ospheric pollution etc. are im portant determ inants in the physical

environm ent affecting health. T he socio - econom ic status, em ploym ent potential,

h arm onious m an tal relationship, positive em ployer-em ployee relationship, etc. are all

o ther im portant factors in m a n 's social environm ent. The biological environm ent is

another influencing environm ent, com posed o f diseases bearing arthropods, insects,

dom estic and m ilch anim als etc. H ealth Infrastructure is the next im portant

d eterm inant and w hich include, accessible and acceptable health facilities have a

direct bearing o n health status. A vailability o f good health facilities w ould result in

im proved health.'’

Im provem ents happened in the health scenario o f K erala, passed through

different stages; the determ inants factors as statea above are fully or partially played a

prom inent role on its developm ental stages.

H ealth d eterm in ant factors o f K erala

K erala is one o f the few areas m the developing w orld w hich has

achieved substantial progress in the fields o f social equality, education, and health. It

w as as a result o f various factors such as social, political econom ic and other

influencing factors T he 19'^ century K erala w as a period o f transition and

transform ation in every realm o f social lives includes health conditions. F actors that

contributed to the grow th o f the health life o f a society can be called as the

determ inants o f health status. In health, there are so m any factors to be considered as

the determ inants o f health. It starts from the birth o f a person. A s stated earlier it can

b e added to the factors o f genetic conditions and situations. I f he is bom in an

educated w ell to do fam ily, he is able to get the support o f better health care. If

anybody is b o m in a low class unhealthy and poor fam ily his conditions on health
care m ay not b e a better one. B ecause he is unaw are about the healthy conditions o f

livelihood, necessity o f sanitation, etc. w ill definitely affect it. In K erala the birth,

grow th, lifestyle, age, w orking places etc. definitely determ ined the health conditions

o f the family.^ H ence, it can b e called as the determ inant factors o f health o f K eraia.

It can be m ainly categorised under three sections o f culture. T hey are. Social and

E conom ic determ inants, E ducational determ inants and P olitical determ inants.

T here are tw o aspects o f socio-econom ic situation m developing

co u n tn es for poo r health situation. T he first one is resource constraints. T he second

o n e is high disparity in the distribution o f incom e, T he relationship betw een health

and socio-econom ic conditions are continuously changing. T he socio-econom ic

conditions prim arily determ ine the health status o f populations. T here are m any socio­

econom ic conditions unique to K erala that m ade health transition possible. T hose

conditions have been postulated health transition possible. Even though the earlier

traditional society o f K erala w as characterized by so m any inequalities, the new

dim ension aroused in course o f tim e o f history helped K erala to gam the status. T he

transition from a society w ith high population grow th rate, high death rate, high infant

m ortality rate to one w ith m oderate population grow th rate, low death rate and low

infant m ortality rate etc are the result o f the restructuring o f society w as happened as a

result o f the introduction o f m oderate econom ic and social conditions.

T he roots o f illness for the people lay in the organization o f econom ic

p roduction and the social environm ent. So m any socio-political, econom ic,

geographic, clim atic and physiological factors interacting w ith one another are

som etim es m aking a situation o f diseases. S alvador A llende w ith a definite M arxist

orientation conceptualized illness as a disturbance o f the individual that often w as

fostered by deprived social conditions.^ A llen d e's w ork show ed strong sim ilarities to

the w orks o f Frederic E ngels and R u d o lf V irchow . A llende developed a class

strucoire and deprivations o f the w orking class in C hile and the other T hird W orld

countries w ithin the fram e w ork o f underdevelopm ent and im perialism . V incent

N avarro a social scientist tried to extend this M arxist approach in order to gain

sharper insights into the health problem s o f present d ay underdeveloped countries as

w ell as un d er developed regions and deprived groups in the developed countries.

 Im portant studies in the field o f health in connection w ith the socio econom ic

and educational background o f K erala w ere m ainly conducted by the K erala Sasthra

Sahitya Parishad. T he studies assessed that the socio-econom ic status o f the state on

the basis o f per capita incom e, housing, education and land ow nership.^ T he different

death rates am ong different socio econom ic classes are m ainly attributed to poor

living conditions. T hey are housing, sanitation and w ater supply, behavioural patterns

such as sm oking and alcohol consum ption, drug abuse and barriers to healthcare

access such as m oney and travelling.'^ T he differential birth rates w ere partly

exam ined on the basis o f the difference in e d u c a t i o n , T h e developm ent in public

h ealth is p rim arily evidenced from the low ering rate o f deaths, it m ay b e correct that

m ost o f the m od em ailm ents such as heart disease, cancer, and other chronic diseases,

arise out o f the stresses o f an industrial society. T he provisions for clean drinking

w ater, sanitary facilities, and im m unization program m es w hich result in the

eradication o f infectious epidem ics viz. sm allpox, cholera and plague are the effect o f

public health aw areness. T he increase in the availability o f nutrients positively affect

the health status o f the people. T he developm ent o f curative m edical technology had

probably very little to do w ith the fall in death rates. But the fall in death rates w as

soon follow ed b y a fall in birth rates, resulting in slow grow th rate o f populations.

K erala society w as not an ideal society in its earlier tim es w here the principles

o f social freedom and equality tied by the clutches o f caste system . N o egalitarian

law m this part prevailed. T he so called upper castes o f the nation enjoyed every

rights and benefits o f the society. T he penal code w as extrem ely severe as far as the

low er castes w ere co n cern ed .‘"The so called low caste people had no chances to get

enough m odem m edical facilities as com pared to the other com m unities. V anous

references show the vulnerable conditions o f the low er caste people since earlier

tim es. T he health status o f the people w as definitely affected by the health conditions

to a large extent. T here w ere no sufficient food for them even though they conducted

the agricultural jo b s fo r long tim es. T hey got m inor share o f food item s w hich w as

not enough for the m em bers o f the fam ily. M ajority o f the low caste people suffered

from poverty and ate the item s w hich w ere available around their surroundings.'^In

the Sangam literature certain indications about such conditions o f the poor are

d e s c r i b e d . T h e low caste people w ere not perm itted to w ear enough dress to protect

them from the natural flow outs. T hey suffered from severe rainfall, cold and hot
changes o f the seasons. In K erala, m ajority o f the diseases w ere result o f the changes

o f the seasons,'^ A bsence o f pacca houses affected the health conditions o f w orking

class people. T he children o f them w ere also passed through such conditions o f lack

o f nutritious food, enough dressing, sanitation and aw areness o f the prim ary health

habits.'^T he lack o f good drinking w ater led them to the w orst epidem ics and endem ic

d is e a s e s .''

T he caste system and slavery also existed in its w orst form till the beginning
18
o f the 19th century. T hey w ere even not ireaied as hum an beings; none o f them

could enjoy social am enities like w earing tine clothes, m oving in conveyances, living

m tiled houses, using m etallic utensiis etc.

In flu e n c e o f Socio -R e lig io u s R e fo rm M o v em en ts o n p u b lic h e a lth c o n c e rn s o f

K e ra la

T he socio religious reform m ovem ents o f the 19’^ century evolved creative

m arkings in the socio econom ic history o f K erala. T he m ovem ents sta n e a to gel

equalization, abolition o f slavery, ja n m i kudiyan system , tem ple entry dem ands,

dem and fo r using the public w ays, public w ells, ponds, using o f clothes and better

utensils, construction o f houses aw'ay from places prone to natural disasters, dem and

for ow n agricultural lands, getting chances for education, etc. finally resulted in better

advancem ents o f public health. T he roles played by Sree N arayana G uru, A yyankali

and others are notew orthy in the social and econom ic r e f o r m s .B o t h o f them , Sree

N aray ana G uru and A yyankali, advised the alienated groups to generate aw areness on

health and hygiene. Sree N arayana G uru advised the m others o f the groups o f the

alienated com m unities to w ash their hands before giving food to their children. T hose

children had suffered infections from various w orm s as they w ere doing jo b s m the

f a r m s , B e f o r e that the w orking classes w ere unaw are about the need for such a

m inor action how m uch save the health and life o f their children. He also advised

them to m ake better sh elter and m ake the dom icile neat and clean.

A s a result o f the socio - econom ic reform m ovem ents the governm ent enacted

law s and regulations for uplifting the backw ard classes. H ospitals and dispensaries

w ere opened in course o f tim e in various parts o f K erala as a result o f the introduction
o f m o d em m edicine. Separate room s for high cast ladies and children w ere started.*^

B ut som etim es the higher castes w ere not interested in going to hospitals, or
dispensaries, yet at that tim e the low caste w ere kept aw ay from the hospitals crecied

for the high castes. T h a t's w hy the governm ents o f the 19'^ and early 20*'^ centuries

tried to open new room s fo r the low castes.^"* A fter the introduction o f the popular

m inistries the policy w as carried out adm irably.

E con om ic D eterm inan ts o f H eaith S ector in K erala

W hile considering the econom ic factors, specifically it is the level o f incom e and

Its distribution, ow nership of land and other assets, em ploym ent situation,

developm ent policies o f K erala, housing, w ater supply and sanitation, agriculture,

public d istribution system etc. w ere instrum ental in influencing the health care

scenario o f K erala. P overty, poor housing and degraded environm ents had a direct

link w ith health to a w ider extent. B efore independence, the expenditure on health by

the native states in T ravancore, C ochin and B n tish M alabar w as significant. B efore

1860 the G overnm ent o f T ravancore allotted around 1% o f its total expenditure to the

h ealth sector and the proportion o f the expenditure w as increased to 2% b y the close

o f the century

O ne im portant finding o f the earlier studies w as that the ratio o f healthcare

expenditure to G D P increased, as countries w ere getting developed econom ically and

industrially. Incom e is a driving force behind the striking health disparities that m any

m inorities experienced. In 1963 and 1967 w hen p io n een n g w ork o f A bel-Sm ith

b rought out this issue in W orld H ealth O rganisation studies. T hey found that after

adjusting inflation, exchange rates and population, G D P is a m ajor determ inant o f

h ealth expenditure."^ Financing on health is an im portant issue in both the developing

and developed countries. H ealth expenditure is a part o f the GDP.

A fairly com prehensive and system atic survey w as conducted as part o f the

1941 census o f T ravancore, covering over one hundred thousand fam ilies in the state.
A ccording to the findings o f that survey, “the average annual incom e o f a fam ily as

determ ined by the m edian is Rs. 102.”^^ “T he average size o f th e fam ilies and

n um ber o f earners p er fam ily com e to 3.76 and 2.01 respectively.” T he average

incom e thus w ould w ork out to Rs.51 p er earner and to R s.27 p er capita including non

- earners.^'’ T his level o f incom e w as insufficient to fetch the bare necessities o f life.

“T he highest incom e group m different com m unities an adult gets only 2 to 4 annas

per day for all the necessaries put to g eth er...co n sisten t w ith condition o f living in
T ravancore, characterized b y a sim plicity o f alm ost S partan in character, particularly

in food and clothing, the pittance at the disposal o f the individual, as disclosed by the

above figures points to the m iserable life eked out from day to day.”^° T he findings

o f an econom ic survey conducted in the C ochin state in 1936 throw light on the

incom e and levels o f living in the state. A ccording to the survey, in m ore th an one

third o f the fam ilies in the selected villages, the annual incom e w as below Rs. 100 p er

fam ily or R s.20 p er head.^' It m eans less than 1 anna p er day. M ore than three

quarters o f the fam ilies reported incom e is less than R s.200 or R s.40 p er head per
32
year.

In 1968 the socio econom ic survey w as specifically designed to collect

inform ation on the social and econom ic conditions o f different caste/com m unities.

T he findings b ro ught out w ide disparities in m com e across different social classes,

T h e p ro portion o f fam ilies in the low est incom e classes w as higher am ong scheduled

castes and tribes than the other com m unities. T he survey revealed that there is a close

association betw een caste, occupation, and levels o f incom e. D uring that tim e

agricultural lab our constituted the m ajor occupation for all types o f com m unities and

there w ere no changes in the case o f the scheduled castes and tribes. G radually it

began to change- Y et the high degree o f inequality in distribution o f incom e affected

public life o f the low er incom e group even though the state introduced various

p rogressive policies. T he governm ent policies on public distribution o f food grains,

m edical care, education etc. m ade a favourable effect on reducing poverty and

u nhealthy conditions o f the low er incom e group.

Such Situations began to change after the fram ing o f the C onstitution. T he

C onstitution assured basic and fundam ental rights to all o f its citizens though different

enactm ents. T he Indian constitution charges the states w ith "the raising o f the level o f

nutrition and the standard o f living o f its people and the im provem ent o f public

health."^'’ C entral governm ent m ade efforts on influencing public health by focussing

on the five-year plans, on coordinated planning w ith the states, and on sponsoring

m ajo r national health program m es. F or m ost national health program m es governm ent

expenditures are jo in tly shared by the central and state governm ents.

H ealthcare expenditure is very necessary in the social expenditure o f a country

is concerned as far as. L ike any other social expenditure, health expenditure also
requires a significant contribution from the G overnm ent. W hether, it is a developed

country o r a developing one. sta te 's role in building a good health infrastructure is

very high. T he state has another responsibility to assure good health to everybody,

and it becom es a very critical and im portant m atter. In addition to the state

representation, in India, m ajority o f expenditure on health, is contributing from

p n v ate households. It is calculated as aro u n a 75 p er cent. State governm ents

contribute 15.212 percent, the central governm ent contributes 5.2 percent, third-party

insurance and em ployers contribute 3.3 percent, and m unicipal governm ent and

foreign donors contribute about 1.3 p e r c e n t . O f these proportions, 58.7 percent goes

tow ard prim ary health care -curative, preventive, and prom otive- and 38.8 percent is

spent on secondary and tertiary inpatient care.^^ T he rest incom e goes for non-service

costs. T he com parison o f health expenditure w ith other countries suggests that india"s

public health expenditure is only 17,9 p er cent o f the total expendim re on health care

w hile it is close to 90 p er cent for sm aller countries like B hutan and M aldives,

C entre and state roles in public healthcare expenditures go hand in hand. T he total

public health care expenditure is com posed o f state level allocations and allocations

from central governm ent. T he centrally sponsored program m es have b een the key

p o licy initiative o f the G overnm ent o f India to support the health sector program m es

directly. T h e centre provides direct and partial -m atching grant- support to the states

in m eeting both recurring and non-recurring expenditure o f program m es under this

policy initiative, T he states' share in the total revenue expenditure has been declining.

T h is is also a reflection o f the fact that state governm ents are going through sen o u s

fiscal problem s. T h e role o f central support in state budgetary allocations is

increasing. W e can see from the follow ing table that the percentage o f State

expenditure is decreasing in total health expenditure and the sam e is rising o f central

expenditure.
P u b lic e x p e n d itu re o n h e a lth in p e r c e n ta g e as on 2001

C o u n try P e rc e n ta g e

Bhutan 90.6

M aldives S3.5

D em ocratic People's R epublic o f K orea 73.4

T im o r-L ’este 59.5

T hailand 57.1

Sri L anka 48.9

B angladesh 44.2

N epal 29.7

Indonesia 25,1

India 17.9

M yanm ar 17.8

T he table clearly show s the share o f expenditure o f eleven co u n tries’ on its

public health sector on the beginning o f the new m illennium . It clearly explain that

the share given for the developm ent o f cu b lic health sector to the states by the cem rai

governm ent is 17.9, w hich is som etim es lesser to the natio n s’ share except M yanm ar

show s the decreasing level o f its share.

W hen thinking about the determ inants such as incom e and com m unity it can

state that w hen m com e o f a fam ily is high, the life styles and healthy circum stances

are also high. It affects in every sphere o f health ailm ents. Incom e-based differences

in life expectancy can also be seen across com m unities, incom e and w ealth directly

support b etter health environm ent because w ealthier people can afford to the

reso urces that protect an d im prove health. In contrast to m any low -incom e people,

they tend to have jo b s that are m ore stable and flexible; provide good benefits, like

paid leave, health insurance, and w orksite w ellness program m es; and have few er

occupational hazards. M ore affluent people have m ore disposable incom e and can

m ore easily afford to m edical care and a healthy lifestyle benefits that also extend to
th eir children. P eople w ith low incom cs tend to have m ore restricted access to

m edical care, are m ore likely to be uninsured o r underinsured, and face greater

financial barriers to affording deductibles, co- paym ents etc. People w ith higher

incom es are m ore likely to experience place-based health benefits, o r otherw ise their

health is positively influenced by the conditions and assets in their living

environm ent. In this context incom e and expenditure on health m K erala is closely

inierrelated. W hen the people began to get n d o f the social inequalities w ith the

support o f socially benefitted schem es, their know ledge and aw areness o n health

co nditions began to change. It gradually shaped the health scenano o f Kerala.

O w nership o f land and other assets form ulated another im portant determ inant

factor o f health stam s o f K erala. In any other regions o f India land ow nership w as not

com m on; m eans the labourers w ere rem ained as only labourers. B ut the land reform s

happened in K erala presented a vital role in the upliftm ent o f a w orking group lo the

status o f land ow ners. A ccording to the T ravancore E conom ic Survey o f 1941, about

41 percent o f the fam ilies w ere landless, and another 46 percent had ow nership o f less

than 1 acre, valued at Rs.lOOO o r less. That is about 87 percent o f the fam ilies had

eith er no land o r ju st a m arginal holding. In C ochin State, the totally landless fam ilies

varied from 40 to 70 percent in the different villages surveyed.^^ Total land ow ned by

the households w'as divided during the 1960’s into four groups. They are, if the land

o w ned is <11 cents, i f the land ow ned is 11 to 50 cents, i f the land ow ned is 51 to 250

cents, if the land ow ned is >250 cents.

T he first group is generally the landless or landed poor, m ost o f them ow ing a

few cents o f hom estead land. U nder the K erala G overnm ent schem e o f redistribution

o f land to the landless, 10 cents w as the upper limit. T he second group w ould be

m arginal farm ers who m ay not be able to derive any substantial incom e from land.

T h e third group com prised o f sm all farm ers; the o ff point corresponds to the norm set

for the distribution o f credit, etc. T he last group w ould be those above the status o f

sm all farm ers and they are grouped together here.*^' T he 1968 S ocio-econom ic survey

reveals a high degree o f inequality in the ow nership o f land, alm ost as high as, i f not

higher than that existed in T ravancore o f 1941. N early one-third o f the households

ow ned no land; the proportion o f the landless am ong scheduled castes and tribes w as

substantially higher.'^^ T he pattern o f distribution o f all assets in rural K erala at the

beginning o f the sixties and seventies reflected a high degree o f concentration. The

substantial freedom in the social and econom ic spheres follow ed by radical land

reform s in the decade o f 1960 w as a landm ark in the developm ent history o f K erala.

It gave a m eaningful m easure o f econom ic freedoin upon large m ass o f agricultural

labour households through land redistribution, conferm ent o f ow nership rights to

hutm ent dw ellers, creation o f colonies for m em bers o f the Scheduled castes and tribes

w ith lands, buildings, and other facilities. T he K erala A gricultural W orkers A ct o f

1974 contributed to a rise in the livm g conditions and standard o f life o f the com m on

people also. T he co efficient concentration o f all the assets am ong cultivator

households in K erala cam e to 0.6769 and 0.6352 in 1961 and 1971 respectively.

A gain K erala ranked first am ong all the states o f India in respect o f inequality o f asset

holding. B ut the position slightly im proved by 1971.

K erala is the first state m tne country in conferring ow nership right o n aii

tenants. “T he grow th o f com m ercial agriculture and ec u atio n ,.... the decline o f

Jcinmisthcwam or traditional land ow nership and the rise o f new land ow ning class

and the introduction o f adult franchise w ere all due to the im pact o f the tenancy

reform s. T he result w as a new and dynam ic s o c ie ty /’ w hich gave a chance to get

m o d em param eters in public health sector o f the state.**^ T he thoroughness and speed

supported the state to abolish landlordism w ithin the state. T he abolition o f such a

rent class generated a new habitation and an address o f their ow n heralded a new era

o f relations o f production.'*‘*It created som e changes in the rural econom ic relations as

a result o f the abolition o f tenancy. T he entire incom e from land gave a chance to

tenants to becom e the ow ners o f the land. In addition to it, the state actively

supported the new ly created farm ers through investm ent m im g atio n , developm ent o f

co op erative credit and a variety o f o th er m easures for increasing agricultural

production. A t the sam e tim e agricultural labourers w ere organized them selves as the
m em bers o f trade unions for collective bargaining for higher w age rate. T he gain in

term s o f high er w age has an indirect benefit for the labourers. T hese changes

supported the agrarian groups in K erala to get a m ore equitable distribution o f the

incom e from it than before.'^^Another result is that it brought out som e changes in the

rural relations o f ow nership o f sm all holdings. The acquisition o f ow nership h ad the

im m ediate effect o f alienating the beneficiary from the existing labour arrangem ents,
leaving him and his fam ily free agents. It therefore created an adverse effect, in

K erala there started a labour m arket w here it was not fam iliar till then. A gricultural

Production, Incom es and P overty etc. on the period follow ing the im plem entation o f

land reform s there has been reasonable increase in the area under cultivation and the

output o f crop production continued to increase till 1974-75. B ut there has been a

significant decline m output since then. This w as due to a collaboration o f

circum stances. H ow ever, the m anner o f im plem entation o f land reform s m ight have

created the conditions supporting a form o f m igration. It w as considered that no

effective results could be produced by agrarian reform on poverty in Kerala. It m ust

have gone dow n both on account o f re-distribution and effect o f land reform s and the

relatively high rate o f agricultural w age rate during this p e r i o d . T h o s e landless

agricultural labourers w ho w ere not benefitted directly from the land reform m easures

and m ovem ents, w ere forced to be brought under the A gricultural L abourers P ension

Schem e (1982) and O ne Lakh H ousing Schem e from early 1972. T he latter w as

d esigned to p rovide perm anent dw ellings for landless ag ncultural labour families.'^'

Further, in addition to the existing institutions o f m inim um w age legislation,

arbitration m achinery etc., the K erala A gricultural W orker's A ct o f 1974 m andated for

p reference for existing w orkers in em ploym ent, regulation o f w orking conditions,

oth er benefits and even a type o f perm anency o f em ploym ent parallel to security o f

ten ure to tenants. N otw ithstanding these m easures labourers continued to b e plagued

by problem s o f underem ploym ent and m alnutrition. “^^The rural poor rem ained a

significant category in Kerala'^^'The post land reform did not w itnessing any m ajor

breakthrough in production and grow th rate in agriculture. T he skew ed distribution

still persists. T hough not docum ented there are evidences o f w idespread re­

appearance o f inform al leasing, low fam ily labour participation and a higher

p ro portion o f hired labour. T herefore alternative agrarian institutions are to b e sought

for unleashing the productive forces in agriculture. T he only process o f land reform s

at p resen t is taking o ver and distribution o f surplus land. It did not achieve the transfer

o f the land to the actual tiller and resulted in ow nership to a series o f interm ediaries

w ho had no d irect involvem ent in cultivation. L and reform s m arginalized the tribal

people because even though they w ere not the ow ners o f the land they held, they

becam e ja n m ie s as p er the definition o f the A ct and the settlers w ho paid rents becam e

K udiyans. In som e cases the tenants becam e land ow ners and landow ners becam e
landless"'*’^Land reform s in K erala is hailed as one o f the great successful stories.

K erala abolished feudal landlordism . It w as able to achieve substantial reduction in

landlessness by confirm ing ow nership titles to hutm ent dw ellers. It had the effect o f

alienating the beneficiaries from the feudal labour arrangem ents and resulted in the

em ergence o f a labour m arket. L abourers organised under trade unions and achieved

h ig her w ages and b etter w orking conditions. S im ultaneously, agricultural practices

have also b een undergoing changes. H ow ever, w hether these reform s w ere able to do

ju stic e to the m otto 'land to the tiller' rem ains doubtful. T he concept o f 'personal

cultivation 'precluded a g ra n a n proletariat from the reform m odel and took the w ind

out o f the sails o f the slogan 'land to the tiller'. In the aspect o f taking over surplus

land and its redistribution, the achievem ent w as far below expectations. T he post land

reform period did not w itness a m ajor breakthrough in production and grow th m

agriculture.

T he ow nership o f land and other assets supported the sm all group and the

alienated groups to get in touch w ith the m odem elem ents o f life. Partially and

indirectly the ow nership o f land and other factors gave the com m on people a chance

to get m odernized in tem is o f m odem param eters. It actually supported the public

h ealth m easures o f the state. L and reform s deserve a high degree o f attention in the

health status o f K erala as the land has been the m ost coveted form o f w ealth, has been

m ost unequally distributed, has been the m ost sensitive, explosive political issue that

affected the fate o f any governm ent and m arked as the progress in any field o f public

affairs.

E m ploym ent situation in K erala can b e consider as another im portant factor

that determ ined the health care system o f the land. T he em ploym ent situation in

K erala now deserves special attention on the health adm inistration. D uring the

thirties, unem ploym ent assum ed serious concern. So the T ravancore governm ent

appointed U nem ploym ent E nquiry C om m ittee. In the forties, it w ent through a

process o f changing w ith the introduction o f em ploym ent facilities in the various

p lantations and oth er areas. A ccording to the census data o f 1901 the w orker

participation rates in K erala w as 44.5 and it w as 33.3 in 1961. O n the basis o f

un em ploym ent surveys it w as estim ated that there w ere 5.3 lakh unem ployed persons

in 1957 i.e., 11.1 percent o f the labour f o r c e . T h e survey o f 1962 show ed that 7.6
lakh unem ployed persons are there i.e.4.2 percent o f the population and it m akes

around 13.8 percent o f the labour force w ere unem ployed. D uring 1966 the ratio

ch anged to 5.5 lakh person o f w hom 2.5 w ere fem ales. T he results o f the surveys o f

1956, 1962 and 1965-66 reveal that there w as a progressive decline in the proportion.

D uring the I9 8 0 ’s a declining trend in em ploym ent elasticity can be seen in alm ost all

sectors o f the econom y in K erala. In course o f tune an increase in the proportion

from 1983 to 1988 is identified. It rose to 29.3 percent in 1983 and 34.9percent in

1987-88. T h e unem ploym ent situation in K erala during 1999-2000 w as a proportion

o f 4.3 percent m ale and 3.9 perccnt fem ale in the rural areas; and 4.0 percent m ales

and 5.8 percent fem ales in the urban areas. It possess 4.1 percent and4.8 percent in

the rural and urban areas respectively. T he decreasing ratio o f unem ploym ent

situations prom pted the state to get in touch w ith the m odem m edical care and m odem

m edical facilities. T he em ployed people w ere got chances to get know ledge about the

n ecessity o f healthy conditions. T hey tried to solve the physical as w ell as mentaS

p roblem s in to uch w ith the m o d em conditions. T he grow th o f em ploym ent facilities

influenced the chances o f im provem ents on health m atters.

D evelopm ent policies enunciated b y the state governm ent directly influenced

the h ealth conditions o f the state. It becam e another notable determ inant o f the health

m easures. K erala achieved a high status in the health sector by considering the

experiences o f the developed countries as w ell as the nature and causes o f the various

diseases. It can be stated that the developed co u n tries’ ach evem ents are due to

different policies introduced and experienced by them . PubI c policies distributed

resources and values. A ccording to the classic w ords o f Dav d Easton, “ P olitics is

the authoritative allocation o f values.’* T herefore, every nation assigned it

adm inistrators to m ake necessary steps for m aking public policies fo r developm ent. It

w as applicable to the health sector o f K erala also. It shaped the social and political

life in a progressive marm er. Elected and appointed public officials inevitably m ade

n o n n ativ e decisions. T hose decisions playing a prom inent role in the social and

p olitical life o f the people. W ith these ideas o f benefits o r underem phasize costs, the

p u b lic health ad m inistrator alw ays develop state-w ide program m es. P olitical science

and public policy program m es generally include know ledge and im parting ideas

beneficial fo r the public. T he policies w ere consciously fram ed as being problem -

oriented, quite explicitly addressing public ssues and posing recom m endations for

th eir relief. T he p o licies are often m ulti-disciplinary in their intellectual and practical

approaches. T his is because alm ost every social o r political problem has m ultiple

factors connected to the various academ ic disciplines. T he policy m akers approach

and its advocates practices deliberately distinguished them selves from early scholars

m p olitical science, public adm inistration, com m unications,

ju risp m d en ce, and sociology by posing three defining characteristics

com bination, transcended the individual contributions from those m ore traditional

realm s o f ideas. T h e policy m ak ers’ approaches are deliberately norm ative o r value

oriented. In m any cases, the recurring them e o f the policies deals w ith the dem ocratic

ethos and hum an dignity. C onsequentialism is the ethical approach taken by m ost

public officials. T h e public health adm inistrator spending a state’s lim ited resources to

im prove the conditions o f prim ary health care sector. A m ong the various econom ic

p o licies on h ealth status im plem ented in K erala, land reform s along w ith the various

tenancy reform s and the K erala A grarian R elations Bill and the K erala A grarian

R elations A ct occupy one o f the top positions. A ll hutm ent dw ellers have secured

p erm anent occupancy right. In addition to the land reform s act. G overnm ent o f

K erala b ecam e a serious p artn er in international and national policies o f the health

sector. T he various policies introduced for the upliftm ent o f the health conditions

supported K erala to achieve its goals.

R esidential stability o r housing has been identified as one o f the im portant

determ inants o f the com m unity health.^^ H ousing conditions influenced the physical

as w ell as the m ental health o f a fam ily. T he housing situation is deplorable in the

low incom e countries both in the quantitative and qualitative sense. Safe and secure

sh elter is one o f the basic needs o f hum an beings and investm ent in housing plays a

d o ubling effect on the econom ic grow th o f the nation. In the developing countries

tw o thirds o f the total populations live below the poverty line. N early one hundred

m illion people are estim ated to b e sh elter less. T he condition o f India o n shortage o f

houses has been grow ing alarmingly.^*’ T he housing em bodies m any factors such as

ph ysical o r m aterial (location, density, building height, m aintenance, air quality,

sanitation, pests, and hazardous exposures), social (threats to safety, noise, social

netw orks, and cost) and psychological com ponents (interpersonal conflict, sense o f
pem ian ence) and any one o f w hich can affect h e a l t h . A d e q u a r e housing provides

p ro tectio n against exposures to agents and vectors o f com m unicable diseases and also

gives protection against avoidable injuries, poisoning and therm al and other exposures

that m ay contribute to chronic diseases and m alignancies.^^

A s far as the housing sector is concerned, K erala has a unique p lace in our

country. T he state introduced various positive steps and schem es that m ade it

possible to attain a considerably rem arkable progress in the field. L inkage betw een

health and housing is a m ajor need even now in the state. Yet. as far as K erala is

concerned the housing condition is m uch better than the other states o f India. Private

con stru ction o f houses in the state is high. In addition to it, the state governm ent

im plem ents a n um ber o f housing schem es under the various Five Y ear Plans such as

subsidized Industrial H ousing Schem e, H ousing for agricultural labourers. C o ­

o perative housing schem e, housing schem e for w eaker sections, poor housing

schem es, low incom e group housing schem es etc. from tim e to time. T he population

o f the state is 3.18 crores according to the census o f 2001 and the density is 819 p er

sq.km w hich is about three tim es the national a v e r a g e . I n rural India, 32 percent o f

the households live in katcha structures. B ut in rural K erala, the katcha dw ellings are

below 19 percent o f the total. M ore than 55 percent o f the households in rural K erala

live in pucca structures; w hich is very high com pared to the other parts o f the country,

In rural K erala 26 percent o f the households live in sem i pucca structures, w hereas

this proportion is 36 percent in all India. T he structure o f the type o f houses in K erala

is m uch better. T he urban and rural housing scenario is far ahead in Kerala. T he

im provem ent in housing conditions has benefitted a large portion o f K erala’s poorer

sections in the last fifty years.

A vailability o f good drinking w ater is another m ajor determ inant o f health

conditions under the econom ic purview . O f all the sanitation m easures, provision for

safe drinking w ater is probably the m ost significant in curbing the spread o f parasites

an d infections. International data indicate that for 33 countries w ith the highest infant

m ortality rates, only 21 % o f rural people have access to safe drinking w ater. A nother

30 p o o r countries w ith slightly better rates have an average o f only 33% o f rural

people w ith access to safe w ater. India a m em ber o f this second group claim s 47% for

rural areas, 80% for urban areas and 54% o v e r a l l . T h e scarcity o f good w ater supply
in K erala is a serious issue to be dealt w ith respect to the health care system- K erala

even now depends on the two m onsoon rainlalls for w ater. It is calculated that Kerala

is getting 3000 m .m ram fall w hich is on p ar w ith or a little below that o f the extrem e

rainy area o f India C hirapunchi. But w hen considerm g the availability o f good

drinking w ater K erala is behind R ajastan. m eans K erala gets 1250 cb.m w hile

R ajasthan gets 1650 cb.m.^^ T here is a high incidence in K erala in using boiled w ater

for drinking w hich had a direct positive im pact on her health outcom e. It is a culture

or part o f living style o f the K erala people to use boiled w ater for drinking. A t the all

India level 4.3 percent o f rural population and 1 percent o f urban population use

boiled w ater for drinking w hile K erala use 49.3 percent and 65.3 percent

respectively.^' T his is a m ajor breakthrough w ith health care scenario o f K erala state.

S anitation o f a society is alw ays necessary for the better life culture and health

conditions. Sanitation m eans the conditions in relation w ith getting clean drinking

w ater and adequate treatm ent and disposal o f hum an excreta and sewage.^^ It is the

next econom ic determ inant o f health scenario. A socially and politically oriented

society roughly needs any situation o f good sanitation. As far as India is concerned

after independence there w e can see the grow ing effects o f urbanization, m igrations

from the countryside, developm ent o f over populated cities etc. m ade a new dem and

fo r good sanitation w ater, electricity, transport, schools, health services, etc. aim ed

specially for the urban poor.^^ A s a result there w as a proliferation o f developm ental

and w elfare schem es, m ostly w ith central governm ent funding and often w ith

substantial international aid from agencies such as the W orld B ank, for

accom m odating the extrem ely grow ing population o f the poor w ithin the structures o f

u rban life, even as those structures w ere being pressed to their lim its.^ But. there w e

can see som e better sanitation m easures w hich had b een started by the governm ent o f

T ravancore since the late 19‘^ cenm ry w'hen tow n Im provem ent C om m ittees and Rural

C onservancy E stablishm ents to disinfect w ells and w ater tanks, rem ove feces from

public roads, graved o f m arkets and religious festivals, construction o f safe latrines

w'as also set as a goal, b u t progress has been m uch slower. T he governm ent allots

huge am ounts for the latrines and for sew age appears insufficient to m eet the sta t's

am bitions target o f safe w aste disposal in 80 to 100 percent o f urban areas and 25% o f

rural areas by the end o f 1980’s. T he dispersed rural settlem ent pattern in K erala,
how ever offers, a b u ilt - in advantage in sanitation. S ince housed in the villages are

not crow ded to gether as in m any o th er p a n s o f India, transm ission o f infectious

disease m ay b e a less serious problem .

L ack o f sanitation alw ays creates w ater related health issues and problem s

such as diarrhoea, cholera, dysentery, typhoid etc. T he introduction o f colonial health

system s and m odem education supported the com m on m an o f K erala to know about

the im portance o f sanitation. A long w ith this the introduction o f sanitary m easures by

the central and state governm ents also supported the state to get a chance of

im p rovem ent in the sanitary m easures.

Public distribution system o r the food security system s o f India was

established by the governm ent o f India under the control o f the M inistry o f C onsum er

A ffairs to distribute subsidized food and non- food item s to the w eaker groups o f

India. O ne o f the im portant steps taken by the governm ent o f India in eradicating

p o verty and scarcity o f food w as overcam e by the introduction o f the public

distribution system s. It directly determ ined the health status in large extent. T he

schem e w as introduced firstly in 1944 during the tim e o f the Second W orld W ar and

it continues from 1947. M ajo r com m odities distributed include staple food grains,

such as w heat, rice and sugar, and kerosene, through a netw ork o f fair price shops also

k now n as ration shops established in several states across the country. F ood

C orporation o f India, a G overnm ent-ow ned corporation, procures and m aintains the

PDS. Public distribution o f food grains in K erala through fair price shops had an

effective coverage on health conditions. T he public distribution system increased

p eo p le's access to food m aterials for daily consum ption. T he w orking o f the system

on various tim e periods classified the households as fiill producers, landholders and

none. T he system created a chance for the low er incom e people to get food grains

w ith m inim um ratio. T he fair shops and open m arkets sold the com m odities on a

h ig h er ratio than in the ration shops. T his naturally led to a larger proportion o f the

po p u latio n to get m arginal/adequate food grains. T he item s such as sugar, edible oil

and kerosene in a susidised p rice supported poverty eradication program m es. It

substantially im proved the health care system o f the low er incom e groups. T he

g roups suffered from anem ic and poverty issues gradually loosened from the

situation.^^
E du cation al D eterm inan ts o f H ealth sector in K erala

E ducation plays a m ajor role in an individual's overal) health and w ell­

being. E ducation affects the health situations and conditions o f a society. It im proves

healthy behaviors, im prove health outcom es thereby m aking the foundations for a

healthy life. T he level o f educational attainm ent increasm gly affects the social

determ inants o f health. E ducation can affect lifespan, incom e and livelihood.

C hildhood education narrates the students about the need for the healthy life and

co nditions to follow . T he C hinese oroverb o f “ if you w ant to build a generation you

w o uld give education to the m .’‘ It show s that how early education gets, the result will

b e so long lasting. K erala stands out am ong all the states and regions o f India for its

rem arkable achievem ents in raising the literacy level o f her people. K erala has been

w ell ahead o f the rest o f India since the closing o f the 19'^ and the begirm ing o f the

20’^ century. It w as as a result o f the expansion o f educational opportunities from the

bottom o f the society. D uring the initial expansion o f education, educational reform s

facilitated this process. E arly educational expansion has a closer connection w ith the

political decisions and social aw akening. T he Social and econom ic factors as said

above w ere the conditions prevailed in the society in the 19'^ century. T he initial

steps for the introduction o f education w ere very com m only started during the late

19'^ and early 20'^ centuries due to the influence o f the colonial governm ents. T he

colonial governm ents w ith the support o f the native rulers started various institutions

for education for all-caste people. T he problem s faced b y the com m on people for

getting m o d em education in K erala and its im pacts w ere encrypted in the history o f

K erala in golden letters. T he grow th o f m odem educational system s im proved the

households to get acquainted w ith the m o d em health care system s. T he release o f

caste based land tenure system and productivity on the lines o f capitalist econom y led
to a new social order. C om petition for w estem education aroused and it definitely

determ ined the health status o f the state.

E ducation and health care are the two im portant state subjects envisaged

in the concurrent list o f the C onstitution. T he nature o f resource allocation fo r health

and education reveals the role and interest o f the governm ent in prom oting the general

p opular w elfare o f the public thereby elevating the standard o f living o f the people.

W hen the society gets aw areness on the conditions affecting health through education
they can im prove. T he condition of K erala was not different on this issue. In a study

the researchers pointed out that the rural households in K erala have at least one

m em ber each having high school level education. T his need not necessarily m ean

high er education leading to degrees etc. only but w ould also include any form al

training program m e beyond the secondary level such as plus tw o, vocational training

in the polytechnics, industrial training institutes and so on enabling them to touch w ith

the h ealth care system s.^' A gain the public health departm ent had started an

aw areness cam paign on public health education from the early thirties using all

available m edia such as lectures, cinem as, leaflets, new spaper articles etc. T he health

education o fficer delivered lectures on health related topics using the audio visual aids

and lecm res to pass inform ation on the hookw orm treatm ent cam paign, vaccination,

cholera prevention and m osquito control w ork etc.^^The colonial and native

governm ents used the classroom s to pass inform ation about the necessity o f hygiene,

sanitation, good drinking w ater etc. along w ith other health care m easures through the

classroom s in the schools and c o l l e g e s . B e s i d e s the form al educational system s,

K erala has developed a no n -fo n n al education apparatus w ith a w ide netw ork o f

libraries and reading room s and a large num ber o f v ernacular new spapers. T he Sastra

Sahithya P arishad has taken a leading role in this direction and its program m es have

also contributed to do aw ay w ith the deeply entrenched prejudices and superstitions

w hich affected health status after the state form ation am ong the masses.

E ducation im proves the earning capacity o f people. W hen the opportunities

on education are h ig her th e level o f chances on incom e also increases. ! f analyzing

the literacy rate and the percapita incom e rate o f K erala it can b e proved. T he literacy

rate o f P athanam thitta district has the first position w hile it has the 4'^ position in the

percapita incom e. E m akulum has the first position in the percapita incom e has the

fourth position in the literacy rate. M alappuram has the 9*^ position in the literacy rate

has the 14'*^ position in the percapita incom e. W hile Palakkad has the 14‘^ position in

the literacy rate has the 10'*’ position in the percapita incom e. A1 these are evidenced

from the 2011 census report and com puted by the E conom ic R eview , show s how far

the relation betw een education and incom e are related. A s stated earlier, education

and incom e are closely connected and both o f them definitely determ ine the health

strategy o f the state.

 Level o f educational or literacy rate indicates the quality o f life o f the population.

K erala possesses the highest rank in the hteracy rate am ong the Indian states. F or the

fifty years the literacy rate o f the stale w as raised from 47.18 percent to 90.92 percent.

A s stated earlier the rate o f literacy and education is high the life style and conditions

should be higher than that o f the low er rate o f literate areas.

G e n d e r w ise lite ra c y r a te fro m S951 to 2001 T able N o .2

Y ear Persons M ale F e m a le

1951 47.18 58.35 36.43

1961 55.08 64.89 45.56

1971 69.75 77.13 62.53

1981 78.85 84.56 73.36

1991 89.81 93.62 86.17

2001 90.92 94.2 87.86

T h e above table clearly exam ines the percentage o f literacy rate on a gender

w ise from 1951 to 2001. T he rate is alw ays show ing a pattern o f increase m the two

groups clearly show s the im portance o f education am ong m ales and fem ales. Society

alw ays supporting b eing educated. A s staged earlier, literacy rate and its connection

w ith incom e definitely influenced the health status o f the state.

P olitical D eterm inan ts o f H ealth S ector in K erala

T he final determ inant o f the health conditions o f K erala is the P olitical

determ inants. It m ade strong influence in the health sector o f the state. A fter

independence India faced various health issues such as m alaria, tuberculosis, etc., and

various oth er co m m unicable diseases including m aternal and child m ortality issues
etc. Al these are not a sudden one. It was a continuation of the problem s that had

already existed here. B ut to overcom e the hurdles, India had to follow m easures o f

im m ense strain. Silent deaths occurring due to tobacco using, m ental and

n eurological problem s etc. m ade an alarm ing scene in this regard. But, from the tim e

o f its form ation, the state had tried to m ake health an accessible one to all o f its

citizens. From the first budget itself, the governm ent o f India had took special care to

allocating m ore funds on the expenditure o f health. It w as m ore, as far as the other
parts o f India is considered. T he left wing governm ent and later coalition

governm ents o f the slate prepared rapid and pow erful ladders for the popular dem ands

on the health sector. R eceiving the socialist and m odem ideas from various

internationally accepted organizations, the state adopted those steps. T he supporters o f

the political parties and factions adopted various steps i f they found any single trouble

in this m atter. T h e village governm ents, trade unions and other stakeholders w ere

ready to subm it their dem ands to the h ig h er officials for the up gradation o f health

care facilities. I f the dem ands o f the groups w ere not satisfied, v an o u s rbm is o f strike

and public agitations w ould happen. A ccording to an anthropologist Joan M encher

K erala if a PH C w as unm anned fo r a few days there w ould be m assive dem onstration

at the nearest collectorate b y local leftist, w ho w ould dem and to be given w hat they

knew they w ere entitled to .“^^ T he period from the form ation to the early 1980s, was

characterized by great grow th and expansion o f the governm ent health services. From

1961 to 1986 the state greatly expanded its health facilities. T he facilities allocated to

the hospitals and other centres w ere increased, T he total num ber o f beds in

governm ent hospitals in the m o d em m edical sector during the period o f 1960-61 w as

13000w as raised to 20000in 1970-71 and again raised to 29000 in 1980-81 periods.

By 1986, the total num bers o f beds w ere 36000and rose to the num ber o f 38000 in

1996.’^During the first fifty years o f the slate form ation there w ere diverse health care

dealings introduced. Som e o f them w ere directly as a part o f the adm inistrative

packages and som e w ere specific. From different studies it can conclude that even the

state had gone through various econom ic crises from its form ation, the expenditure on

health and education w as extrem ely high w hich resulted in fram ing a state o f high

health care m easures.

T he extensive series o f m edicare organizations under the public sector enabled

K erala to carve out an enhanced stm cture in the health m anagem ent organism . T he
co n siderable proportion o f state governm ent budget and allocation engrossed the

private sector also. D ifferent trends and outlooks tw isted the sphere from tim e to

tim e. T he fixtures or the determ inants on the health sector equipped the state to m eet

the requirem ents and to achieve the goal o f “heahh for all in the new m illennium .

T h e determ inant factors o f health has provided the stale a chance to w in o v er w ith the

conditions o f health care facilities that are existing in the developed nations o f the
w orld. It w as a continuous process through centunes. T he roles o f the colonial

g overnm ents and state governm ents are notew orthy in the particular arena.

C o n clu sio n

Even a sm all state in the south w estern co m er o f India, K erala take credit o f so

m any unusual achievem ents. H ighest literacy rate, low est birth and death rate,

distribution o f em ploym ent and incom e proportionate are som e o f the exam ples.

Low est birth and d eath rates indicates the level o f im provem ents achieving in the

public health sector. In the case o f K erala, the public health sector is acknow ledged

for its achievem ents. A ll the achievem ents, the land acquired due to determ inant

factors existed in this land. Even though there are so m any determ inants a state could

not achieve such positions if the situations are not convenient. A s far the case o f

K erala, the situations w ere too supporting to achieve the g o a l It becam e easy w ith

the support o f the introduction o f different policies and program m es o f the central and

state governm ents. T he central governm ent o f India, opened a num ber o f policies.

A ll the program m es both central and state supported the state to achieve its goals after

the state fom iation.

 END N O TES

M. C. G upta, H ealth a n d L aw , (N ew Delhi: K anishka Publishers, 2002), p .l

Ibid..

Ibid.

Ibid, p.2.

P. G. K. Panikar. C. R. Som an, H ealth Status o f K erala, op. cit., pp. 10-11.

Ibid.

Ibid.

Ibid.
9
Journal o f H ealth sciences 2012; (2):JS002, pp.39-47.
!0
Ibid.
11
Ib id
12
A Sreedhara M enon, A Survey o f K erala History. (K ottayam : Sahithya

Pravarthaka C o-operative Society, 1967), p. 390.

13
K. D am odaran, op. cit., pp. 152-154.
14
Ib id
15
Francis. T. B uccanan, op. cit.
16
Ib id
17
A /642, R eport on the adm inistration o f C ochin for 1865-66, p.38, R egional

archives. E m akulam .
18
Ibid.
19
Ibid.
20
A. Sreedhara M enon, op. cit., p.391.
21
P. K. M ichaile T harakan, S ustshira vikasanam K eralathil: oru C harithra

vidyarthiyude K azhcbapadil, K. Suresh K um ar (et.al), M a tto n i K eralam

Sadhyam anu, fIVlal), fThiruvananthapuram : Prabhath Books, 2016), p .338-

345.
 G o .N o .M s3 6 i7 A a iQ d 17.12.46. G o .N o .M s.l0 3 5 dt.4.4.46, G o ,N o M s.5 8 PH

dt.8.1.46. State A rchives. Thiruvananthapuram .

Ibid.

Ib id
26
P.K. M ichaile T harakan, op. cit.
27
A . N aray anan T ham pi, E conom ic S w v e y 1941-Travancore,

(T hiruvananthapuram : G overnm ent Press. 1943), p .l4 .

Ib id
29
Ibid.
30
Ibid, p.39.

E .M .S .N am boothirippad, The N ational Q uestion in K erala, (B om bay;

P eo p le's Publishing H ouse, 1952), p .89

32
Ib id
33
Socio E con o m ic Survey on caste /C om m unities K erala, (K erala: B ureau o f

E conom ics and Statistics. 1968), T able 8-18.

?4
The C onstitutional F ram e work. C hapter 8, W hatever H appened to H ealth fo r

A ll b y 2000AD ?, (N ew Delhi: N ational C oordination C om m ittee, 1999).

35
Ibid.
36
R am esh B hat and N ish an t Jain, A nalysis o f p u b lic expenditure on health using

state level data, (A hm edabad: Indian Institute o f M anagem ent, 2004), p p .l 1-

12 .

37
Ib id
38
Ib id
39
E .M .S, op. cit.
40
K .P.K annan, K .R .T hankappan, V ,R am an K utty, K .P.A ravindan, H ealth a n d

D evelo pm ent in K erala, (T hiruvananthapuram : Integrated R ural T echnology

C entre o f the K erala Saslhra Sahithya Parishad, 1991), pp.26-27.

41
Ibid.

So cio E conom ic Surx’ey on caste/com m unities, op. cit.

 M. N o o ijam B eevi, EvoluUon o f the Land T enure system in T ravancore

(1810-1949), (D octoral D issenation. U niversity o f K erala, T nvandrum .

D ecem ber 2001), p p.200-20L

44
N. H. A nitha, The Social p a th to K era la 's H ealth, M. A. O om m en, (ed.)

K e ra la 's developm ent E xperience. (New Delhi; Institute o f Social Sciences,

1999), p. 122.
45
K.N R aj, (et.al.) E ssays on the C om m ercialisation o f Indian A griculture,

(D elhi: O xford U niversity Press, 1983), p.27,

46
Ibid.
47
U N O fficial D ocum ents. 1975. pp. 196-200,
48
P.G.K..Panikar and C .R .S om an, op. cit.
49
Ibid.
50
E cono m ic R eview , (T hiruvananthapuram : K erala State P lanning B oard, 1997),
pp. 2.8.17.
51
P .G .K .P anikar and C .R .S om an, op. cit... p. 19.
52
Ibid.
53
V irgina A. R auh, Philip. J. L andrigan and Luz C laudio, H ousing a n d H ealth-

Intersection o f p o v e rty a n d E nvironm ent Exposures, (N ew Y ork: A nnals o f the

N ew Y ork A cadem y o f Sciences, 2008), pp.276-277.

54
R u ral Urban D ivide w ill a ffect D evelopm ent, The E conom ic Times. (Tune:

B ennet C olem an & C o. Ltd, 21’’* M ay 1986).

55

56
Franke and C haisan, K erala: D evelopm ent through R a d ica l R eform , (S an

Francisco: Institute for Food and D evelopm ent Policy, 1993), p .37.
57
C ensus o f India, p ro visio n a l P opulation Totals Kerala, Series 33, P aper-2,
(K erala: D irector o f C ensus O perations).
58
Sarvekshna, V ol. 22, N o .3, Issue N o .78, (N ew Delhi: N ational Sam ple Survey

O ffice, January-M arch 1999).

59
Ibid.
 M. A. O om m en, Jw ia n g a lu d e Jeevith o N ilavaram U yartJnmathakanam

Susthira Vikasanam , R .K .S uresh K um ar, (et.al.), (M ai), pp.32-33 =

61

52
O xford D ictionary.
63
Partha C hatterjee, The P olitics o f the G overned -R eflections on P opular

P olitics in M o st o f the W orld, (N ew D elhi: O rient B lacksw an, Pvt. ltd., 2005),

p .l3 4 .
64
Ibid, pp.134-135.
65
R ichard. W .F ranke, B arbara.H . C hasin, op. cit., p.34.
66
F .G .K .P anikker and C .R .S om an, op.cit, pp-28, 57-58.
67
K .P .K an n a a op.cit. pp.27-3C.
68
T. K. V elu Piilai, op. cit., pp.810-813.
69
Ibid.
70
K.P. K annan, op. cit., pp.60-61.
71
C ensus R eports o f India various years.
72
R ichard. W . Franke, B arbara. H. C hasin, op. c/V., p.45.
73
V. R am an K utty, H istorical analysis o f the developm ent o f health care

fa c ilitie s in K erala State, India, H ealth Policy and Planning, 15(1), (O xford:

O xford U niversity Press, 2000) p p .103-109.

74
Ibid.
75
Ib id
 CHAPTER Ilf

PROCESS OF HEALTH CARE MEASURES AND ITS IMPACT

ON SOCIETY FROM 3956-2000

K erala gained appreciation in the process o f health care m odifications w orid

w idely after tw enty years o f its form ation. It w as the state’s circum stances and the

policies adopted possibly, supported the state to achieve this goal. T he state on this

process p assed through different stages. L ot o f m easures introduced w ere responsible

for Its attainm ent on the public health sector. A chieving and m arinating health is an

ongoing process, shaped by both the evolution o f health care know ledge and

practices, as w ell as personal strategies and organized interventions for slaying

healthy. F o r enhancing the public health conditions each governm ents are ready to

introduce policies and strategier applicable for entire society. A fter independence the

governm ent o f India w as responsible to m ake changes in the existed system o f public

health adm inistration. D u n n g that tim e there w ere no new m easures and the colonial

p ast gave her chances o f m odernization in a m odem sense. In the w ords o f B ipan

C handra, “ In d ia's colonial past w as w eighed heavily or her developm ent since 1947,

In econom ic spheres as in others the B ritish rule drastically transform ed India. B ut

the changes that took place led only w hat has been aptly described by A. G undr F rank

as the ‘d evelopm ent o f underdevelopm ent. T hese changes-in agriculture, industry,

transport and com m unication, finance, adm inistration, education and so on- w ere in

them selves often p o sitiv e......... further they led to the crystallization o f the colonial

econom ic structure w hich generated poverty and dependence on and subordination to

B ritain.” ’ C olonial rule in India tied h er to the clutches o f the econom ic transitions

and draw backs and tem pted to continue the situation w hat they had started here. As

stated by B ipan C handra in his book, India after Independence, the conditions o f india

at the time o f independence w as contm ued for a long tim e nere. T he existed

situations started for the colonial benefits o f Britain. Lack o f aw areness about the

policies o f the colonial governm ents, Indian adm inistrators w ere forced to follow the

system s existed here w ithout m uch m ore innovations.

I f a nation is sufficient on its ideologies and m easure for health care system s

that state should m ake it practical and success through three tier pattern o f health care.
Il is a universally accepted three tier pattern. T hey arc generally know n as the

prim ary health care, secondaiy health care and tertiary health care pattern.^ P rim ary

H ealth care m eans health care services w hich plays a prom m ent role in the local or

general com m unity. T his is the essential health care provided at the first level o f an

individual or the fam ily w ith the national health system . It is provided at the prim ary

level in the health centres o r in the sub centres by the m edical officer and the health

w orkers respectively. Patients m ay referred to secondary o r tertiary health care

centres on the nature o f health conditions. Prim ary health care m ainly an d basically

includes m aternal and child health care services, fam ily planning, vaccination, basic

advices on healthy life etc. T he prim ary health care system are also vested w ith

aw areness p rogram m es on prevailing health problem s and about im m ediate m ethods

o f preventing and controlling those problem s. O ther factors such as food supply

p rom otion, responsiveness o n proper nutrition, supplying o f safe w ater adequately,

b asic sanitation, issues in connection w ith fam ily planning and related m atters,

im m unization program m es against m ajor infectious diseases, control and prevention

o f local epidem ic diseases, suitable treatm ent for com m on diseases and injuries and

facility for essential drugs etc. are also handled by the prim ary health care system .

Secondary h ealth C are level o r interm ediate health care level is dealing w ith m ore

com plex problem s w ith the district hospitals and com m unity health centres.

S om etim es they are acting as the first referral centres. T ertiary health care level is a

m ore specialized level requiring specific facilities and attention o f highly specialized

h ealth w o ik ers and regional M edical C ollege H ospitals and such other institutions. In

a sound referral system a tw o w ay exchange o f inform ation and returning patients to

those w ho referred them for follow - up care is possible.

H ealth care m easures are assessing through different variables. T hose

variables are generally called as Indicator variables. Indicator variables help to

m easure changes that are occurring the health care scenario o f a state. T hey are m ost

often resorted to w hen a d irect m easure o f the change is n o t possible. A s a m atter o f

fact, h ealth being a holistic concept, health change cannot b e m easured in specified

units. It can only be reflected by health indicators.^ T here are various types o f health

indicators. Som e o f them are m ortality indicators, m orbidity indicators, disability

indicators, service indicators etc. M ortality Indicators prim arily include crude death

rate, infant m ortality rate, m aternal m ortality rate etc. C rude death rate is th e total

93
num ber o f deaths per year per 1000 people. Infant m o n ality rate m eans the num ber o f

deaths am ong children less than one y ear old per 1000 live births. M aternal m ortality

rate m eans num ber o f m aternal deaths as p er 1000 w om en o f reproductive ag e in the

population. M orbidity indicators refers to rates o f incidents and occurrence o f

transferable diseases. D isability Indicators plays a supportive role to other vital

m dicators. T hese include sickness absenteeism rates, paralytic poliom yelitis rate,

blindness prevalence rate etc. Service Indicators reflect the provision o f health

facilities. E xam ples are proportion o f population served by the PH C /sub centre.

D octor, population ratio, proportion o f population having access to safe drinking

w'ater, literacy rate etc,*^

India is a federal dem ocratic state in w hich the constitutional sharing o f

pow ers betw een the C entre and the new ly form ed stares constitute the sta te 's m ost

excellent existence in all realm s. At the tim e o f independence, public adm inistration

o f India w as in a prim itive state. T he adm inistrators d id n 't get enough orientation or

experience like that o f E uropeans nations. T heir inexperience directly affected India’s

all sectors o f adm inistration. T he health care system o f India w as an exam ple. F or

attaining better levels in the field o f public adm inistration the new ly form ed

governm ent w as ready to introduce various tools and m easures. T hrough the

constim tion o f India leaders w ere ready to support the aspirations o f com m on m an

highly. T he Indian C onstitution becam e the w o rld 's largest and lengthiest

constitution because it included all m atters in relation w ith the com m on issues.

T h e Indian C onstitution has recognized that the health condition o f the nation

is indivisible. A ccording to the A rticle 21 o f the C onstitution health security is one o f

the m ajor com ponents o f hum an developm ent and it is a public right. G ood health is

not only an end product o f developm ent but also a necessary condition for econom ic

developm ent. It can be considered as another com ponent o f social security. T he

Seventh schedule o f the C onstitution reads about the im portance o f public health and

sanitation, hospitals and dispensaries.^ T he D irective principles o f the State Policy

also th ru st the issues o f nutrition, standard o f living and im provem ent in public health

as the state subject. At the sam e tim e population control and fam ily planning are

com ing un der the purview o f interests o f the state and C entral governm ents. T he

Indian C onstitution has recognized that the health o f the nation is indivisible. T he
C onstitution judiciously suppoiled leaders o f the nation to attain general goals put

foi'vvarded by them prim arily. T he item s in the concurrent list include prevention o f

the spread o f infectious and contagious diseases, adulteration o f food, trade in drugs
etc.

Even the G overnm ent o f India and it's C onstitution put forw ard the socialist

ideals for the public adm inistration it had to practice and follow the international

ideals set by the organizations o f U N and others. U niversal health was a term

considerably used from 19‘^ century and w as popular in early 2 0 ‘^ century. T he UN

from its very inception, gave special attention in the subject o f health for all. The

W H O w as an unquestionable agency o f international health fro m l9 4 8 . It was

organized as a result o f the idea o f a pen n an en t institution for international health

started in 1902 in the form o f international S anitary O ffice o f the A m erican

R epublics, and decades later it becam e the Pan A m erican S anitary B ureau and

eventually the Pan A m erican H ealth organization.® E ven though there w ere m any

m eetings and organizations w ere conducted to create an international health

organization. A s a result the W orld H ealth A ssem bly m et in G eneva in June 1948 and

form ally created the W H O by m erging the O ffice o f H ygiene Publique, L eague o f

N ation H ealth O rganization, and the UNRA.. A fter its form ation the W H O divided

the w orld into a series o f regions nam ely the A m ericas, Southeast A sia, Europe,

E astern M editerranean, W estern pacific and A frica. B ut serious regionalization was

ab sen t until the 1950s.‘ In the 1960s and 1970s W H O w as influenced by the

changing political scen an o o f decolonisation m ovem ents o f A frican nations. T he

spread o f nationalist and socialist m ovem ents and new theories o f developm ent

em phasized long term socio econom ic grow th rather than short term technological

intervention. In 1960, W H O tried to strengthen health infrastructure and prim ary

health care by solving the basic econom ic and environm ental hitches. It prim arily

focused on the control o f epidem ics across the boundaries betw een nations.

H ealthcare services in India w ere utterly inadequate and urban-based and

curative in nature. It w as because all these w ere introduced by the colonial

governm ent w hich w as urban in nature. M ajority o f the population especially the

po or and those residing in rural areas did not have access to m odem health facilities.

Im provem ent in the health status o f the country was a m ajor concern for the nation
during those days. India, after independence had to build up an enorm ous health

infrastructure and hum an resources at the three tier health care levels- prim ary,

secondary and tertiary care levels. T he governm ent had the responsibility to introduce

agencies in the governm ent and private sector voluntarily. T hose agencies should be

operated through professionals and para- m edicals.^ To achieve the goals put

forw arded by W H O , U N E S C O and other international organisations, govem m em o f

India envisaged a health strategy and policy. F or attaining such goals, the

governm ent appointed various com m ittees and agencies before and after its

independence, to study about the situations and conditions existing. O ne such

com m ittees fo r studying the issues and problem s o f the public health o f India before

independence w as the B hore com m ittee. It w as appointed on 1943as Sir Joseph

B hore as the C hairm an. T he com m ittee subm itted its report on 1946 an d laid

em phasis on the integration o f curative and preventive m edicine at all levels. Its

recom m endations w ere to rem odel the existing health services in India It

recom m ended, the services m ust be acceptable to an individual in the curative and

p reventive fields. T here m ust be active im provem ent o f progressive health through

different services providing to com m unities. By w hich they are intended to assist.

T h e health organizations also have the responsibility to m axim um support and

co o p eration b etw een the health w orkforces and the people For prom oting the

h ealth program m es the support o f the all m edical and auxiliary professions are

necessary. For Exam ple, service o f dentists, pharm acists and nurses, is essential etc

Instrum ents o f b oth hum an and m achine, o f these professions have to encouraging the

h ealth policy o f the c o u n try ." M o d em m edical practice is becom ing com plex day by

day. D iagnosis and treatm ent, consultant, laboratory and other m edical institutional

experiences are different one another in its character and now it is m ore expensive.

B ut all these m atters together constitute “group” practice. So special provision is

therefore required for m others, children, the m entally deficient etc. To secure

adequate curative and preventive m edical care by creating and m aintaining a healthy

environm ent in hom es, m eans w here they are engaging for their w ork, am usem ents,

recreations are essential is also envisaged in the B hore Committee.*^

In tro d u c tio n o f N a tio n a l H e a lth policies a n d fra m in g o f D iffe re n t C o m m itte e s

T he B hore com m iliee, one am ong the initial com m ittees appointed, suggested to

solve the existing inequality in health services m the rural and urban areas. It
suggested m easures to solve this inequality by drafting a plan w ith specifically giving

m ore im portance to the rural population. It planned district as a unit, and assured the

health conditions should be sufficiently com prehensive to satisfy m odem standards o f

health adm inistration. M udaliar C om m ittee o f 1962 w as another com m ittee

ap pointed by the governm ent fo r studying the conditions o f public health plan and

developm ent w as appointed in 1959 under Dr. A. L. M udaliar. It w as the H ealth

Survey and P lanning C om m ittee It assessed the report subm itted by the B hore

com m ittee, and found certain conditions form ulated w ere unsatisfactory. T he

com m ittee subm itted its report on 1962 and docum ented that the disease control

program m es resulted in the controlling o f certain dangerous epidem ic diseases. It

suggested the basic health facilities had not reached at least h a lf o f the nation. In

regard to m edical hum an pow er the com m ittee suggested m easures to im prove the

service condition o f doctors and o th er personnel in order to attract them to rural areas.

T h e next com m ittee appointed w as the C hadha C om m ittee o f 1963 w hich was

ap pointed under the Dr. M .S. C hadha, w ho w as the D irector G eneral o f H ealth

s e r v i c e s . I t w as assigned to advice about the basic needs o f the health sector. It

suggested the assim ilation o f health and fam ily planning services. It suggested to

appoint one m ale and one fem ale m ultipurpose w orker per 10,000 population to

integrate the program m es. R educing population as a policy w as firstly adopted by

India, in 1951. In the first two Five Y ear Plans, the fam ily planning program m e w as

exhausted by different voluntary organizations under the aegis o f FPA I and after the

com m ittee an independent departm ent in the m inistry o f health w as started for this.'^

In 1966, the M ukheijee com m ittee w as appointed under the chairm anship o f

the then U nion H ealth Secretary, to study about the m ultiple activities o f m ass

program m es such as fam ily planning, sm all pox, leprosy, trachom a, N M E P etc. T he

com m ittee activated the features o f the B asic H ealth Services. It fixed target fixation,

paym ents for m otivation and incentives to acceptors o f the fam ily planning
p rogram m e etc. It suggested to reorganize the FP program m e as a straight

p rogram m e like m alaria. It again recom m ended the enhancem ent o f one or m ore
h ealth visito r p er prim ary health centre (phc) to supervise the auxiliary nursing

m idw iferies (anm s) for the target o f the program m e.''^ Jungalw alla C om m ittee o f

1967 o r the C om m ittee on Integration o f H ealth Services was appointed m 1964 under

Dr. Junganw ala, D irector o f N ational Institute o f H ealth A dm inistration and

E ducation.'^ It studied about the integration o f the various departm ents o f health
18
sectors.

In 1973 the K arthar Singh C om m ittee w as appointed to study about the

m ultipurpose w orkers under the health and fam ily piaim ing. It recom m ended the

m akeover o f single com m itted w orkers including auxiliary nursing m idw iferies into

m ultiuse m ale and fem ale workers.'*^ It envisaged that each pair o f those w orkers

should assist a population o f 10,000 to 12000."^ It w as w ith an aim to su p p o n the

program m es conducting in the rural areas. T he Jain C om m ittee w as appointed on

1967. T h e com m ittee report on the M edical care services w as an attem pt to im prove

m edical care by applauding and strengthening the facilities o f district hospitals. T he

Jain com m ittee recom m ended collaboration and im provem ent o f m edical and health

services at the district level. It suggested that both the responsibilities being entmsKed

in the civil surgeon o r c h ie f m edical officer O f all the com m ittees appointed, it w as

the only one com m ittee from independence for the first tim e talked about the

strengthening o f cu rative services in rural areas. B ut it was not seriously

c o n sid e re d ^ ’

C om m ittee under the chairm anship o f Shrivastav w as organized in 1974. A im

o f the com m ittee w as to support hum an resources to finalize m oves essential to

acquaint m edical education in accordance w ith national needs and priorities w as given

to foster a curriculum for health assistants. T hey w ere liable to perform as a nexus

betw een m edical officers and m an pow ers. It also recom m ended for the creation o f

com bined health w orkers o f paraprofessional and sem iprofessional sections to form

the three cadre system from w ithin the com m unity. It w as possible by com bining

m u ltipurpose health w orkers, health assistants and com m unity level w orkers and

doctors at phc. D evelopm ent o f a referral service com plex w as also suggested b y the

com m ittee. It recom m ended to constitute a m edical and health education

com m ission. It w as for m aking re fo n n s that are sam e to the U niversity G rants

C om m ission."^
 A n expert com m ittee under Dr. J. S. Bajaj on 1985 w as created to study on

H ealth m anpow er planning, production and m anagem ent and subm itted its report on

1986. T his C om m ittee w as the Bajaj C om m ittee. It m ade the recom m endations to

form ulate national m edical and health education pohcy. A gain it recom m ended for

estab hshing health science universities in various states and union territories. A lso

the com m ission w ished to establish health m anpow er ceils at the centre an a in the

states. V ocationlisation o f education o f health related subjects w ith proper incentives

ap p ro p n ate for quality param edical personnel w as another suggestion o f the

com m ittee.

W ith different ideas and vision governm ent o f India had form ulated its

policies and strategies by follow ing socialist ideals and concepts started during the

periods o f nationalist m o v e m e n t s . I n addition to that the constitution also supported

those form ulas and the strategies. C ontrolling com m unicable diseases, regulating

population grow th, prom oting health research and specialized m edical services w ere

cam e und er the direct control o f the C entral G overnm ent. H ealth is a constructive

com ponent for the harm onious developm ent o f both the physical and m ental

capacities o f an individual. H um an resource is m ost precious bequest left on the

progress o f a nation. T he item s in the concurrent list include prevention o f the spread

o f infectious and contagious diseases adulteration o f food, trade in drugs etc. T he

M in ister for H ealth is in overall charge o f this field. T he C entral G overnm ent assigns

public health, sanitation and curative services to the State governm ents. H ealth is

State subject m atter and state policies w ould have significant bearing on the public

health expenditures in India. A lso now adays G overnm ent at the state level is run by

differen t political parties and com petition am ong them should m ake the perform ances

o f individual states, a m atter o f high political and electoral interest.

P olicies and P rogram m es introd uced in K erala after 1956

A s a state new ly form ed K erala co u ld n ’t have to do m uch m ore in public

health adm inistration as it w as follow ed the policies and strategies o f the W H O and

G ovt, o f India. T h e governm ent cam e into effect in 1956 w as the result o f the general

elections held in the year. T he governm ent constituted follow ing the general elections

o f 1956, under the leadership o f EM S N am boodiripad w as a left w ing governm ent. It

w as based on the ideas o f socialism and com m unal harm ony to be achieved through
equal status to all in'espective o f caste or gender. T he governm ents o f the successive

p erio d s also follow ed the activities o f the policies adopted by their predecessors. A s a

result public m atters like health, education and other socio and econom ic dom ains got

special attention and care,

E ven before the form ation o f the state o f K erala, the land cam e under the

m fluence o f the Five y ear plans introduced by the G ovt, o f I n d i a . T h e E conom ic

developm ent and planning o f F irst five year plan directly influenced the health

scenario o f T ravancore-C ochin and M alabar. H ence, the initial im provem ent o f

h ealth status o f K erala w as a result o f the health care program m es introduced by

various authorities. T he policies o f the native rulers along the m fluence o f the

colonial governm ents w as a stim ulus for the health status o f K erala. So it w as easy to

follow and introduce the new program m es after independence- K erala had already

built a platform to construct new ideologies, R ulers and subjects w ere aw are about

the im portance o f health and hygiene. It is evidenced in the statistical data o f

T ravancore and C ochin. B efore 1940 as the death rate in T ravancore-C ochin

decreased to about 15 sim ilar to the rate o f France and Sw eden w ere attained later.^^

T h e m ajo r reasons o f death in the earlier days w ere infectious diseases such as

cholera, sm all pox, w orm infestation etc. T he controlling m easures o f com m unicable

d iseases through public health program m e such as sanitation, vaccination,

introduction o f health education effected in low ering the death rate o f particular areas.

D uring the colonial period, sanitation and vaccination program m es focused on the

tow ns o r cities w here elite groups and Europeans w ere settled. A fter independence,

through various m easures, the program m es spread to other areas o f the state. T he

P ublic H ealth A dm inistration departm ent o f K erala initially know n as the D irectorate

o f H ealth Services. It regulated the w orks o f the departm ent w ith one A dditional

D irector, four D eputy D irectors and a few A ssistant D irectors who w ere in charge o f
various subjects such as m edicine, vigilance, m alaria, fam ily w elfare etc.^^At the

district level the organization com prised one D istrict M edical O fficer and a few

A ssistant M edical O fficers. A nd at the bottom o f the structure w ere the P n m a ry

H ealth C entres w ith their core o f m edical param edical and auxiliary s ta ff K erala

co m prised o f about 13 districts before som e tim es and after it w as raised to 14.
 T he M edical and public health departm ent o f the state w ere o f tw o separate

departm ents, w ith separate D eputy D irectors in charge. T he P ublic health w ing

handled the R egistration o f B irth, D eath, m arriages, control o f com m unicable

diseases, vaccination, M alaria and F ilaria control, B C G vaccination w ork, m aternity

and child health, health education, m ilk distribution, rural sanitation and food and

w ater analysis.^^ T he m edical w ing controlled free m edical re lie f through hospitals

and dispensaries, laboratory services, drugs control and n u r s i n g . T h e D irector o f

H ealth Services w as the R egistrar G eneral o f B irths, D eaths and M arriages. T he

P ublic H ealth w ing w as concerned w ith the registration o f births, deaths, m arriages,

control o f com m unicable diseases, vaccination, m alaria and filariasis control, B CG

v accm ation w ork, m aternity and child health, health education, m ilk distribution, rural

sanitation and food and w ater analysis.^*^ T he D epartm ent o f Statistics continued to be

the C entral agency for com pilation o f vital statistics.^'

Infectious diseases w ere one o f the serious threats that caused the m ajority o f

deaths in the tw o form er centuries. T he infectious diseases w ere occurred in the

u nhealthy situations and other natural calam ity tim es. In history there are references

ab out those deaths and w ipe o u t o f hum an beings from the arena. B ut the public

h ealth m ovem ents o f the late nineteenth and early tw entieth centuries identified the

harm s that are generating issues. T he m ajor issues identified w ere poverty and

starvation, overcrow ding, poor sanitation and increasing effects of speedy

urbanizations. T h e introduction o f vaccination and eradication arrangem ents

encouraged the h ealth care sector to com e across the field w ith m ore advanced

activities to the disposal o f the problem s existed. T he eradication o f infectious

diseases w as a serious problem o f the 19'*’ and 20*^ centuries. F or eradicating the

infectious diseases the colonial governm ent established the N ational Institute o f

C om m unicable D iseases or N IC D established at K asauli in H im achal P radesh in 1909

as the centre for m alaria control and it cam e to b e know n as the C entral M alaria

B u r e a u . B y m aking som e expansions on its outlook and activities in 1927 it w as

renam ed as the M alaria Survey o f India. T he organization w as shifted to D elhi in

1938 and cam e to b e called as the M alaria Institute o f India o r ^

governm ent o f India expanded the institute w ith a view to acl^^V e-the goa!"'oi
1/
eradication o f m alaria and o th er com m unicable diseases. T h u s ^ e r e started the

N atio nal M alaria E radication P rogram m e. T hus, o n July 30, 196& thfe erstw hile M i l '
w as renam ed as N IC D to take on other additional tasks. T he institute was

established to m eet the task as a national centre o f excellence for controlling

co m m unicable diseases. T he institute also took the duties o f training and research by

usm g m ulti-disciplinary integrated approach. It w as expected to provide expertise to

the States and U nion T erritories on fast health evaluation and laboratory based

diagnostic services. S urveillance of com m unicable diseases and outbreak

investigation also form ed an indispensable part o f its activities. T he institute u n d er the

control o f the D irector G eneral o f H ealth Services o f Govt, o f India. T he D irector, an

o fficer o f the P ublic H ealth sub-cadre o f C entral H ealth Service, is the adm inistrative

and technical head o f the Institute.^* T he Institute has its headquarters in D elhi and

h as eight o ut-statio n branches. T he regional institutes are located at A iw ar in

R ajasthan, B engaluru in K arnataka. K ozikode in K erela, C oonoor in T am il N adu.

Jag d alpu r in C hattisgarh, Patna in B ihar. R ajahm undry in A ndhra P radesh and

V aranasi in U ttar Pradesh.^

D ifferent types o f vaccination and eradication program m es w ere started all

o v er India after her independence. K erala becam e centre o f excellence o f the

program m es introduced by governm ent o f India. ‘T h e long cam paign o f inoculation

and vaccination has its place in this m ovem ent to organise around the child a system

o f m edical care for w hich the fam ily is to b ear the m oral responsibility and at least

part o f the econom ic cost, via different routes, the policy for orphans follow s an

analogous strategy. Special institutions are opened. T he m edical politics outlined in

the eighteenth century in all E uropean countries has as its first effect the organization

o f the fam ily, o r rath er the fam ily-children com plex, as the first and m ost im portant

instance for the m edicalisation o f individuals. T he fam ily is assigned a linking role

b etw een general objectives regarding the good health o f the social body and

individuals' desire o r need fo r care enables a 'private' ethic o f good health as the

reciprocal duty o f parents and children to be articulated on to a collective system o f

hygiene and scientific technique o f cure m ade available to individual and fam ily

dem and by a professional corps o f doctors qualified and, as it w ere, recom m ended by

the State. T he rights and duties o f individuals respecting their health and that o f

others, the m arket w here supply and dem and for m edical care m eet, authoritarian

interventions o f pow er in the order o f hygiene and illness accom panied at the sam e

tim e by the institutionalizing and protection o f the private doctor-patient relation, all
these features in their m ultiplicity and coherence characterise the global functioning

o f the politics o f health in the nineteenth cenuiry, yet they cannot be properly

understood if one abstracts them from this central elem ent form ed in the eighteenth

century, the m edicalised and m edicalising fam ily.”

Im m unisation can be consider as the fruitful m ethod in controlling infectious

diseases, it is possible by building up im m unity am ong im m unized persons agam st

som e diseases. By using specific vaccines o f certain diseases can be stopped from its

spreading am ong people. S anitation and vaccination program m es com bined w ith the

w ide spread access to professional health care in K erala to produce dram atic

reductions in several m ajor diseases associated w ith under developm ent,^^

V accination becam e strict and com pulsory throughout the state from the colonial

period itself. In T ravancore, C ochin and M alabar, the program m e w as conducted by

the T rivandrum C orporation and m unicipalities o f T ravancore C ochin and M alabar

respective. T he practice becam e possible and they conducted the w ork in accordance

w ith the rules passed under the respective M unicipal Acts.'^'^ In the rural areas o f

M alabar vaccination was ea rn ed on as per rules fram ed under the M adras Local

B o ard 's Act. In the rural areas o f T ravancore -C o c h in the rules fram ed by the Govt,

in M arch 1958 u n der section 86 o f the T.C Public H ealth A ct w ere in f o r c e . T h e

m unicipal and corporation s ta ff w as in charge o f the duties. B C G V accination was

started in the state in July 1949 u n d er the jo in t auspices o f the U N IC EF, the C entral

G overnm ent and the State Govt."^^ In K erala the EPI w as started in 1978.'^^’'^“* T .T

im m unisation to pregnant w om en w as started in 1975-76.'^^ Polio and typhoid

vaccinations w ere started in 1979-80.'^^ im m unisation o f T .T for school children w as

announced strict from 1980-81. A t the sam e tim e, B C G vaccination and M easles

vaccination w ere brought under E P i 19981-82 and 1985-86 respectively. T here w ere

about 151 N E S blocks o f EPI in the state during the period o f 1982. From i983 it

becam e a continuous m atter.

For m aking vaccination m ore fruitful changes w ere started from 1985 onw ards

throughout in India. N ational Im m unisation M ission w as also started in K erala as a

part o f the U niversal Im m unisation P rogram m e. Im m unisation o f all children below

one year o f age w as its m ain objective. In 1985, in the districts o f P alakkad and

Idukki UIP w as firstly started. T hree years later in 1988 all the 14 districts w ere
covered under the program m e o f UIP. Through the program m e m fanis beiow one

y ear are strictly protected aw ay from the effects o f D iphtheria, W hooping cough,

Tetanus, child hood TB , P ohom yelitis and M easles.

V accines w ere m aintained under a cold chain system under the UIP. T he

system o f storing and transporting o f the vaccines under a low temperaUire cool

system from its m anufacturing to the point o f using is know n as cold chain system.^'^

It was because, vaccines are generally sensitive and there w as a possibility to heat. So

it w as kept and transported under a low tem perature cool system . D ifferent types o f

m achines w ere used for this purpose. D ifferent types o f im m unisation program m es

w ere strictly un der the control o f the C entral G overnm ent o f India. T here w ere

w'arehouses in different regions o f the states to store and supply the vaccines. In

K erala regional store centres w ere m ainly located in T hiruvananthapuram , E m akulam

and K ozhikode.^' PHC, C H C s. PP units etc got vaccines from the regional stores and

district stores. T h e potency o f the vaccines w ere alw ays tested in the potency testing

centre at Coonoor.^"’^^

■‘K erala state entered the m aintenance phase o f N M E P in 1965.^‘^'^^The

m alaria free status was m aintained till 1968. A s a result o f im ported cases, sm all

o utbreaks o f m alaria occurred in 1976 w ith 1951 cases in K annur district and it w as

effectively controlled by im m ediate containm ent m e a s u r e s . T h e m odified p lan o f

o perations und er NM EP was im plem ented in 1977.^^’^^ O ne zonal m alaria

org an isatio n w as sanctioned in 1977 w ith 50% o f central a s s i s t a n c e . T h e zonal

m alaria organization, w ith 50% o f central assistance helped the coordination o f the

N M E P w ork in the state and now there are at present 14 D istrict M alaria O fficers in

the s t a t e . T h e Zonal M alaria organisation had the responsibility to conduct

entom ological studies in ’‘vulnerable areas o f various districts and the program m e is

im plem ented und er M ultipurpose W orkers schem e since 1983,^^'^'^ T he M inistry o f

H ealth and Fam ily W elfare, G overnm ent o f India appointed an expert com m ittee in

1994 to identify the problem areas and form ulate specific strategies to tackle problem s

in such areas.^^ A s per the suggestions "T he m alaria action program m e’* has been

launched from 1995 and w as im plem ented w ith the D eputy D irector o f H ealth

Services (M alaria) as the P rogram m e Officer.^^ D etection o f m alaria cases through

active and passive sur\'eillance and rem edial operation tlirough radical treatm ent plan

and con tract survey, follow up o f positive cases and D D T focal spray.”^^

“T h e N ational TB C ontrol w as form ulated in 1959 by the N ational

T uberculosis institute. Bangalore.^^’^^ T he Institute gives training to m edical and

param edical personnel and also conducts research w ork in the field o f TB and the

entire program m e is operated on the guidelines and direction o f N ational T uberculosis

institute/*^ T h e N ational TB C ontrol P rogram m e w as started in 1962 as 50% centrally

sponsored schem e w ith central share in kind i.e in the form o f anti TB D rugs, X -ray

film s , X -ray m achines w ith odeoca cam era etc for detection o f cases through sputum

exam ination, X -ray testing and supply o f anti TB drugs and laboratory c h e m ic a ls /'

U nder the program m e short course chem otherapy w as im plem ented in 7 districts m a

phased m anner. " T here are D istrict TB C entres m all the 14 districts besides 7 TB

clinics and 2 Sanatoria. T here are 45 TB w ards attached to G overnm ent H ospitals and

a total num ber o f 1983 TB beds area available in the state. T he N ational TB

C ontrol P rogram m e is a com prehensive socially acceptable and econom ically feasible

program m e evolved to control the problem o f T uberculosis in the country/'*

A ccording to health studies 0,2% o f the population in India is suffering from TB and

is estim ated that there are 60000 patients in Kerala.^^ T he aim o f the program m e w as

to give the patients chances for im provem ent as possible to treat them effectively.^^

T o detect as large a n um ber o f patients as possible and to treat them effectively so that

the infectious patients becom e non-infectious and the active and noninfectious cases

do not becom e infectious is the m am objective o f the p ro g ra m m e /’ R evised N ational

TB C ontrol P rogram m e im plem ented through 100 % W orld B ank assistance and was

first im plem ented in P athanam thitta district in 1994.^^'^^ T he prim e aim is to achieve

85% cure rate.''^°

“ Filaria w as p revalent in the entire coastal regions o f K erala. T he program m e

o f F ilaria C ontrolling m easures w ere launched in the State during 1955-56.^’’®^ It is

im plem ented through 16 N F C P unitS through 2 F ilaria Survey U nits and the F ilaria

control w orks at Cherthala.^^ T he F ilaria Survey U nit at T hrissur w as shifted to

T hiruvananthapuram in M ay 1995 and continues to function as m ain central unit at

V aliyathura in T hiruvananthapuram .*’^''

 “T h e N ational L eprosy E radication P rogram m e was started m 1959.^^ T he

m ain strategy o f the program m e w as to detect cases o f leprecy and its treatm ent w ith

dapsone and also health education to the affected ones.^^ L ater the program m e faced

setbacks, due to extended nature o f treatment.^^'^* In 1981, G overnm ent o f India

constituted a com m ittee to study about different issues in this realm and as a result the

C om m ittee N ational L eprosy C ontrol P rogram m e w as redesignated as N ational

Leprosy E radication Program m e. For com plete eradication o f leprosy from India by

2000 AD. a 20 point program m e w as m itiated by the g o v ern m e n t.^ A s a result a new

and effective program m e w as introduced and it cam e to know n as M .D .T (M ulti D rug

T h erap y )’*^’. In K erala M .D .T w as firstly im plem ented in A lappuzha o n 1987 In

T h rissu r and P alakkad the M D T program m e w as started in 1990. and in K ollam and

T hiruvananthapuram on 1991. In the districts o f E m akulam , K annur, K asargod,

M alappuram and K ozkikode the program m e started on 1993 and later in the other

districts.^"

S exually T ransm itted D iseases (ST D s) are another m ajor problem in Kerala.

W om en are the m ain sufferers in this category and they are suffering from issues like,

infection m syphilis, increasing ratio o f untreated abortions, m iscam ag es. T h at’s why

STD clinics attached to district / taluk hospitals, w hich are know n as Skin and V.D

departments.^^'^'^ Increasing rate o f H IV / is the next issue and the governm ent is

suffering from this. To give aw areness on A ID S and related m atters, a surveillance

centre was estab h sh ed in 1986 at M edical C ollege, Thiruvananthapuram .^^ But, the

N ational A ID S C ontrol P rogram m e w as im plem ented in the state from S eptem ber

1 ^ 9 2 96 a i d s cell w as created under an A dditional D irector o f H ealth Services

and the “ State A ID S C om m ittee and Stale T echnical A dvisory C om m ittee trying its

best to im plem ent program m es o f prevention and control o f H I V / A I D S . F o r

escaping from this w orst situation, m odernization o f blood banks, establishm ent o f
zonal blood testing centres, com ponent separation unit and incineration, strengthening

and establishm ent o f STD clinics, training o f staff, lE C activities including adolescent

education"^^ are extrem ely n e e d e d . B y using the popularity o f electronic

instrum ents various aw areness program m es for the public is conducting through All

India R adio and D oordarshan. T he state governm ent is using different such lE C

m achineries along w ith giving enougn iram ing to the doctors, other m edical

w orkforces, in the private and public sectors to handle the patients o f suffering from

106
H IV /A ID S and such s i t u a t i o n s . " K e r a l a State A ID S cell is conducting

w orkshops for doctors, educationalists, social w orkers, D irector of Public

Instructions, D irector o f C ollegiate E ducation, H ead M asters and Principals o f

colleges for evolving a strategy to give sexual health education to high school

students from 8th standard onw ards and introduced a m odule nam ed Fam ily Life

E ducation for training the teachers o f high schools to im part training for their students

w as form ed and w as printed and supplied by UNICEF,

W ith its ow n M ental H ealth P rogram m e the first D istrict Psychiatry unit o f the

state w as opened in 1970 as a part o f the D istrict H ospital o f Em akulam . Psychiatric

serv’ices o f the state w ere provided through the 3 M ental H ospitals in its beginning

and now w ith “ 3 M ental H ealth C entres, 5 psychiatric units and district psychiatric

units (in teaching hospitals) in the public sector.” ’®^ In addition to the public sector

there are hospitals / w ards / rehabilitation centres in private sector. N um ber o f

voluntary organisations are also engaged in this particular i s s u e . T h e y are giving

training to m edical students and nurses on how to m anage the O P and IF care i f they

are facing such situations o f stress and other m ental disorders o f the state. T he sta ff o f

Taluk H ospitals and P rim ary H ealth C entres are also getting training in this issue.

Selected PH C entres are som etim es distributing the Psychiatric drugs. “A project

nam ed T h e N eed A ssessm ent o f S evere M ental M orbidity o f K eraia State w as

introduced and State M ental H ealth A uthority w as opened T hiruvananthapuram on

29-7-1997 ***06>i07

T he physical m edicine and rehabilitation units o f the state w ere established for

providing m axim um care and support to the physically disabled o r challenged. For

that purpose a D epartm ent w as stan ed in T hiruvananthapuram in 1968 and the

108
advisory com m ittee on state level w as introduced in 1975.' T here are 11 Physical

M edicine and R ehabilitation units in the m ajor hospitals o f all d istn cts except

P athanam thitta, Idukki and K a sarg o d .’*^^

N ational Iodine D eficiency D isorder C ontrol P rogram m e is one to reduce

goiter and such oth er diseases. F or that purpose a G oiter cell was started in 1988 and

from 1990 it cam e to full ro le .'’'’ From 1989 the IDD cell is conducting G oiter

p revalence surveys in 14 districts o f K eraia to give aw areness about the issue.

 Fam ily W elfare P rogram m e started in India to control the overw helm ing

population o f the country. India is the second m ost populous state o f the w orld next

to C hina. T he history o f In d ia's population grow th since 1891 divides h s e lf into four

natural parts, and the pom ts o f separation is being 1921, 1 9 5 1 a n d l9 8 I ." ’ T his

division show s the range o f the troubles existed here. T he y ear 1921 is defined as the

year o f “G reat D ivide” as it celebrated the earlier period o f chequered population

grow th to a phase o f reasonably increasm g g ro w th .’*^ T he 1951 m arked the

b egim ung o f a period o f quick population grow th. T he c u t-o ff point w as 1981 after

w hich the high grow th registered som e exact signs o f slow ing d o w n .'‘^The changing

pattern o f population am ong different states is due to differentials in decadal grow th

rates o ver tim e. D uring the thirty y ear period o f 1921 to 1951 India population grew

slow ly but surely fo n n s 251 m illion to 361 m illion o f the grow th o f 44 percent.'*'^

D uring the next thirty years o f 1951 to 1981 it w as approxim ately doubled, and

increased from 36,1 m illion to 683.3 m illio n .” ^ T he period from 1981 to 2001 all the

states and union territories experienced an increase in population but at varying rates,

there w as a tendency o f the decline m the grow th i.e. the northern zone w itnessed the

increase o f 21.3, w as few er than in the decade o f 1981-991, and the southern zones

w itnessed a decline o f 1 3 .3 p e rc e n t'

P opulation grow th has close connection w ith the health care m easures. B ut

the relations betw een the econom ic conditions under w hich people live and their

longer lives, on the one hand, and the relationship betw een the enhanced health

po sitio n o f adults and their econom ic output as w orkers, on the other hand, are two

p o ssible causative relationships. A ccepting these fundam ental associations could

notify the selection o f population policies related to health, fam ily planning, and

m igration, and im prove the foundation for predicting future econom ic developm ent.

O v er population alarm s the usual spheres o f hum an beings forever. T he loss o f fresh

w ater, loss o f oth er natural resources, lack o f freedom and increasm g restrictions,

increase o f epidem ics, starvation and poverty, increasing global w arm ing and clim ate

change are som e com ponents o f the harm s o f over population. All those issues w ere

relatively solved by a nation all the w ay through the introduction o f v an o u s health

care m easures. F am ily planning w as the policy o f the Govt, o f India to control the

fast grow ing population o f India. In India, Fam ily planning program m e w as started in

India 1952."^ It w as m odest in the first and second five year plan periods. It got
attention during the third plan and it becam e stricter and tim e bound one in the fourth

plan period. D uring the fifth plan period it included m atters in relation w ith m aternal

and child health and nutrition etc. T here w ere eleven clinics in K erala in 1955 w hen it

w as started. T h e state follow ed different styles for the perfection o f the program m e.

For that, the state conducted m ass cam ps in the tlrst stage. “L ater here started a

n u m b er o f fam ily planning centres, and lastly concentrated on m aternal and child

health. D uring the period 1956-61. o f the first phase, 70 fam ily planning clinics w ere
1 I
o pened in the state w ith facilities for sterilization in 53 institutions.” D uring the

next fo u r years, 50 m ore clinics w ere started and fam ily planning clinics w ere opened

in 93 p anch ayats.” ^ C om m ittees w ere constituted to prom ote the w ork o f Fam ily

P lanning clinics. '‘In 1964 on the basis o f the recom m endations o f the M u khanee

C om m ittee, a netw ork o f service units w ere established and it had to w ait a period for

recoganisation till 1970.'"' From 1970-1973 conducting o f m ass sterilization cam ps

w as the hallm ark o f the p ro g ram m e,’" Since 1970 the state has stepped up the pace

and reached several m ilestones in the im plem entation o f the v an o u s fam ily w elfare

p rogram m es.” '"^ For giving m ore aw areness o f m edical and param edical personnel at

the sub centres. P H C 'S and C H C ’S, tw o Health and Fam ily W elfare T raining C entres

w ere s t a r t e d . I n the m id o f 1970's, it w as renam ed as Fam ily W elfare P rogram m e

and from there, K erala has m ade rapid strides in the im plem entation o f Fam ily

W elfare P r o g r a m m e s . T h e different types o f fam ily planning program m es rsulted in

the decline o f birth rates. It is calculated that, the birth rate had a declining effect o f

23.2 in 1985 to 17.7 in 1995. From 1986. it is again dropped from 2.3 to 1.8 in 1991.

T he program m e m ade a feeling o f responsible and Planned P arenthood am ong the

people also.'"^
Population grow th o f K erala from 1951 to 20) 1 T able No. 3

Y ear T o ta l M ale FemaSe

1951 13549118(100) 6867217(50.68) 6681901(49.32)

1961 16903715(100) 8541788(50.53) 8361927(49.47)

1971 21347375(100) 10759524(50.41) 10587851(49,59)

1981 25403217(100) 2915256(50.84) 12487961(49.16)

1991 29098518(100) 14809523(50.89) 14288995(49.11)

2001 31838619(100) 15468664(48.59) 16369955(51.41)

2011 34563000(100) 16859000(48.72) 17704000(51.22)

127

T h e population o f the state in 1901 w as 63.9 lakhs o f w hich 31.9 lakhs w ere

m ales and 32.1 lakhs w ere fem ales. T he population o f the state m ore than doubled

b etw een 1901 -1951 adding a population o f 715 lakhs. B ut in the next 50 years i.e.

from 1951-2001, the population grow th in K erala has slow ed dow n adding only 182

lakhs to total population. C ensus data show that over the last 100 years it took m ore

than 40 years for the s ta te 's population to double. But it doubled in the next 30 years

from 110.3 lakhs in 1941 to 213.5 lakhs m 1971. A s per 2001 census tne population

o f the state w as 318.4 lakhs w ith m ale population 154.6 lakhs and 163.6 lakhs

fem ales. K erala’s dem ography is also skew ed positively tow ards w om en. T hroughom

the census period, the p roportion o f fem ales to total population in the state is higher

than m ales. T he proportion o f fem ales to total population has increased from 50.1

percent in 1901 to 50.53 percent in 1961 and further to 51.4 percent in 2001."*^® The

trends o f population grow th after the introduction o f the m odem m edicm es and fam ily

w elfare planning p rogram m es reduced the rapid grow th o f population in K erala.

E ven though it is highly population dense second state, the health aw areness about the

n ecessity for a healthy condition m ade K erala a m odel fo r the other states o f India.

A gain K erala giving a preferable consideration for the f e m a l e s . A s a result o f the

p rogram m es enunciated by the state the state has achieved its goals in 2000 before the
period estim ated by the N ational H ealth P o l i c y . K e r a l a ’s achievem ents in the

Fam ily W elfare area are m ainly in. birth - death rates, neonatai - m fant m o n aiity

no
rales, couple protection rate high fem ale literacy, higher age at m arriage o f girls,

status o f w om en etc.'^' V arious factors had contributed to such an achievem ent. The
132
roles o f N G O ’s, and other socio-econom ic factors are deserving special m ention.

T h e birth rate in the urban areas w as m ore than that o f the rural areas. It show s the

people are m ore d ensely populated in the urban region; the registration w as frequently

done am ong the urban population etc. T he ratio is low in the rural m ay be due to

som e reasons. T hey w ere aw ay from m am hospitals o r dispensaries and so the

hospital facilities affected their lives, as they used the govt, hospitals for treatm ents.

A nother in rural areas the registration w as not properly done in the earlier tim es. T he

lacks o f nutrition, aw areness on health issues, excess w orking hours, bitter w ays o f

livelihood etc w ere other reasons.

M aternal and C hild H ealth P rogram m e w as another im portant im m unization

program m e. ’‘Since independence H um an R esource D evelopm ent program m es

focused on m aternal and child health. T he im m unization program m e is one o f the

m ost cost effective public health m easures and is an im portant com ponent o f the

prim ary health care services. R ecognizing the need for im m unization, G overnm ent o f

India launched the expanded program m e o f im m unization (EPI) UN 1978, w ith the

o bjective o f increasing the average levels o f various ant i gens” . M a t e r n a l m ortality

rate in K erala is relatively low though the decline in M M R is not as fast as the decline

in infant m ortality rate. IM R w as quite high in the first h a lf o f 20th century. It is

observed that o v er the years this rate has com e dow n to 120 per 1000 live births in

1951-61 and66 p er 1000 live births in 1961-71. In 1991 IM R in K erala further

declined and reached 16 per 1000 live births w hich is the low est in the country. L arge

investm ents m ade by the governm ent in health services particularly to im prove the

condition o f children and w om en m the state have contributed for this sharp decline in

IM R. R ecent Sam ple R egistration System estim ates show that though this decline
continued up to 2022, from 2004 onw ards IM R in the state has m arginally increased

to 12 p er 1000 live births and later to 15 p er 1000 live births.'^“^The im provem ent in

m aternal and child health indicators m K erala is som etim es the result o f the socio

econom ic changes that w ere occurred in the state. T he m ajor factors influenced it are

age, parity and birth interval, environm ental factors like air. food, soil, flies, nutrition,

low internal and accidental injuries, personal illness control e tc .‘^^ T he childbirth in

hospitals is another im portant reason for the decline o f infant m ortality. ^ H igh
fem ale literacy rate in the state has strong influence m low ering rate

Infant M ortality Rate.

In fan t M ortality rate in K erala fro m 1911 - 2006 T able No. 4

Y ear IM R /1 0 0

1911-21 242

1921-31 210

1931-41 173

1941-51 153

1951-61 120

1961-1971 66

1971-1981 54

1991 16

2001 11

2002 10

2004 12

2005 14

2006 15

IM R w as quite high in the first h a lf o f 20th century. It is observed that over

the years this rate has com e dow n to 120 per 1000 live births in 1951-61 and66 per

1000 live births in 1961-71. In 1991 IM R in K erala further declined and reached 16

p er 1000 live births w hich is the low est in the c o u n t r y . L a r g e investm ents m ade by

the governm ent in health services particuiarly to im prove the condition o f children

an d w om en in the state h av e contributed for this sharp decline in IM R. R ecent Sam ple

R egistration System (SR S) estim ates show that though this decline continued u p to

2002, from 2004 onw ards IM R in the state has m arginally increased to 12 p er 1000
139
live births and later to 15 p er 1000 live births.
G e n d e r w ise L ife E x p e c ta n c y in K e ra la

L ife E x p e c ta n c y (in y e a rs ) Table N o .5

M ale-fem ale
Y ear M ales F em ales
d iffe re n c e

1961 46,2 50 3.8

1971 60.5 61.1 0.6

1981 60.6 62.1 1.5

1991 66.9 i 72.8 5.9

1
2001 68 74 6

2001-06 75.20 81.20 6

140

T h e life expectancy ratio o f K erala from 1961 to 2006 has done because after

com pleting five years o f its form ation the m easures began to change. T he table

explains increasing ratio o f life expectancy. B efore the introduction o f m any m odem

m edical treatm ents the youth o f K erala w ere on the verges o f death. B ut after the

introduction o f different life m easures the expectancy is increasing.

O R T or oral dehydration program m e was launched from 1985 along w ith UIP

as a national child h ealth program m e. T he O R T w as m troduced in 1971 b y WHO.'*^'

In K erala the program m e w as started in 1987 to prevent diarrhoeal deaths causing

from d e h y d r a t i o n . “ By 1988-89 D iarrhoeal T reatm ent U nits w ere established in all

M edical C olleges and in seven district hospitals an d O R S depots w ere established in

all villages and urban areas at the rate o f one p er thousand population.” *'^^ T he IM R

and child m orbidity rates o f the state have declined rem arkably due to its nice

execution.

T h e C SSM program m e o r C hild Survival and Safe M otherhood P rogram m e

w ere started in the state on 1992-93. T he program m e w as supported by W orld B ank

and UNICEF'*^. T he program m e w ished to increase im m unization services. T he

p rogram m e introduced w ith the aim o f providing enough services for controlling

anaem ia am ong pregnant w om en and try to control o f blindness occurring absence o f

vitam in am ong children. It again w ished to introduce program m es for controlling

acute respiratory infections occurring am ong children. For the easy installation o f

program m es, im m unisation cam ps w ere arranged in different areas. A w areness o f

healthy life tem pt m others to change the existing situations. T h at’s w hy the

program m e w ished to give m ore im portance to educating m others, m otivating and

rem inding them about the doses o f vaccination. A gain, they w ere info n n ed about the

availability o f vaccines even in private h o sp itals.’"*^ T he state’s achievem ents in the

elim ination o f neonatal tetanus and polio is another notable one. It resulted in the

red uction cases o f polio in m any districts. In addition to this series o f polio m op-up

rounds, K erala also conducting the pulse polio im m unisation program m e on

D ecem ber 7th and January 18th every y ear w ith all other states o f the n atio n .’*’^

Seventy one FR U s have b een identified and program m es w ere adopted to control

neo n atal issues.

N o t only h ad the State plan, but also in the developm ent agenda o f local self-

governm ent institutions g iv en m ore im portance to w ater supply and sanitation.

W ith intended progress K erala offer safe drinking w ater to 62.67 % o f its people. E ven

the proportion o f the safe w ater facilities and population are increasing intendeds, a

substantial portion o f the people rem ains not covered.*"*^ Im proving sanitation has

been an activity o f the governm ent o f T ravancore since the late 19'*^ century w hen

to w n Im provem ent C om m ittees and R ural C onservancy E stablishm ents w ere set u p to

disinfect w ells and w ater tanks, rem ove farces from public roads, graves, m arkets and

religious festivals, construction o f safe latrines b u t progress has b een m uch slow er.

T h e sanitation activities o f the D epartm ent com prised o f m aintenance o f conservancy

stations in 43 tow ns in the fo n n e r T ravancore area. M aintenance o f sanitary

conveniences, m aintenance o f all public w ater supplies and chlorination and

disinfection o f drinking w ater supply sources, special sanitary arrangem ents o n the

occasion o f various festivals and fairs, inspection o f m arkets, schools and other

p u b lic places o f interest w ere also cam e under the responsibilities o f the departm ent.

D etection o f offences u n d er the P ublic H ealth A ct and prosecution o f offences w ere

also handled by the departm ent. In the C ochin and M alabar areas rural sanitation

activities w ere carried on by P anchayats and Local B odies the role o f the D epartm eni

th ere b eing restricted to technical advice and supervision. ^^°The areas for sanitation in

T rav an co re w ere entrusted under the P anchayaths on 1958-59.’^* . T he governm ent

alloted huge am ounts for the latrines and for sew age appears insufficient to m eet the

stat’s am bitions target o f safe w aste disposal in 80 to 100 percent o f urban areas and

25% o f rural areas by the end o f 1980’s.*^^ T he dispersed rural settlem ent pattern in
K erala, how ever offers, a b uilt - in advaniage in sanitation. Since housed in tne

villages are not crow ded together as in m any other p a n s o f India transm ission o f

infectious d isease m ay b e a less serious problem

E ven though the m easures w ere introduced for the advancem ents in the public

health scenario, one o f the m ain stream s o f the society kept aw ay from the m ain

stream . D eficiency o f adequate num ber o f health care institutions is cited as one o f the

m ajor reasons for the low health care outcom e. T hese areas are lying far aw ay from

the cities w ithout adequate transport facilities; hence the availability o f health care

institutions will have a h igher im pact on their health care outcom e. It is not only the

p h y sical p resence o f the health care institutions, but the kind o f m frastructure

available w ith them also has an im pact on its outcom e. T he tribal societies constitute a

w eaker section o f the population constituting about 1.14 percent o f the total

population o f the state, T he tribal com m unities o f K erala are com ing u n d er the

different econom ic categories such as food gatherers, agricultural and daily w age

w orkers, and settled agriculturists. T heir heterogeneous nature o f culture m ade them

to b e aw ay from availing the m o d em m edicinal practices introduced in the land.

T ribal regions as it is aw ay from the m ain stream o f a society and situating in the hilly

and other ethnical areas are alw ays facing the absence o f the m odem m edical health,

care system . Even though the C entral and state governm ents adopted varied m atters

for th eir uplifting, m atters did not reach in the roots o f the sections due to greediness

and presence o f m ediators. T he com m unication disparities, taboos and such other

troubles played a crucial role in doing aw ay w ith innovative m easures o f the

govem m ent. Y et, the governm ents are trying to introduce health care institution in

the tribal areas. N ot only the introduction o f institutions but also the infrastm cture

w as ano th er question. S om etim es the doctors and other responsible persons w ere not

ready to go to such rem ote areas. T he lack o f transportation prevents them and the

tribes to get in touch w ith each other. T hey as a custom continued the system s they

follow ed created som e far o r m ore problem s as the situation w ere changing as a result

o f the new policies introduced by the various govt. In the form er days the tribal
com m unities com pletely depended the forests for their livelihood. H unting, trapping

o f b irds and anim als for food procurem ent w as alm ost com pletely stopped and

im posed certain restrictions upon them for using the forest. B ut in course o f tim e this

original inhabitants lost their hom e land, food, m edicine, and it forced them to place
them selves in the w orst situation o f their life. T he census reports from 1951 to 2001

show s a decline in population o f the tribal com m unities. T he shortage o f traditional

resources generated a condition to accept the other econom ic activities o f agricultural

labour under the non-tribal groups. These circum stances along w ith the introduction

o f public w elfare m easures by the dem ocratic govenm ients drag them to get in touch

w ith the m o d em instrum ents o f life such as education and schooling etc. Introduction

o f various governm ent policies tem pted them to get the support o f the public health

adm inistration. K erala has the highest coverage o f private dom estic latrines in India.

In the n inth plan about 300 G ram a P anchayats gave top priority to sanitation and

achieved the goal o f m ore than 95 % coverage o f the fam ily unit sanitary latrines.

D uring the ninth plan about 4.32 lakh sanitary latrines w ere constructed under

decentralized plan cam paign, w hich w as achieved through different G overnm ent

program m es.

W ith the introduction o f the m o d em m edical treatm ents and practices, the land

got close connection w ith the advancem ents w hich w ere occurred in the other

d eveloped areas o f the w orld. T he introduction o f different types o f m easures like

vaccination, sanitation etc. paved K erala to achieve the goals envisaged b y the

international as w ell as national agencies. In addition to the introduction o f m odem

item s o f m edical practices the national and state governm ents w ere ready to

incorporate indigenous system s o f m edicines w ith m odem m edicines. A s the

influence o f the m o d em m edicine the traditional form s o f m edicine in India firstly lost

its priority. B ut 80 percent o f the total population o f the w orld itself residing in the

vast rural areas o f the developing and under developed countries still follow ing

traditional m edicine for easy curing diseases. T he W H O established the T raditional

M edicine P rogram m e in 1977 stresses the need for the governm ent to give adequate

support to traditional m edical practitioners.'^^ The W H O is aw are that m any elem ents

o f traditional m edicines are beneficial, but others are not. In this respect, it encourages

and supports countries to identify and provide safe and effective rem edies and

practices for use in the public and private health services. T he W orld H ealth

O rg anisatio n studied about it and noticed in 2002 that around one m illion village

b ased com m unity are supporting the traditional healers in India. T hus the historical,

sociological and epistem ological evidence have led to conclude the healing traditions

have sym biotic relationship w ith A yurveda, Siddha and U m m i system s o f India.
T hus Indian system s o f m edicine and H om eopathy D epartm ent w as created in 1995

M arch w as re-nam ed as the D epartm ent o f A Y U SH in N ovem ber 2 0 0 3 .’^^ T he

D epartm ent o f A yurveda, Yoga and N aturopathy, U nani, Siddha and H om eopathy

becam e a p art o f the M inistry o f H ealth and F am ily W elfare o f the Govt, o f India.

T he m ain purpose o f the departm ent is to provide focussed attention to the

d evelopm ent o f education and research in A yurveda. Yoga and N am ropathy, Unani.

Siddha and H om eopathy system s. T he departm ent is changed w ith upholding the

objectives to upgrade educational standards in the Indian system s o f m edicines and

H om eopathy colleges in the country, to strengthening existing research institutions

and ensure tim e bound research program m e on identified diseases for w hich these

system s have an efficient treatm ent, to draw up schem es for prom oting the cultivation

and regeneration o f m edicinal plants, used in these system s . and to evolve a w orking

on pharm acopoeia standard for Indian system s o f m edicine and hom eopathy, T he

m ain bodies und er the A Y U S H are; to establish C entral R esearch C ouncils in

A yurvedic Sciences, in U nani M edicine, in H om eopathy, in Y oga and N aturopathy

and in Siddha. T he research councils w ere established as autonom ous organizations

registered under the societies A ct to m itiate and guide, im prove and coordinate

scientific research in different aspects o f the system s both fundam ental and allied.

S tatutory R egulatory bodies established by the governm ent to regulate education and

p ractice- central council for Indian M edicine and C entral C ouncil for H om eopathy.

N ational institutions for teaching, research and clinical practices has to establish w ith

D rug m anufacturing unit, L aboratories, P harm acopeia com m ission, a drug quality

control cell, traditional know ledge digital library and the national m edicinal plants

boardJ^^

A yush w as a new term using to incorporating the traditional form s o f m edicine

in India, w hich initially lost its priority. B efore introducing the program m e in K erala
there w as a com bination o f the traditional and m o d em m edical practices. T here is a

p erm anent place in K erala for indigenous system s o f m edicine. In India, K erala is

single state follow s A yurveda tradition so actively. T here are a num ber o f A yurveda

centres and institutes being reported b y the G overnm ent its e lf T he people o f K erala

p refer this form o f m edicine for preventing different diseases. T hey believes that such

practices can prom ote health and longevity besides curative aspect. E ven though the
state has a policy to support the Indian system s o f m edicine, by opting support from
the political situation, it faces immii.iation from the allopathic system o f m edicine.

M odernization, com m ercialization and m aterialization o f the traditional concepts

generating negative im pact on the grow th o f A yurveda. A yurveda is m ore severe to

learn and practice also, B ut by generating a universal m anner A yurveda is trying io

get back its old tradition. H ere lies the role o f the D epartm ent o f Indian System s o f

M edicine. T he departm ent takes its best efforts for bringm g back the traditional

system s o f treatm ents in India as a w hole, especially A yurveda. T his is opening a

new epoch in this w idely acclaim ed treatm ent system s o f m edicines o f India.

A yur\'eda possess an inseparable connection w ith the health status o f Kerala.

S hortage o f raw m aterials, god practitioners, better environm ent etc. are the hurdles in

the grow th o f A yurveda. Here, G overnm ent support leading ayurv'eda practitioners

to m ake changes in the sector. T he first and forem ost attem pt to establish an

institution for A yurvedic studies was started by K aviyoor Param esw aran M oosad in

1886 at Thiruvananthapuram.'^*^ In M alabar region a w ell-know n organisation under

the nam e A rya V aidya S ainajain cam e into exi.stence in 1902.*^’ T his registered

organisation had been patronised by great personalities like V allathol, th e poet,

P unnasseri N eelakanta S harm a. the scholar and educationalist and V aliya R aja o f

N ilam bur royal fam ily and later this w as taken up b y V aidyaratnam P.S V arier

(1869-1 944), w ho started a centre for A yurvedic studies at C alicut in 1917.'^^ T he

centre w as shifted to K ottakkal, w here he started K ottakkal A rya V aidya Sala in

M alappuram in 1902 to m ake available ready - m ade A yurvedic m e d i c i n e s . T h i s

institution is now a hll-fledged m odem A yurveda college w ith postgraduate courses

and attracts patients from all over the w orld; the centre has m.echanised the production

o f m edicine by using steam and electricity. A fter independence the governm ent o f

K erala follow ed a p olicy patronising traditional m edical system s. T he governm ent

started A yurveda colleges, and hospitals in a num ber o f villages o f K erala. To ensure
the sm ooth supply o f m edicine, the governm ent o f K erala started an A yurvedic drug

p roduction centre O ushadhi at Trichur.

H om eopathy also enjoyed a long and honourable history in Kerala. “In 1928,

H om oeopathy got a suitable position through the acknow ledgem ent o f the M aharaja

o f Travancore. C uirently governm ent has a policy o f providing a hom eopathic

institution in every panchayat in the state. N ow H om oeopathic health care services are
delivered through 31 H om oeopathic H ospitals, 611 H om oeopathic D ispensaries, 348

N R H M H om oco D ispensaries and 29 dispensaries at SC /ST dom inant areas, 5

H om oeopathic m edical college hospitals, 13 dispensaries and 1 hospital under ESI

and a few m unicipal and corporation dispensaries. A lso about 4000 H om oeopathic

physicians are engaged w ith private sector.”''^ ’

A ccording the annual report o f the Indian System o f M edicine and

H om eopathy in India in the y ear 2000, there are 116 A yurveda hospitals and 716

dispensaries in Kerala, T he total bed strength in K erala is 2644. T here a re l4 , 000

registered A yurvedic practitioners and 900 drug production firm s in K e r a l a . T h e

financial o u tlays show the G overnm ent's shift tow ards the recognition and support for

the traditional system s o f m edicine (TSM ). The total sum s allocated for them w ere

Rs. 4 m illion in the F irst Five Y ear Plan. Rs. 160 m illion in the F ourth Plan, Rs. 257

m illion in the Fifth Plan and Rs. 1290.5 m illion in the Seventh Plan. T he allocation in

the N in th Plan is nearly Rs. 5000 m illion.'^^

M edical E ducation and T raining is the another sector o f the public health

adm inistration. T raining and education m ainly aim s to im parting know ledge and

aw areness on public health m atters. In d ia's first M edical school w as opened at

C alcutta on 1822.'^^ In 1826, schools w ere opened at B om bay and M adras. Such a

school w as also op ened at C alicut also. In 1835 the first M edical C ollege was also

started at C alcutta on the basis o i the recom m endations given by the G overnor
168
G eneral L ord W illiam B entic and the B ram ley-G oodeve C om m ittee T he first

M edical C ollege in South India w as started at M adras as a result o f the

recom m endation o f Dr. W illiam M ortim ar and it cam e b e to know n as the M adras

m edical C o l l e g e , A f t e r 116 years, the first M edical college o f K erala was started at

T hiruvananthapuram on 1951by Sri C hithira Thirunal M aharaja and w as inaugurated

by the P rim e m inister Sri Jaw aharlal N ehru. T he schem es under the T hird Five
Y ear Plan include training program m es, control o f com m unicable diseases, health

education, fam ily planning and other schem es providing additional facilities and

special am enities to existing institutions. A new schem e o f School health E ducation

w as im plem ented for giving training to the teachers o f the teacher training
171
institutions.
 Tliree system s o f m edicinc have separate educational and training institutes

M edical education, training, research are m ainly im plem ented through govt, co

operative and private o r self-financial sector. T eaching hospitals o f K erala are

G overnm ent M edical C ollege T hiruvananthapuram , T.D. M edical C ollege

A lappuzha, G overnm ent M edical C ollege, K ottayam . G overnm ent M edical C ollege

T h n ssu r, G oven m iem M edical C ollege, K ozhikode. G overnm ent D ental C ollege

T hiruvananthapuram , G overnm ent D ental C ollege, K ottayam and G overnm ent D ental

C ollege, K ozhikode.

T h e follow ing are the T eaching hospitals im parting m edical education in three

different sections under the G ovt, sector. G overnm ent M edical C ollege

T hiruvananthapuram , T.D . M edical C ollege, A lappuzha, G overnm ent M edical

C ollege, K ottayam , G overnm ent M edical C ollege, T hrissur, G overnm ent M edical

C ollege, K ozhikode, G overnm ent D ental C ollege, T hiruvananthapuram , G overnm ent

D ental C ollege, K ottayam , G overnm ent D ental C ollege, K ozhikode are the allopathic

m edical institutions. Total A yurveda institutions under the Govt, secto r are

G overnm ent A yurveda C ollege, Trivandrum . G overnm ent A yurveda C ollege,

T hrippoonithura and G overnm ent A yurveda C ollege, K annur.’^^Total H om eopathic

institutions are G ovt. H om eopathic m edical C ollege, T rivandrum , G ovt. H om eopathic

M edical C ollege, K ozhikode. A ccording the annual report o f the Indian System o f

M edicinc and H om eopathy in India in the year 2000, there are 116 A yurveda

hospitals and 716 dispensaries in K erala. T he total bed strength in K erala is 2644.

T h ere a re l4 , 000 registered A yurvedic practitioners and 900 drug production firm s in

K e r a l a . T o t a l A yurveda institutions o f K erala are, G overnm ent A yurveda C ollege,

T rivandrum , G overnm ent A yurveda C ollege, T hnpp o o n ith u ra and G overnm ent

A y urveda C ollege, K annur. Total H om eopathic institutions o f K erala are, Govt.

H om eopathic m edical C ollege. T rivandrum and Govt. H om eopathic m edical C ollege,

K ozhikode

T he approach to institutional concern and health m anpow er developm ent has

m ostly contributed to the sole posture. K erala has an enorm ous infrastructure w hich

has outstandingly contributed to the accom plishm ent o f the contem porary health

values. A n inclination scrutiny o f the allopathic infrastructure under governm ent

sector w ould show that at the inauguration o f the first five year plan, the State had 230
institutions. It w as increased to 963 in 1981, 1249 in 1994 and 1310 in 2003. In 2003

situation further elicit that in 2003, there w ere 933 (72% ) prim ary health centers, 115

(9% ) com m unity h ealth centers, 130 (10 % ) hospitals an d 121 (9 % ) dispensaries and

other institutions including grants in aid institutions, n K erala there are 1303

institutions and 41077 beds u n d er the D irectorate o f H ealth Services; it include 136

hospitals, 929 prim ary health centres, 114 com m unity health centres, 59 dispensaries,

18 TB clicnics/cenires, 29 G rand -in -a id institutions and 18 leprosy control

clinics/units besides 5094 sub centres in 2 0 0 6 ’.'^^ O ut o f the total beds, 23665 m eans

57.6% beds are in hospitals, 7675m eans 18.7% in prim ary health centres and 4730

m eans 11.5% are in the com m unity health centres and 366 m eans 0.9% are in the

dispensaries and TB C linics.'^^T otal num ber o f G ovt. M odem M edicine Institutions

a re l2 5 0 w ith 37021 beds, the n u m ber o f G eneral H ospitals are 12 w ith 4866 beds,

D istrict H ospitals 15with 4854 beds, Specialty H ospital 19with 5740 beds, T aluk

H ospital 80w ith 9502 beds, C om m unity H ealth C entres 230w ith 6527 beds. 24X 7

P rim ary H ealth C entres 175w ith 3343 beds and Prim ary H ealth C entres 660w ith

2 18 2 b ed s.’^^ T he total num ber o f PH C is 835 w ith 5525 b e d s.’^^Other Specialty

H ospital C ategory w ise: W C H ospitals -Swith 1786 beds, M ental H ealth C entre -3

w ith I3 4 2 , T.B. centres- 3 w ith 608 b ed sX ep ro sy H ospital- 3 w ith 1916 beds and

others 2 w ith 88 beds, thus totally 19 w ith 5740 beds create the total strength o f public

hospitals from 1956 to 2006.*^^ O ther Institutions o f G ovt. H ospitals/H ealth C linics 8

w ith l 16 beds, M obile U nits/M obile C linics 170 and G overnm ent D ispensaries 23w ith

82 b ed s.'^ ' In K erala m ore than 90 percent o f the PH C 's are having ow n building,

toilet and electricity connection. B ut only 42 percent o f them are having labour room

and only 48.6 percent are having at least one bed.'^^ T he infrastructure in the public

secto r available in other stream s o f m edicine m cludes 117 ayurveda hospitals w ith

2764 beds and 747 ayurveda dispensaries. T here are three governm ent ayurveda

m edical colleges in the state. T h e infrastructure in the hom eopathic stream includes

31, hom oeo hospitals w ith bed strength o f 970 and 525 hom oeo dispensanes. B esides,
183
th ere are two hom oeo m edical colleges in the state.

In addition to the M edical education. N ursing education and param edical

courses are conducted by the governm ent. In both sector there are institutions for the

courses. N ursing education is im parted by D H S m n institutions, approved p n v ate

institutions, m edical colleges and nursing colleges in the self-fm ancing sector.*®"^
T here are 15 governm ent nursing schools under the D irectorate o f H ealth sei'vices

including a nursing school exclusively for SC /ST in K ollam

F ollow ing tables show the different types o f m edical care institutions under

G overnm ent sector o f K erala as on 2005.

T o ta l M o d e rn M cd ica l In s titu tio n s u n d e r G o v e rn m e n t S c c to r as on 2005

T able N o .6

No. o f In stitu tio n s 1250 37021

G eneral H ospitals 12 4866

D istrict H ospitals 15 4854

S pecialty H ospital 19 5740

T aluk Hospital 80 9502

C om m unity H ealth C entres 230 6527

24X 7 Prim ary H ealth C entres 175 3343

P rim ary H ealth C entres 660 2182

T otal PH C i (6+7) 835 5525

j
i ,B. C entres /C linics 17 176

O th er Institutions 19 198

S p ecialty H o sp ita ls- C a te g o ry w ise as on 2005 T able No.7

C a te g o ry No. o f H o sp ita ls No, or’ B eds

W om en and C hildren 8 1786

M ental H ealth C entre 3 1342

T.B. H ospitals 3 608

L eprosy H ospitals 3 1916

O thers 2 88

T o ta l 19 5740
O th er In stitu tions C ategory w ise as on 2005 T able No. 8

-------------------------

C ategory No. o f H ospitals N o. o f B eds

Govt. H ospitals/H ealth C linics 8 116

M obile U nits/M obile C linics 17 0

G overnm ent D ispensaries 23 82

.

S tate-w ise C lassification o f p rim ary heaith centres in India according to A verage

Population as on 2005

S tates/ U nion T erritories A verage p opulation covered

(XUU1}

A ndlira Pradesh 35287

A ssam 38059

B ihar 45095

G ujarat 29664

H aryana 36836

K arnataka 20755

Kerala 25878

M adhya Pradesh 37232

i
M aharashtra 31336

O rissa 24405 1
1
Punjab 33257

R ajasthan 25273

T am il N adu 25306

U ttar Pradesh 35972

W est B engal 49232

India 31954
 All these tables show that the num ber o f different types o f m edical care

institutions o f the state u n d er the governm ent sector. T he num ber o f these institutions

play a prom inent role in im parting m edical support to the entire population o f the

state. It support the state to achieve its goals in the health care sector.

In addition to the institutions describes above, D m gs C ontrol D epartm ent and

P ublic H ealth L aboratory are other two segm ents o f the public health adm inistration.

T h e D m gs C ontrol A dm inistration began to function as an independent w ing o f the

H ealth services departm ent from 1/9/1961 under the control o f the State D rugs

C on troller w ith drug inspectors as the technical assistants. '^ T h e D rugs A ct o f 1940.

D m g s and M agic R em edies (objectionable A dvertisem ent) A ct o f 1954, P oisons A ct

o f 1919 and the N arcotic Policy o f the G ovem m ent o f India stm ctured the D m gs

C ontrol D epartm ent o f K erala. Issuing licenses for the im porting, m anufacturing

and selling o f d m gs, m edicines, phaim aceutical chem icals and m achinery, and
10^
executing prosecutions regarding the section are the m ain duties o f the departmenx

Issuing licenses for the im porting, m anufacturing and selling o f dm gs, m edicines,

pharm aceutical chem icals and m achinery, and executing prosecutions regarding the
107
section are the m ain duties o f the departm ent. T he state requirem ents o f the

m an ufactured d m g s w ere form ulated w ithin the state itself and thereby the interstate

m ovem ents o f the m anufactured dm g s w ere com pletely avoided as required under the

N arcotic Policy o f the Govt, o f India. L icenses under the K erala m anufactured D m gs

R ules w ere issued by the State E xcise D epanm ent on the basis o f the

recom m endations from the D m gs C ontrol D e p a r t m e n t . w a s in 1959 that the D m gs

and C osm etics A ct w as am ended to include dm g s derived from traditional Indian

m edicine. T he A yurvedic P harm acopoeia C om m ittee w as set up to prepare

p h arm acopoeia for A yurvedic dm gs. In 1993, an expert com m ittee developed

g uidelines for the safety and efficacy o f herbal m edicines, w hich w ere incorporated in

the D m g s and C osm etics A ct and R ules. A dm g is treated as a classical preparation if

p repared as p er any o f the classical texts o f A yurveda w hich are m entioned in

Schedule 1 o f the D m gs and C osm etics A ct, 1940.’’^^ T he Public health L aboratory in

T ravancore opened in 1938 by com bining the B acteriological laboratory under the

M edical D epartm ent, the vaccine depot o f the sanitary departm ent, the chem ical
ex a m in e r's Laborator> directly under the governm ent and the hookw om i laDoratory

un der the control o f a S u p en n ten d en t and he had to control the w orks o f the

B acteriological and Pathological sections. R esearch. E ntom ological L aboratory,

Public A n a ly st's Section. C hem ical E x am in er's section, etc.'*^^

T he B acteriological Laboraicr>' w hich w as under the M edical D epartm ent

becam e the Public H ealth L aboratory. T he M edical E ntom ology D epartm ent w as

started on the basis o f the M edical E ntom ologist o f the C alcutta School o f Tropical

M edicine on 14’^ O ctober 1931.'^^ T he D epartm ent o f G ovt. A n aly st’s L aboratory

w as new ly form ed in D ecem ber 1957, com bining the laboratories o f the Public

A n alyst and the W ater analyst w hich w ere till then attached to the public health

laboratory under the adm inistrative control o f the D irector o f H ealth Services and

called Govt. A n a ly st's laboratory. T his D epartm ent consisted o f three sections based
198
on analysis o f w ater, food, and drugs respectively,

T he public expenditure on health care is an im portant determ inant o f health effect.

In India health is the jo b o f the State governm ents and therefore the budgets'

allocations o f each State include the allocation to health sector program m es. B esides

this State governm ents also receive support from central governm ent through

centrally sponsored program m es and various national program m es. In India the

governm ent budget allocations to health sector w ould reflect m ore o f supply side

factors than dem and side. K erala and Punjab are the two states giving am ple

im portance to the health care sector, T he K erala governm ent spends fairly substantial

am ount on m edical health com pared to other Indian states, w hich is evident from the

per capita governm ent health ex p en d itu re.’^^ It w as largely through the state

initiatives, the state could augm ent the point o f hum an developm ent, w hich was

already attained at the prelim inary stages. K erala has allocated large portions o f its

m eans to h ealth and education.

W hen discussing about the public health adm inistration o f K erala it m ust to

analyze the contributions rendered by the tlve year plans to the particular sector. T he

FY P played a vital role in the advancem ents o f all sections o f life o f the state. Yet,

the contributions o f the FY P to the public health sector is notew orthy. T he first two

Five Y ear Plans co n tn b u ted to the essential physical fram ew ork o f the public health

care s y s te m '^ . U rban areas alw ays m ajor share o f the resources w hile the rural areas
reccive special attention under the com m unity developm ent program m e. T he third

Five Y ear Plan launched in 1961 tried to find out a solution to the issues upsetting

condition o f PHCs. It gave thorough consideration to the ‘shortage o f health

em ployees, delays occurrm g m the construction o f phcs, buildings and sta ff quarters

and inadequate trainm g facilities for the different categ o n es o f s ta ff required m the

rural a r e a s . T h e F ourth Five Y ear Plan w as form ulated w ith a view to giving equal

m iportance to people reflecting social stigm a, but it d id n ’t get m uch acceptability.

T he plan m ainly focused on the fact thai populadon grow th is the m ain problem as far

as India is concerned. D uring this p lan period H ousing and R egional developm ent

section got the privilege to take care o f w ater supply and sanitation. T hose w ere

separated and allocations w ere m ade separately under this s e c t i o n . T h e Fifth Five

Y ear Plan involved in the im portant issues o f going dow n o f ‘infant m ortality rale,

going up life expectancy, the num ber o f m edical institution, functionaries, beds,

health facilities etc, gave m ore em phasis to the rural sector.'^®‘*In the m iddle o f the

fifth plan fam ily planning got m uch m ore im portance as an influence o f the state

interference in 1975.^^''^ It w as passed through the period o f national em ergency. The

‘A lm a A ta declaration o f H ealth for A ll by 2000 A .D and the IC S SR -IC M R report

d eeply influenced the Sixth Plan o f I n d i a . T h e plan assessed about the serious

d issatisfaction o f the existing m odel o f m edical and health services o f the nation as a

w hole. So the plan decided to give im portance and em phasis on the m aintenance o f

hospitals, by introducing and m aking them specialized and super specialized centres

o f treatm ent w ith highly trained doctors for the w eaker and better sections o f the

society a l i k e . T h e sixth an d seventh plans tried to get a success in “the plan

d epends crucially on the efficiency, quality and texture o f im plem entation. A greater

em phasis in the d irection o f com petitive ability, reduced cost and greater m obility and

flexibility in the developm ent o f investibie resources in the private sector”^®^’^^^ w as

given. In 1983, the N ational H ealth P olicy w as inaugurated and the governm ent tried

to give general broad prim ary health care services, to the genuine needs and prim acies

o f the com m unity. T hus the govt, began to open PH C s for on an average o f 30000
p er population and one sub centre for the population o f 5000.^*® But, the eight plan

suffered from the insufficiency o f m oney to spend. O f course this w as the period on

the verge o f the privatization and the idea o f health for all by 2000 w as changes and
211
em phasized the new m otto that health for the underprivileged. T he ninth plan
filled w ith num ber o f innovative ideas and w ished to recollect the ideals forw arded by

the B hore C om m ittee as it realized the reality that even the ideas forw arded in the

1940s had not b een achieved yet. T he nm th Plan proposed to strengthen the detection

and rapid containm ent o f any outbreaks from the district level.^’^ T he ideas set up by

the ninth plan w as m arvelous. B ut. the M inistry o f H ealth w as in a position to

restructure the H ealth policy and as a result the health policy o f 1983 w as restricted,

on the recom m endation in connection w ith the fam ily planning. L ater a new national

p o p u lation policy w as announced."'^ in 2001, the lO'^ plan drafted the national health

policy and it announced to collect the feedback from the people about the p n m ary

h ealth care m easures in India. AnotJier m ove from this plan w as it lauded to regulate

and strengthen the private sector through statutory licensing and m onitoring o f

m inim um standards by creating regulatory mechanism"'"*

C o n clu sio n

T he public health adm inistration after the state form ation w as a m ere

continuation o f the policies adopted by the colonial governm ents. B efore the state

form ation, the land becam e a part o f the national policies on health. It had to follow

and fulfill the ideas set on by the international agencies through the national agencies.

T he co nstim tio n supported the developm ent o f public health adm inistration o f stales

o f India by adopting cardinal and strong policies from its side. A part, the five year

plans and other national program m es supported financially to achieve the goals. In

addition to the financial support, the state played an active role in the em ancipation

and practice o f different strategies introauced by the national governm ent. It

su pported K erala, to achieve high status in different health related affairs. A s a result

o f the policies adopted in different areas K erala w as able to overcom e the problem s

faced. As a result o f vaccination program m es all o f the new b o m babies except three

or four percentage o f the total population got vaccinated. It reduced m easles and

oth er infectious diseases. Sm all pox, one o f the serious issues caused to a num ber o f

deaths is has been com pletely eradicated. Situations leading to occurring different

diseases w ere abolished through the introduction o f health education and aw areness

program m es. T he policies o f the socialist m ode o f presentation in all spheres o f

adm inistration also supported the grow th of K erala on her public health
adm inistration. V arious non- govem inentai agencies and others also supported the

w ave o f K erala on h er health affairs.

 E fid N otes

B ipan C handra, (et.al), India Since Independence 1947-2000X N ew D elhi'

P enguin India. 2008),p. 11

w w w .veryw ellhealth.com /’p n m ary -seco n d ary , 28 A ugust, 2018.

Dr. P. K. lyenkar (ed.). Science f o r Health, state C om m ittee on Science.

T echnology a n d E nvironm ent, V .C .V elayudhan Pillai, P resent Status H ealth

Infrastructure in K erala, (C alicut: C alicut U niversity Press, 2007), p .64

Ib id

Ibid.

Pro Salute, N pvi M undi: H istoria d e la O rganizacion P anam ericana d e la

Sahid, (W ashington DC: 1992)

http://w w w .ncbi.m lm .nih.gov/articles/P M C 147G 434.

Ib id

Ibid.

R. K. Patel, H ealth status a n d P rogram m es in India, (N ew Delhi: N ew

C entury P ublications, 2015), p p .20-21.

10
gm ch,gov.irv'e-study/e lectures/C om m unity M edicine, 28 A ugust 2018.

Ib id

12 B hore C om m ittee Report. Vol.II.. (N ew Delhi: M anager o f Publications,

1946), p .!7 ,

com m unityhealth.in/~ com m un26/w iki/index.php?title= H ealth.. 26 A ugust,

2018.

14
Ib id

15
Ravi D uggal, H ealth P la n n in g in India- India H ealth - A R eference D ocum ent,

(Pune: R ashta D eepika Ltd. 2002), p. 10.

16
M ukherjee C om m ittee Report, (New' Delhi: M oH FW , 1968).
 com m unityheallh.in/''C om m un26/w iki/index.php?title= H eaIth., op. cit.,

\vw w ,nlip.gov.in/jungaIw alIa-com m ittee-l 967_pg, 28 A ugust,2018.

Ibid.

en.w ikipedia.org/w iki/A uxiliary_nurse_m idw ife, 28 A ugust 2018.

Ibid

2i
R avi D uggal, op. cit., p .l3 .

Ibid.

23
http.V/ww"^’.n ih fw .o rg / R eports O fN C C .a sp x.

:4
R avi D uggai, op. cit., p.31.

25
A dm inistra tive report 1957-58, (T hiruvananthapuram : Govt, o f K erala, 1959),

p.196.

26
PG K Panikar. C R Som an, op cit., p.46.

27
A dm inistrative report 1957-58. op. cit.

28
Ib id

29
Ib id

30
A dm inistra tive R eports o f K erala 1957-58, op. cit., p .198.

31
Ibid.

32
http://\\'v,M\ ncdc.gov. in.

33
Ib id

34
Ib id

35
Ib id

36
Ib id

37
Ib id
 M ichel Foucault. P o w er a n d K nowledge^ S elected Interview s a n d other

w ritings 1972-1979. The P olitics o f H ealth in the eighteenth century, C olin

G ordon (ed.), (N ew York; P antheon Books, i 980), pp. 175-176.

39
R ichard. W .F ranke, B arbara.H .C hasin, K erala D evelopm ent through R adical

R eform , (S an Francisco; Institute for Food and D evelopm ent Policy, N ew

D elhi; Prom illa and Co. Publishers. 1992), p.63-65.

40
A dm in istra tive R eports o f K erala 1958-59, op. cit., p. 166.

41
Ibid.

42
Ibid, p .l6 8 -

43
kerala.gov.in/health-fam ily-w elfare. 25 A ugust, 2018.

44
Ibid., A d m inistration Report, 1978-79. p. 178.,

dhs.kerala.gov.in/index.php/schem es-a-program m es?tm pl., 28,A ugust,2018.

45
Ib id

46
Ibid.

47
w w w .isical.ac.in/~ w em p/P apers/P aperN ilanjanP atra.pdf, 25 A ugust, 2018.

48
A dm inistration R ep o rt1985-86. op. cit.. p p .194-200.

49
Ibid., k erala.gov.in/health-fam ily-w elfare, 28 A ugust,2018.,

dhs.kerala.gov.in/index,php/schem es-a-program m es?tm pl 28 A ugust 2018.

50
http s://w w w .roam bee.com /, 25 A ugust, 2018.

5i
k erala.gov.in/health-fam ily-w elfare, op. cit.

52
A d m in istrative R eports o f K erala 1965-66 op. cit., p p .206-207.

w w w .isical.ac.in/~-w em p/Papers/P aperN ilanjanPatra.pdf, op. cit.

54
A dm inistrative R eports o f K erala 1965-66 op. cit.

55
k erala.gov.in/health-fam ily-w elfare, op. cit.

56
A d m in istra tive R eports o f K erala 1975-76. op. cit., p .93.
58
A dm inistra tive R eports o f K erala 1977-78, op. n Y .,p .l2 1 .

59
kerala.gov.in/health-fam ily-w elfare, op. cit.

60
A d m inistrative R eports o f K erala 1983-84, op a7., p p .174-178.

61
kerala.g ov.in/health-fam ily-w elfare, op. cit.

62
Ib id

63
A dm inistra tive R eports o f K erala 1994-95, op. cit., p p .210-221.

64
kerala.go v .in/health-fam ily-w elfare, op. cit.

^Ubid
66
Ib id

67
Ib id

A dm inistrative R eports of K erala fro m 1951-2007.op.cit.

dhs.kerala.g o v.in/index.php/schem es-a-program m es?tm pl, op. cit.

6Q
kerala.go v .in/health-fam ily-w elfare, op. cit.

70
Ib id

71
Ibid.

72
Ib id

73
Ib id

74
Ib id

75
Ibid.

76
Ibid.

77
Ibid.

78
A d m in istrative R eports o f K erala 1994-95, op. cit., p. 137.
 kcrala.gov.in/health-fam ily-w clfare, op cit.

dhs.kerala.gov.in/index.php/schcm es-a-progranim es?tm pl, op. cit.

Ibid.

Ibid

A dm inistrative R eports of K erala 1959-60. op cit.. p p .125-126.

kerala.go v .in/health-fam ily-w elfare, op. cit.

d h s.k erala.gov.in/index.php/schem es-a-program m es?tm pl, op. cit.

83
Ibid.

84
Ib id

85
Ibid.. '

86
Ibid.

87
I b id .,.

88
Ib id

S9
Ibid.

90
Ib id

91
Ib id

92
Ibid.. >

93
Ibid.

94
kerala

95
Ibid.

96
Ib id

97
Ibid

98
Ibid. A

99
Ib id
1 (K )
H a ndb o ok o f P u b lic H ealth departm ent 1994-96, (T hiruvananthapuram :

Public H ealth D epartm ent o f K erala. 1996),

Ibid, kerala.gov.in/health-fam ily-w elfare, op. cit.

Ib id

103

104
A dm in istra tive R eport o f K erala 1970-71, op. cit., p p .147-162.

105
k erala.gov .in/health-fam ily-w elfare, op. cit.

106
A d m inistra tive R eport o f K c r a h 1997-98, op. cit., p p .178-196.

107
kera la.g o v.in/health-fam ily-w eifare, op. cit.

!08
Ibid., A d m inistrative R eport o f K erala 1975-76, op. cit., p .93.

IQi)
Ibid.

HO
A d m inistrative R eport o f K erala 1988-89. op. cit., pp.204-218.

A d m inistrative R eport o f K erala 1989-90, op cit.. pp. 212-227.

A d m inistrative R eport o f K erala 1990-91, op. cit., p p .197-212.

A dm in istrative R eport o f K erala 1991- 92, op. cit., pp.206-238.

M ahendra K.. Prem i. P opulation o f India.- In the new m illennium : C ensus

2 0 0 L (N ew Delhi: N ational B ook T rust India. 2006), p p .37-41.

kerala.gov.in/health-fam ily-w elfare, op.cit.

!12
Ib id

113
Ib id

;14
Ibid, p.45.

115
Ibid.

116
;19
Ibid.

120
Ibid.

i:i
Ibid.. planningcom m ission.nlc.in/plans/pianrel/fiveyr/9th/vol2/...28 M arch

2018,.

Ib id

123
Ib id

124
Ib id

125
Ibid.

126
h ttp s://k erala.gov.in/health-fam ily-w elfare, op. cit.

C ensus o f India, various years, (N ew Delhi: O ffice o f the R egistrar G eneral

and C ensus C om m issioner India).

128
F am ily W elfare Year B o o k 1992-93, (T hiruvananthapuram : G overnm ent o f

K erala, 1993).

129
F am ily w elfare B ook, 1995-96. op. cit.. 1996.

130
Ibid, https://kerala.gov.in-1iealth-fam ily-w elfare, op, cit.,

planningcom m ission.nic.in/plans/planrel/fiveyr/9th/vol2/. Op. cit.

131
Ib id

!3 2
K .P.K annan, K .R .T hankappan„V .R am an K utty and K .P.A ravindan, H ealth

a n d developm ent in R u ra l K e ra h ,{ T hiruvananthapuram : Integrated R ural

T echnology C entre o f the K erala Sastra Sahithya Parishad, 1991), pp.4-11.,

h ttp s://kerala.gov.in/health-fam ily-w elfare, op. cit.

133
Ib id

134
Ibid. p p .8 1 -9 1 .

135
Ib id
 C ensus R eports o f India fr o m 1961-2011, (O ffice o f the R egistrar G eneral and

C ensus C om m issioner India. M inistry o f H om e A ffairs. G overnm ent o f India).

138
Ibid.

139
Ibid.

140
Ibid,

141
https://kerala.gov.in/health-fam iiy-w elfare, op. cit

142
Ibid.

143
Ibid.

i4 4
A d m inistration R ep o rt 1993-94. op. cit., pp, 198-206.

145
H a ndb o ok o f P ublic H ealth D epartm ent, (Thiruvananthapuram : D epartm ent o f

Public H ealth. 1994).

146
Ib id

147
Ib id

148
Ib id

14<? E con o m ic Sur\>ey India: 2002-03, (N ew D elhi; M in istry o f F inance E conom ic

D ivision, G overnm ent o f India, 2004), p p .480.512

150
A d m in istrative R eports o f K erala 1957-58, op. cit., p .205.

151
A d m in istrative R eports o f K erala, 1958-59, op. cit., p .170.

152
R ichard. W .F ranke, B arbara.H .C hasin, op. cit., p.63.

153
Ibid.

154
G .R .K rishnam urthy, A w adesh K um ar Singh and S hailendra K um ar Bajpai,

Indian: H ealth Scenario perspectives a n d dim ensions, (N ew D elhi: Serials

Publications, 2008), p. 111.

155
https:/^^■^\^v/ncbi.nlm.nih.gov/pmc/articles/P^^C1470434.

http://\vhqlibdoc. w ho.int/hq/2002/\vho_edm _trm _2002.1.pdf.

157
h ttp:/india nm edicine.nic.in/

158
Ibid,

159
Ibid.

160
N .V .K rishnankutty V arrier, op. cit.., 2009, p .323.

161
Ibid.

162
Ibid, p.324-

163
Ibid.

164
w w w .scribd .com /.../H eallh-P olicy-K erala-2013. 25 August, 2018.

165
D eparim eni o f ISM & H om oeopathy, Indian System s o f M edicine and

H om oeopathy in India, (N ew D elhi: M inistry o f H ealth and F am ily W elfare.

1998), p.358.

166
T. G opinathan, People's Plan and D evelopm ent o f A yurveda (M aL),

{Bangalore: A ptha, A pril-M ay, 1998), p.41.

167
Dr. K. M adhavan K utty, Vaidycividyabhyasam, T. N. Jayachandran (C .E d),

K eralam , 2000 (m al) (T hiruvanthapuram : K erala L anguage Institute, 2000),

p.513.

Ib id

169
lb id ,p .5 \A .

170
Ibid, pp513-514.

171
A dm inistra tive R eport o f 1964-65, op. c/7., pp. 199-200.

172
en.w ikipedia.org/w iki/G ovem m ent_M edical_C ollege., 26 A ugust 2018.

173
Ib id

174
Ibid.

175
Ibid

176
Ibid., w w w .scrib d .co m /.../1 9 il 15811/K erala-H ealth-Policy, 26 A u g u s t2018.
 A dm inistration R ep o rt of K erala fro m 1956-2006, op. cit.

w w w .scrib d .co m /..y i9 1 1 1 5 8 1 1/K erala-H ealth-Policy

H andbook o f P ublic H ealth D epartm ent, (T hiruvananthapuram ; D epartm ent o f

H ealth services, G ovt of K erala, 2006).,

W W W . scn b d ,co rn /.../1 9 1 115811/K eraJa-H ealth-Poiicy

;7g
Ibid.

180
Ibid.

18!
Ibid.

182
Ib id

183
Ibid.. A dm inistration R eport o f K erala2006, op. cit., p p .248-262.

184
Ib id

185
Ibid.

w w w .scribd.com /.../H ealth-P olicy-K erala-2013, op- cit.

Ibid. V arious A dm inistrative Reports.

Ib id

IS^ Ibid. H andbook o f M inistry o f H ealth and Fam ily W elfare. (N ew Delhi: Govt,

o fln d ia , 2001).

IW A d m in istrative R eports o fK e ra la l9 6 1 -6 2 , op. cit., p p .133-134.

191
Ibid.

192
Ib id

193
Ib id

194
A d m inistrative R eports o f K erala 1972-73, op. czV., ppl2 2 -1 2 3

195
F easibility R ep o rt on A y u n ’edic M edicines with D etails o f G M P (C hennai:

ITC O T , 2001), pp.7-9.

196
T .K .V elu Pillai, op. cit., p p .765, 799.
19?
Ibid. p.788.

198
A d m in istrative R eport o f K erala 1957-58. op. cit., p .217.

K erala P ublic E xpenditure R eview C om m ittee F irsi R eport,

(T hiruvananthapuram : D epartm ent o f H ealth, G overnm ent o f K erala, 2006).

;oo shodhganga.inflibnet.ac.irL/'bitstreain/10603^7213/14/14., 26 A ugust 2018.

201
F ive Year P lan III, (N ew Delhi: G overnm ent o f India P lanning C om m ission,

1966), p.657. gm ch.gov.in/e-svudy/e lectures/C om m unity M edicine. 26

A u g ust 2018.

202
Ibid. pp.31-32.

203
//j/W, 398-414

20 4
F ive Year Plan V, 1974- op. cit., p. 234., gm ch.gov.in/e-study/e

lectures/C om m unity M edicine.

205
Ibid, pp.247-256.

20 6
Ibid.

207
D raft F Y P VI. Vol. Ill, 1978, op. cit.. p.250.

208
F Y P VI. 1980, xx i a n d 86. op. cit.

20<5
\\M -\v.researchgate.net/publication/265238377. op. cit.

210
Ravi, op. cit., p. 17.

211
FYP, VIII. op. cit., p.322.

212
Ibid. p.477,

213
Ibid. p p .519, 557.

2 14
R avi, op. cit.. p .23.
 C H A P T E R IV

THE DEVELOPMENT OF HEALTH SECTOR:

KERALA MODEL OF DEVELOPMENT

T h e achievem ents gained by the state in the field o f public health w ere not a

sudden one. It w as the result o f a variety o f factors like continuous efforts and

outlooks. A s discussed in the earlier chapters the efforts w ere started even before

independence. So the state got enough space and tim e to continue the process o f

dev elop m en t in health sector. T he policies adopted by the central and state

governm ents supported the public to follow the program m es once started.'

K eraia, com paratively a sm all state in the country, but attained an international

status in public health circles. It is recognized that the land and its people are

enjoying good health and life. W hen the other areas o f the nation is suffering from ill

health, m alnutrition and poverty the state achieved the status o f health care equal to

that o f the E uropean nations.^ T he m edical health care system o f the state has a

dom inating nature com pared to the other zones o f the country. It received a

w orldw ide appreciation. G enerally it is affirm ed that the state has attam ed high health

standards w ith respect to the all accepted indicators o f m aternal, m fant and child

health. T h e D evelopm ent policies introduced in K erala are extrem ely different as

com pared to the other states o f India. In 2001. P ro f A m artya Sen, the N obel Laureate

staled, “ from K erala’s experience and from objective indicators o f w hat it has

achieved in social, econom ic and political fields through education, w hich has been

spectacular, the rest o f India had m uch to l e a r n . L a u d i n g K erala’s achievem ents in

hum an developm ent, he had earlier com m ented “ K erala, despite its low m com e level

has achieved m ore than even som e o f the m ost adm ired high grow th econom ies such

as South K orea”*’

T he dem ocratic leftist governm ent elected through ballet paper had deep

concerns on society as it w as based on the concepts o f socialism and com m unism . As

the first governm ent, it drew up variety o f policies that should be adopted for the

state. It supported the state to elaborate its outlook and thereby form ing its policies in

the com ing years. In K erala political scenario, the right and left w ing governm ents
are seen alternatively assum ing power. T his in turn has a deeo im pact on the health

strategy form ation o f the state. T he proccss o f health care m easures and its im pacts

on the society has already stated, T he achievem ents in all spheres o f adm m isiration

and its im pact on society is popularly nick nam ed as the ‘K erala M odel o f

D evelopm ent ‘in general, and w hich is applicable to the public health sphere also.

K erala M odel o f D eveiopm ent

D uring 1970s, w ith the request o f the then K erala C h ief M inister C. A chutha

M enon, the C entre for D evelopm ent Studies o f T hiruvananthapuram conducted a

study on the conditions and issues o f Kerala^ T he study w as supported b y the U nited

N ations O rganisations and the study w as led by the fam ous E conom ist Dr. K. N. Raj.^

T he results o f the study and its recom m endations introduced a new term “K erala

M odel" in 1971, to specifying the achievem ents gained by the state in different fields

o f life.^ T he achievem ents w ere chiefly occurred in the fields o f land reform s,

poverty reduction, educational access and child w elfare (health) etc.

T h e m odel o f developm ent attained by K erala in all fields o f life is totally

know n as the K erala M odel o f D evelopm ent. T he achievem ents o f the sta te 's K erala

M odel D evelopm ent w as acclaim ed w orldly from 1975 onw ards. T he U nited N ation

O rganisation concluded discussions about the achievem ent.^ T he state had achieved

several im provem ents in the m aterial conditions o f life, social conditions, and

econom ic levels. T he m ajor reasons attributed were: K erala has a low p er-capita

incom e but the standard and quality o f m aterial life indicators w ere high total

population, resource redistribution program m es w ere responsible for the attainm ent o f

such a high quality o f m aterial life, high degree o f political m ovem ents and activism

prom oted the ordinary people aw are o f th eir rights and the m odes o f life. K erala

m odel developm ent has proved that, the state got achievem ents in both econom ic

g row th and hum an developm ent. A ccording to various studies, K erala achieved ten

percent grow th in G D P w hich w as tliree percent higher than the then national average.

H ealth as the fundam ental right provided K erala a chance to enhance its
conditions as proportionate to the international level. W H O has defined health as “a

com plete state o f physical, m ental and social w ell-being and not m erely the absence
o f illness or disease.” ’® K erala provided good health at low cost along w ith C hina,

C osta R ica, C uba and Sri L a n k a ." T he incredible achievem ent attained b y the state
w as through a narrow strip o f low econom ic status.'^ G ood health care m easures at

low cost including w ide spread education, land reform s, public distribution o f food

and housing etc. supported the state to achieve its lifetim e goal in the health sector.'^

K erala financial system and its developm ental success have received a global

attention. T he state has achieved such a high degree o f developm ent through different

policies and investm ents. T h e state has achieved high hum an developm ent as

com pared to other states o f India. K erala has achieved a steady grow th and success in

the h ealth care sector also.''* T he state present h erself as the best exam ple for attaining

high degree o f health standards am ong the other states o f India. Im provem ent in

health care facilities m eans the developm ent in the fields o f m edical care

infrastructure, different ratios proportionate to the goals achieved, stakeholders,

Incom e and expenditure relations etc. T he category o f m edical care and infrastrucm re

includes - n um ber o f hospitals for a particular num ber o f population, num ber o f

hospital beds in the different hospitals for the population, num ber o f w ater supply

schem es for population, housing facilities for the population etc.'^ D ifferent ratios

include the low birth rate, low infant m ortality rate, high life expectancy rate, high

fem ale sex ratio, good literacy ratio etc.'^ W hen these factors conceived together a

d eveloped health care will arise. K erala passed through all those com binations and

thereby it w as able to attain a status o f the developed nations. T he state accom plished

such a p ositio n all the w ay through the ju d icio u s m ixture o f policies introduced b y the

central and state governm ents. T he state com pletely follow ed the national visions o f

the h ealth policies and introduced certain policies o f its ow n for its requirem ents.

K erala has attained the status later as it had started the steps for the health

developm ent from the beginning o f the state form ation, o r before independence.*^

T h e goal o f ‘h ealth for all by 2000 A D ' played a cardinal role in shaping the health

sector o f K erala. T he aim w as alw ays a m otivation for the state in realizing the
derived goal. State governm ent w ith the support o f N G O s an d other socially and

politically com m itted organizations tried to accom plish the situation. For that purpose

the state w as ready to allocate a m ajor share o f its budget on health and related

program m es. T he state spent fifteen percent o f its incom e to im prove the health

co nditions o f the state from its first budget its e lf It w as continued fo r a long period.

D uring that tim e the national expenditure w as below to the state expenditure. T hat
sharing supported the governm ent sector to im prove its conditions and infrastructure.
It gave am ple support to the com m on and poorer sections o f the society to approach

the governm ent hospitals for treatm ent. In the governm ent hospitals the comm.on

people got good health care m easures at a low or free cost. In addition, the

governm ent m ade different m easures for spreading the necessity o f good health.

A s a result, the health status o f a state attam ed a position alw ays com m endable

through assessing its birth and death rates. I f a state is achieving the goal o f low birth

and h igh life expectancy it can b e assessed a positively grow ing society in the realm

o f health. A s stated in the earlier chapters, the m orbidity and m ortality rates o f K erala

is w orthw hile as far as concerned, in addition, the educational status, literacy rate in

general and fem ale literacy in p an icu lar, m ale-fem ale ratio etc. are the influential

factors. In the case o f K erala all the instances are significant. T he birth rate in the

state declined to 16.70 p er 1000 population in the period o f 2004 against the national

average o f 24.80 p er 1000.'* T he total fertility rate dim inished to 1.99w hile the

national level w as 3.30 in the period. D eath rates in the slate w ere reported as 6.3

during the period o f 2004 -2006 and nationally it w as 8 for 1000.’^ Life expectancy

and birth rate was noticed as 71 for m ale and 75 for fem ale. T he national average was

reported as 64.10 for m ale and 65.80 for female."^ In the case o f infant m ortality rate

K erala achieved the status o f 11 for 1000 children during the period o f study w hile the

national average w as reported as 60 p er 1000, A ccording to the census o f 2001, the

prop ortion o f literate is also high in K erala as other states o f India. K erala has an

average o f 90.9 percent o f literate. O n it 94.2 percen t belongs to fem ale and 87.9

p ercen t belongs to m ale.^’ A t the sam e tim e, the national average is calculated as 65.2

percen t for 1000 population, am ong this 75.6 percent is m ale and 54.0 percent is
22

T h e R o le o f W o m e n a n d th e D e v e io p m e n t o f P ubH c H eaU h S e c to r o f KeraHa

F am ily is the basic unit o f the society and the position o f w om en in a fam ily is

alw ays determ ining the life and culture o f the society. I f their position and condition

are in an adm irable level the developm ent o f the society is also adm irable. I f the

w om en are educated they took steps to im prove the conditions especially the

educational level o f their children. I f they are able to understand the healthy and

hygienic conditions they w ould definitely im part those know ledge to th eir children.

In the case o f K erala, the percentage o f educated w om en in high as com pared to the
 oilier states o f India, ll affected the health condition o f the stale. B ut the process o f

w o m en uplift o f K erala w as not a sudden one. It w as passed through different phases.

T he task and responsibility o f im proving the conditions o f w om en is

notew orthy w hen it is discussing about the gains o f public health adm inistration.

H istory o f the life o f w om en m India is a serious question even now, T here are

difference o f opinions about their lives. Som e scholars by interpreting the Sm rithis

slate that the w om en w ere not perm itted to m ake a life o f their ow n interests. B ut

others argue that they led a better life. B ut there are so m any exam ples for the good

and bad lives o f w om en in the Indian society. T he conditions o f the w om en in K erala

w ere not so good. In the w ords o f the fam ous novelist Lalitham bika A ntharjanam ,

ladies will n ever w ish to b o m in the B rahm in C om m unity agam , as against, they w ish

to be b om as dogs ten tim es again, It is she stated in h er N ational A w ard w inning

novel A gnisakshL T he situation w as not so different in the other castes also.

S om etim es it can be said that the ladies led a life w orse than that o f the so caUed

alienated com m unities in the K erala society w ithout any discrim ination o f their caste

barriers. C asteism and com m unalism w ere two evils that play as reversing forces in

the advancem ent o f w om en to the forefront, T he conditions o f 19*'’ and early 20'*^

cenm ries w ere m ore rigid and w orst. T he upper class, m iddle class including fam iers

w ere not ready to allow their ladies to jo in the labor sectors and labour forces. T he

o ff roots o f the jo in t fam ily system s also prevented the w om en from entering into the

stream o f w o rking class. C asteism and m ale chauvinism determ ined the roles a iady

has to perfom i. T hey decided the w om en should enter into m arriages, produce

children and look after the day to day affairs o f the houses. So it ca n ’t be im agine

w hat condition o f the w om en was during 19’^ and 20 centuries. C ertain com m unities

and p eo ple still con sider that w om en are only m achines to produce children and to do

household w orks. C hastity and m orality decided the conditions o f their life, the two

hurdles not to be broken by the w om en even today. False m orality and superstitions

prevent them from social m ingling and m aking them kitchen bound m echanical
instrum ents. A ccording to K .Saradam ani, who w rote about w om en and land reform s

stated that, “the shadow o f m edieval feudal custom s loom s large, still, in the form o f
false ethical duties”^^ C aste, religion and superstitions even exerting them from

engaging on econom ic m atters.

 W om en got a prom inent role and im portance m the adm inistrative reaim o f

India from the tim e o f the national m ovem ent only. E ven before that, there w ere

w om en, m the different spheres o f adm m istralion; who did not get enough space and

recognition they got after independence. T he role o f w om en leaders like Sarojini

N aidu, A runa A a sif A li, V ijayalakshm i Pandit, K asturba Bhai and Indira G andhi in

m od em tim es inspired m ale national leaders to show attention and care on the issues

o f the w om en in India. T he Indian C onstitution then considered the m atter w ith great

care and attention. So distinctive principles w ere included to reduce gender

d iscrim ination in fundam ental rights o f the C onstitution.

In the health care scenario o f K erala, w om en w ere adopted as health w orkers

nearly from 1871 w hen four obstetric nurses o f N air caste com pleted their training

and started attending obstetric m atters. From there onw ards w om en w ere enrolled to

w o rk as h ealth W orkers in m aternal and child W elfare C entres. Efforts w ere m ade

b oth in C ochin and in T ravancore to train w om en as qualified m id-w ives. D uring

1901 there w ere 32 licensed m idw ives. 6 nurses affiliated w ith the State M edical

D epartm ent and 8 fem ale vaccinators attached to the Sanitary D epartm ent in

Travancore''* From the m id o f the 20'^ century only changes m the econom ic and

social relations am ong w om en w ere started. M odem education, health and

environm ent factors helped the m ental and physical developm ent o f m en and w om en

during that p e r i o d . W o m e n are alw ays engaging actively in the m ultifarious

activities o f w ork at a tim e. Y et the notion o f that w om en are incapable o f doing

perilous w orks, they w ere engaged in the m ost lab o n o u s and sensitive jo b s w hich m en

do not care for.^^ E ven though nearly 40 percent o f the total labour force is

m aintaining by the w om en the society is not ready to accept the fact openly.^^

A fter the Intem ational C onference on P opulation and D evelopm ent held at

C airo, Egypt in S eptem ber 1994 and the Fourth W orld C onference on W om en, h eld in
B eijing in S eptem ber 1995 India tried to im prove their attention tow ards the

conditions o f w om en. B oth these conferences placed m assive im portance on w om en’s

health, em pow erm ent and reproductive rights. N ot discounting the im portance o f

health needs and h ealth status o f m en, the fact rem ains that over a lifetim e the health

o f w o m en is usually w orse than that o f m en. M oreover, certain health problem s are

m ore p revalent am ong w om en than am ong m en and certain health problem s are
unique to w om en or affecting w om en differently than men. fu rth e rm o re, som e

environm ental problem s have a disp ro p o n io n ate im pact on w om en com pared to their

m ale counterparts.

F em ale literacy and em ploym ent training facilities are high restrictions are

even im posed em ploying the hereditary social custom s. T he clutches o f feudalism , are

inclined to enjoy the benefits o f capitalism and they are concerned w ith the econom ic

utility o f w om en as m eans for extension o f w ealth and assets. A s the fam ily plarm m g

schem e is w ell accepted by the K eralites, the burden o f frequent pregnancy and allied

liabilities are no m ore a nightm are for them . The m ental and physical advancem ent

attained by the w om en o f K erala is not seen reflected in their m aterial life. T he

em pirical evidences reveal that w hile 37% m en are full tim e w orkers, the percentage

o f fem ale full tim e w orkers is ju s t 10. A m ong those w ho have registered the nam es

w ith the em ploym ent exchanges, the strength o f w om en candidates soar high. T he

case o f non-w orkers is notable. A m ong the students the strength in both the genders is

som ew hat equal; 20% boys and 25% girls. H ousehold fem ale w orkers com e to about

35% o f the total w om en population. A bout 50% am ong them seek regular

em ploym ent. T he n um ber o f w om en jo b seekers m K erala is higher than o th er states.

It com es to ab out 20.8 lakhs, as p er the report o f the D irector G eneral o f E m ploym ent

and T raining, 2003 .These statistics show the m ounting figure of fem ale

unem plo y m en t in the form al sector. Y et, w hy does it happen so? W om en in K erala

are sufficiently literate. T he burden o f pregnancy and child care are com paratively

low in the state. A long w ith the low fem ale w ork force participation in K erala, they

are seeking jo b s all over the world. T hen why don't they jo in the labour force in

K erala? T he industrial crisis affects b o th the genders. T he decline o f the agricultural

sector also affects both. T herefore, it is for other reasons that fem ales are tied tightly

to the household w ork. To trace its roots, m odem fam ily relations and the social and

econom ic stigm a that prevail in our state are to be analysed.

T he huge n um ber o f fem ale teachers in the education departm ent and their

services to educate the future citizens o f our country is quite prom ising and exciting.

It is very im portant to note that the children below three years in the B alaw adis and
28
k indergartens are cared for and nurtured by w om en all over tne world. In the

technical sector o nly m edicine and nursing could attract w om en. W om en engineers
w ere ju st a handful. T he n um ber o f w om en factory technicians w as also very sm all. In

brief, gen der based division o f labour prevailed in the technical sector. M ost o f the

technocrats are m en. A t the sam e tim e, the m edical field is crow ded w ith w om en. In

the health sector there exists further division o f labour. M ost o f the surgeons are m en

and m ost o f the gynecologists and pediatricians are w om en. W ith the increase in

N ursing Schools and M edical C olleges and also w ith dem ographic m ultiplication, the

n um ber o f fem ale nurses has m ultiplied and the care and concern o f K erala nurses is

w o ven into entire fabric o f m edical care. T he accum ulations o f foreign m oney by

K erala nurses w orking abroad enrich o u r econom y and enhance the rate o f grow o f

the G N P. M any fam ilies depend on incom e generated by this better h a lf o f hum anity.

T h e pom p, pow er and extravaganza show by their fam ilies are an index o f th e incom e

accum ulated by K erala nurses by the sw eat o f their brow.^^

In m atters o f health and education, the w om en do outshine the m en, in Kerala.

L iteracy rate o f w om en, com pared to o th er states, is far higher in K erala, T he rate o f

dropouts at school level w hen com pared to that o f b oys is very low am ong giris.

W hen com pared to boys, an equal o r even greater num ber o f girls are adm itted to the

institutions o f hig h er education. In longevity also w om en excel m en. P renatal and

postnatal d eath rate is very low as far as K erala is concerned.

V ital health statistics o f K erala and India from ) 951 to 2001 T able No,

Infant Sex Ratio

Y ear B irth R ate D eath R ate
M ortality Rate

K erala India
K erala India K erala India K erala India
Fem ale M ale

1951 44 40 18 22.8 128 146 1028 946

1961 39 41 16.11 17.6 94 129 1029 941

1971 32 37 11 15.4 61 114 1016 930

1981 26 34 34 6.6 13 34 110 1034 935

1991 18 30 6.0 10 16.5 92 1040 928

2001 17.3 26 6.6 9 11 70 1058 933

 T he table show s the condition o f the w om en in K eraia. T he above table show s

the statistical analysis o f the birth- death rates o f India as a w hole and K erala in

p articular. It also show s the rate o f Infant m ortality rate by specifying the sex ratio

also. It reveals the status o f health conditions o f the state. It is evident that all these

w ere possible through the policies adopted by the governm ents both central and stale

governm ents. T he fam ily planning program m es reduced the birth ratio o f K erala than

the national ratio. Just like that the death rate and infant m ortality rate also show a

positive sign. T hus it becam e clear that the conditions o f the w om en are the best in

K erala.

‘K e ra la M o d e l’ D e v elo p m e n t o f H e a lth a n d V u ln e ra b le S ections o f Kciralla

T he w orld renow ned K erala m odel developm ent could not m ake m uch good

results in the health and m edical conditions o f the vulnerable sections o f the society.

T hey are still living a life w ith the lim ited available resources, it creates serious

health issues am ong them . T he health status o f the m ajority o f the tribal com m unities

is still in its w orst situation. R eferences show that the situation w as not changed as it

w as in the tim e o f colonial period. T he different political parties are not interested in

the in-depth upgrading o f the tribal com m unities. T he alienated life o f the tribes in

the forests and hilly regions prevent the health care takers to reach there w ith the

inform ation and am enities for them . So the m erits and easy recovenng nature o f the

m o d em m edical system s are still inaccessible to these alienated groups.

Just like the tribal people the C oastal population also suffers from different

diseases. T h e m ain reason behind it is the lack o f safe drinking w ater and sanitation.

T hese call for long term efforts and political com m itm ent to m ake a difference

W ithin the constraints governm ent departm ents will continue to provide am eliorative

m easures to urb an population, especially persons living in slum s having no access to

p rim ary health care services. U rban sub centres and prim ary health centres have to be

reconfigured so as to provide prim ary care preventive and curative services

W hile describing the K erala M odel D evelopm ent on H ealth, fam ous

econom ists D reze and A m artya Sen argued positively that, "K erala has

C om paratively low levels o f basic gender inequality is reflected, for instance, a high

fem ale-m ale ratio. A R elatively equitable educational opportunities - indeed, near-

universal literacy, especially am ong the young can see here. E xtensive social
security arrangem ents -e.g. broad-based entitlem ents to hom estead land. old-age

p ensions and the 'public distribution system is existing in K erala. L im ited incidence

o f caste o ppression -e.g. few violent crim es against scheduled castes are noticed.

R ural-urban disparities is very low m the case o f K erala."^’

T he achievem ents the state had m ade in different w alks o f life gave h er an

im age o f a developed state w ithin a developing nation. T he achievem ents in different

fields like such as H ealth, education, social equality, political aw areness, and service

oriented sectors got considerable grow th during the early decades o f state form ation.

M ost analysts have seen K e rala's achievem ents in health as som ething o f an

enigm a. K erala‘s achievem ent in health in spile o f its econom ic backw ardness has

prom pted m any analysts to talk about a unique “K erala M odel o f H ealth” - ‘G ood

health at low c o st’, good health w ith social ju s tic e ’, worth em ulating by other

developing parts o f the world.^^ A variety o f socio-econom ic conditions unique to

K erala, m ade this health m odel possible. K erala possesses a m ore literate population

com pared to other Indian states. H igh fem ale literacy rate provided am ple space for

the social essentials. T he educational level am ong the fem ales supported the grow th

o f m o dem ideals for their fam ilies and com ing generations. E xistence o f a large

n um ber o f public health institutions w ith sub-centres and Prim ary H ealth C enters,

C om m unity H ealth C enters, Taluk / D istrict H ospitals and M edical C ollege H ospitals

at the prim ary, secondary and tertiary levels provided the com m on people a chance to

get the assistance o f universally accepted m odem m edical care.^^ T he traditional

know ledge on A yurveda, naturopathy and other altem ative system s also set aside the

m o d em m edical systems.^** T he socio -econom ic conditions and the health care

uniqueness m ade p ossible K erala to achieve the status o f better living conditions.

A ll these factors reduced the infant m ortality, child m ortality, pre natal and neonatal

m ortality and m atem ity m ortality etc.

E ven though, K erala em braced a key position in the developm ental index

am ong Indian states, there are contradictory issues and challenges to the sustainability

o f the developm ents. M ost im portant am ong the disparities are the investm ent and

industrial grow th, the foreign rem ittances, increasing inequality, increasing effects o f

co n su m er state etc. Low investm ent and industrial grow th refers to the increasing

level o f dependence on the service sector rather than the m anufacturing and
ag ricultural sector. K erala depends m ainly on the service sector and thereby

b ecom ing a consum er state in all aspects.

T oday, the state is facing the draw backs o f industrial developm ent,

unem ploym ent, stagnant environm ent to attract new business probabilities failed to

attract new investm ents. W hen com paring to developed areas o f the w orld, K erala

d o esn ’t achieved no gains like that. Kerala, possess an econom y w ithout

technologically and industrially supported. K erala is not an industrial friendly state

and cannot see large o r heavy industnal sectors in private sector. B ut the state is

presentm g exam ples o f grow th in the construction sector, travel oriented service

sector and self-em ployed business. E conom y supported from g u lf m oney,

co n struction sector and o th er service sectors, K erala achieved the status o f

developm ent. It resulted in the construction o f good/big houses, sanitation m easures

and other determ inants for the health care. E ven the state has good housing

conditions w ith m od em am enities, the gap betw een rich and poor is som etim es high

in the society. E ven now . 23 percent o f the gross dom estic product o f the state is

fulfilling from agriculture and m dustry, w hile alm ost 61 percent is deriving from the

service sector.

N ext d isp an ty is grow th o f the state w ith foreign rem ittances. T he foreign

rem ittance is as a result o f the brain drain o f the efficient and educated youth w ho are

opting jo b s abroad. T he differences in the distribution o f w ealth and incom e am ong

the people again develop a cultural and social d isp an ty am ong the people. T he

history o f the socio religious m ovem ents and the problem s faced by the older

generations w ere forgotten by the youth. Increasing levels o f incom e and other

advantages getting from outside o r from foreign countries, encouraging younger

generations to settle abroad. It reducing the levels o f connection and affection to their

native land. T hey are m ainly focusing on current issues. It will lead to the decline o f

the hard grow th earned. Just like the people w ho w ere aw ay from the m ainstream s o f

K erala m odel will again rem ain in the sam e situation i f the sustainable developm ent

will not be introduced. T he financial grow th rendering new generations to forget the

nastiest situations o f life faced by older generations. It gradually will lead to revival
o f various inequalities once rem oved. T he g u lf betw een the haves and have n o t’s are

increasing in K erala in an alarm ing condition. A gain, the disparities on colour, caste,
religion and w ealth is increasing in K erala presently. T he increasing effects o f

in equalities is a hurdle in the grow th o f the state.

A d m in istrative D ecen tralisation and P ublic H ealth Sector

D uring the 1990s K erala governm ent introduced decentralization in its

adm inistration. It w as the result o f the P ancbayati R aj am endm ent done by

G overnm ent o f India. D ecentralized planning paved the w ay for the transfer o f

adm inistration m to local self-governm ents instead o f a centralized adm inistration.

K e rala's step tow ards developm ent w as a continuous process as stated earlier. In the

field o f health another m ajor contribution w^as ensued through the introduction o f

pa n ch a yath ira j! or decentralization o f pow er and through its institutions. It

transferred all the health care institutions from the district ow ned level to the

P a ch aya ti R aj Institutions under the control o f the local, block and district levels o f

adm inistration.^^ A ll health care institutions except general hospitals, w om en and

children hospitals and specialty hospitals have been transferred to the three tier

Panchayati Raj Institutions (PR Is). K erala w as the first state in the country to initiate

adm inistrative decentralisation in an extensive w ay including that in the health sector.

T he governm ent w as ready to share up to 40 % o f the plan fund o f various sectors

including that o f health sector is being disbursed through these institutions, w hen

governm ent identified certain problem s in the sector.^^ G overnm ent level, expert

com m ittee has identified som e o f the lacunae in the health adm inistration o f the state.

T he im portant problem s identified w ere the lack o f technical support from the

departm ent and the absence o f public health perspective in planm ng, unnecessary

construction w ork etc.^^Those w ere taken place at the PH C /C H C leveis and m ost o f

the projects w ere repetitive in nature. To solve the problem s certain policies w ere

introduced. T he p olicies m.ainly focused on the field level m edical cam ps and drug

purchases. Since the state is still continuing the decentralization in health secto r it

need support from the B lock, D istn c t and State levels. O therw ise the decentralization

o f p o w er in the h ealth sector w ill not b e a successful one. A ll sectors should b ear the

responsibility o f the sector through different form s o f hum an resources and

dev elop m en t policies.

T he decentralization on public health adm inistration is still in a stage o f

childhood. T he report subm itted in 1996 is still renew ed according to the situation.*^'
O nce the public health system is reinforced the poor people w ho cannot afford to the

priv ate health services will be benefited and social equity in health care w ill be re-

established. T h e local governm ent can open a higher flow o f funds to the

im provem ent o f the health sector. T he governm ent should take necessary steps to

increase th eir salary and w orking conditions o f governm ent doctors that the young

doctors are attracted to the state ow ned health sectors.

By realizing the situations and results produced by the K erala M odel

D evelopm ent and the econom ic crisis o f 1990s generated an alternative thought o f

developm ent in the m inds o f the econom ists and adm inistrators o f the state. T h a t’s

w hy the new ideology o f the sustainable developm ent w as accepted. It aim ed to m eet

the needs o f the present w ithout com prom ising the ability o f future generations to

m eet th eir ow n n e e d s . S c h o l a r s proposed the new them e b y accepting the them e o f

K erala M odel developm ent is the prim ary stage o f the developm ental status o f the

state. T he them es included in the sustainable developm ent schem e are im proving the

quality o f life b y increasing a progressive m ode on the standard o f life by reducing the

m fant m ortality and birth rates, im proving the environm ental stability by m aking

irreversible ecological changes and frugal and efficient use o f energy and natural

resources, im proving the relative social and econom ic inequality and the im portance

arrived to social ju stic e as a prerequisite for developm ent and dim inishing the

political strife orchestrated by the establishm ent o f dem ocratic institutions, and

traditional com m unal harm ony w ould by m aintained betw een the three m ajor

religious groups.

C o n clu sio n

T he developm ents o r achievem ents occurred in the state after its form ation are

p op ularly know n in the nam e o f K eraia M odel D evelopm ent. So m any advancem ents

w ere m ade in the sector rather any state o f India can achieve. E conom ist o f different

areas w rote ab out the advancem ents m ade b y the state. A dvancem ents w ere m ainly

o ccurred in the field o f incom e distribution and social developm ents. E conom ically

the state w itnessed distribution o f w ealth in an equalized way. A s a result o f the

agrarian reform s, the land tenure system s w ere changed. N ew agricultural landlords

w ere aroused. A s a result o f that, econom ically backw ard sections got the chances to

get o pportunities o f b etter living conditions. T heir social, educational and econom ic
standards got better. B ut in the health sector K erala M odel developm ent attained a

partial gain. T he three tier system o f health care m easures, p rim ary health centres,

C om m unity health centres, T aluk or D istrict hospitals and M edical C olleges,

contributed to the g row th o f health care m easures in rural and urban areas. T he

extensive n um ber o f health and m edical care institution including that o f H om oeo and

A y u r\'ed a also supported this. T he m ortality and m orbitdity rates show s on the one

side that, the state supported all the better health indicators and health care

d ev elo pm en t m easures in term s o f IM R , M M R , B irth rate, death rate etc. A nd it

outstrips all the Indian states in term s o f m orbidity rate especially in chronic diseases.

Socially and econom ically K erala’s achievem ents can be consider as high

level achievem ents. B ut m the case o f health conditions, the achievem ents w ere

happened in the sections o f eradication o f diseases, vaccination, health education etc.

In the case o f eradication o f com m unicable diseases, policies adopted by the central

and state governm ents supported the state to eradicate the diseases such as, sm all pox,

m alaria, m easles, cholera etc. W ater generating com m unicable diseases w ere

eradicated through pro p er health aw areness program m es and other m easures.

O pportunity to use good drinking w ater also provided a step to eradicate such

situations. A s a result cases o f different diseases such as m alaria, sm all pox, cholera

etc. w ere reported few. A s a result o f the health education program m es, K erala got

A long w ith the developm ents a n um ber o f issues and problem s w ere also aroused in

the h ealth sector

 END NOTES

N. A jith K um ar, E n try B arriers to M edical E ducation in K erala, (R esearch

Project, E m akulum : C entre for S ocio-cconom ic and E nvironm enial Studies,

1997), pp.1-15,

V .R am anK utty, The K erala H ealth M odel: Time f o r re-assessm ent,

(Thiruvananthapuram : A Sym posium on K erala in T ransition, 2012), p.295.

D reze, Jean and A m artya Sen H u n g er and P ublic A ction, (O xford: C iarendon

Press, 1991), p p .967-968.

A ntony Palackal, K erala M o d e l L eg a cy a n d Paradox.

w w .academ ia.edu/4656161//;

Ibid,

Ib id

Ibid.

Ibid.

Poverty, U nem ploym ent a n d D evelopm ent P olicy, W orking paper,

(T hiruvananthapuram : C D S, 1975).
10
N ithya N. R, K era la M o d el o f H ealth C risis in the N eo-liberal Era,

ijsr.net V olum e 2 issue 8, A ugust 2013), p ,2 0 i.

V. R am an K utty, op. cit.

K oji N abae, op. cit.

13
Ibid.
14
V .R am anK utty, R eth in kin g the K erala M odel in H ealth, op. cit., p .l.
15
Ibid.
16
Ibid.
17
K oji N abae, The H ealth care system in K erala- Its p a st accom plishm ents a n d

N ew C hallenges, (Japan: N ational Institute o f Public H ealth, 2003), pp. MO­

MS.

E co n om ic R eview 2005, (Thiruvananthapuram : State Planning B oard,

G overnm ent o f K erala, 2006), pp.516-518.

19

20
Ibid.
;i
Ib id
22
/6/£/,p. 33,
23
K. Saradam oni. C hanging L a n d Relations a n d Women: A case study o f

P alghat D istrict, K erala, (N ew D elhi: C oncept Publishing H ouse, 1983),

24
L eela G ulati. {tX. 2A )G ender P rofile - L ooking B a c k into H istory, {New Delhi:

R oyal N etherlands E m bassy, 1991), p. 1-6.

25
Ib id
26
W . Frank R ichard, L ife is a B etter P lace. (C olorado: W estview Press. 1993).

p.251.
27
Ib id

L eela G ulati, op. cit

29
M aria M ies, D ynam ics o f Sexu a l D ivision o f L a b o u r a n d Women L acem akers

o fN a rsa p u r, (B om bay: E conom ic and P olitical W eekly, M arch, 1981), p p .l2 -

13.
30
Various C ensus R eports o f India, op. cii
31
D reze and Sen. India: D evelopm ent a n d P articipation, (N ew D elhi, O xford

U niversity Press. 2002), p. 99.

32
K .P.K annan, K .R .T hankappan, V .R am ankutty, K .P.A ravindakshan, H ealth

a n d D evelo p m ent in R ural K erala, (T hiruvananthapuram : Integrated R ural

T echnology C entre o f the K erala Sastra S ahithya Parishad, 1991), pp. 18-47.
33
Ibid.
34
Ib id
35
Ibid.
36
D rez and Sen, op. cit.
 S.M . V ijayanand. D ecentralisation a n d H ealth: The K erala Experience,

C .C .K artha fed.), K erala in F ifty Years a n d B eyond, (Thim vananthapuram :

G autha B ooks, 2007), p.311.

38
Ibid.
39
Ibid.
40
Ibid.
41
R .K .Patel, H ealth status a n d P rogram m es in India, {New Delhi: N ew C entury

Publication, 2015), p .55.

42
G ovindan Parayil, The K erala m o d e l' o f developm ent: developm ent a n d

sustain a bility in the T hird W orld. (Third W orld Q uarterly, Vol. 17, N o 5, N ew

Delhi: R outledge, 1996), pp. 941- 957.

43
Ib id
 CHAPTER V

KERALA HEALTH SECTOR: CHALLENGES AND PROSPECTS

K e ra la ’s ac h ie v e m e n t in h ealtii in spite o f its ec o n o m ic b ac k w ard n e ss has

p ro m p ted m an y an a ly sts to ta lk ab o u t a u n iq u e “K e rala M odel o f H e alth ” - ‘G ood

h ealth at lo w c o s t’, g o o d h ealth w ith social ju s tic e ’, w orth em u latin g by o th e r

d ev e lo p in g p arts o f th e w orld. M ost o f th e w riters, eco n o m ists, so cio lo g ists etc.

arg u e th a t K e rala M o d el o f D e v elo p m e n t w as a form o f d ev e lo p m e n t, b u t lo st its

su stain ab ility . H en ce, K e ra la is try in g to d ev e lo p a p o licy o f su stain ab le

d e v e lo p m e n t now . K e rala faces serio u s th rea ts in th e p u b lic h ealth affairs now .

T h e h ea lth o f a so ciety is alw ay s p u t in o rd e r th ro u g h v a n o u s routes. In K e ra la th e

state h a d p a sse d th ro u g h a m ix tu re o f ch a n g es in tro d u ced b efo re an d a fte r its

fo rm ation. T h o se c h a n g e s h elp ed th e sta te to a c h ie v e an am u sin g p o sitio n in the

h ea lth co n d itio n an d statu s o n th e w orld. T h e h ea lth a c h ie v em en ts w ere

co m m o n ly n ick n am ed as th e K e ra la M odel D e v elo p m e n t o f H e alth ev e n th o u g h

later it p ro v ed to be a little failure. Af^er fin ish in g th e first fifty years o f th e s ta te ’s

fo n n a tio n , th e p eo p le are su ffe rin g fro m n u m ero u s lim itatio n s an d ch a lle n g es in

th e h ea lth c a re sector. K e rala h as attain ed a c o m p arativ ely h ig h h ea lth statu s an d

h as m a d e re m a rk ab le a c h ie v em en ts in h ea lth alm o st co m p arab le to th at o f even

d e v e lo p e d co u n trie s. T h e w id e ly a c cep ted h ea lth in d icato rs lik e cru d e death, rate,

in fan t m o rtality rate, an d life e x p e ctan cy etc. ev id en c e this. M o st o f th e an a ly sis

has seen p ro v e n th at a c h ie v e m e n ts o f K e ra la in th e field o f h ea lth as so m eth in g o f

an enig m a.

C h a lle n g e s a n d P r o b le m s o f H e a lth s e c to r o f K e r a la

H e alth as a su b je c t m atter, d ep e n d in g u p o n tw o te n n s o f p riv ate liberal

m ed icin e, su b je c t to th e m ech a n ism o f in d iv id u al in itiativ e and law s o f th e m ark e t

an d a m esca l p o litic s d ra w in g su p p o rt from stru ctu re o f p o w e r a n d co n c ern in g

its e lf w ith th e h e a lth o f a c o lle c tiv ity .' F rom th e eig h tee n th c e n tu ry o n w a rd s the

p ro c e s s o f m ed ica l an d clin ical re la tio n s d e v e lo p e d in an ec o n o m ic a ffair in the

w h o le w o rld . It w as th u s a d o u b le sided p ro c e ss o f d e v e lo p m e n t o f m ed ical

m a rk e t an d ex ten sio n o f a n etw o rk o f p erso n n el co n trib u tio n . S k illed m ed ical

157
co n sid eratio n , g ro w th o f in d iv id u al and fa m ily d e m a n d fo r h e a lth care, su rfacin g

o f a scien tific m ed ica tio n stro n g ly c e n tre d on in d iv id u al ex a m in a tio n , d ia g n o sis

th era p y , b e c a m e o p e n ly m o ral an d sy stem atic d u rin g th e period.^

S oun d h ea lth b e c a m e a u n iv e rsa lly accep ted social g o al in th e 20'^ century.

‘T h e a ttain m en t o f h ea lth fo r all citizen s o f the w orld by the y e a r 2 0 0 0 o f a level

o f h ealth th a t w ill p e rm it th em to lead a so cially an d e c o n o m ic ally p ro d u c tiv e

life '', w as th e m ain g o al o f the T h irtie th W orld H ealth A ssem b ly o f 1977.^ T h e

In tern atio n al C o n fe re n c e in A lm a -A ta 1978 aim ed to ach iev e th e g o al o f H ealth

fo r A ll. T h e c o n fe re n c e th u s fo n n u la te d th e p rim ary h ea lth ca re ap p ro ach trie d to

p ro v id e p rim itiv e, p re v e n tiv e c u ra tiv e and re h ab ilitativ e services. It agam

in v o lv e d all th e h e a lth -re la te d secto rs such as ag ricu ltu re, anim al h u sb an d ry , food,

in d u stry , e d u c atio n , h o u sin g , w a te r su p p ly an d san itatio n , p u b lic w orks, etc.

P rim a iy h ea lth c a re re p resen ts an in teg ra te d ap p ro ach in v o lv in g all secto rs o f th e

sy stem . It re co g n izes th e c o n trib u tio n o f h ea lth to so cio -e co n o m ic d ev e lo p m e n t

an d th at o f o th e r secto rs to h e a lth im p ro v em en t as w ell. In d ia stan d s co m m itte d to

both.

T o d ay , h e a lth se c to r o f th e state is facm g so m e im p o rtan t ch allen g es. L ow

m o rtality rate, h ig h m o rb id ity rate, n ew d iseases, in cre asin g level o r life style

d isease s, e c o lo g ic al im b alan ce s, tln a n c ia l crisis, co m m o d itiz atio n o f health , etc.

are th e s e n o u s threatS:

E v en th o u g h th e m o rta lity is low , th e m o rb id ity ra te is h ig h in K erala.

H en ce, th e situ atio n o f K e ra la has b ee n d escrib ed as th e “ L o w M o rtality H igh

M o rb idity S y n d ro m e.’"* T h e term m o rb id ity is d eriv e d from a L atin w ord

“ m o rb id u s’* m eans sick, u n h ea lth y , has sy m p to m s o f sick n ess o r c o n d itio n o f

b ein g diseased.^ D e m o g rap h ic c h a n g e o v e r m ark s a tran sfo rm atio n fro m high

m o rtality an d h ig h fe rtility statu s to lo w m o rtality -lo w fe rtility statu s in K erala,^

T h e liv in g co n d itio n s, so cio ec o n o m ic ad v an cem en t, w o m e n em p o w erm en t, h ea lth

co n sc io u sn e ss, im p ro v ed h ea lth ca re an d u n iv ersa l access to h ealth ca re etc. in tu rn

re su lte d in lo w b irth a n d d ea th rates.

 1995 1995 2004 2004 j
D ise a se s (D e a th ) '
(A tta c k ) (D e a th ) (A tta c k )
A cu te d ia rrh o e a 700974 16 5 41439 17

W h o o p in g co u g h 1566 - 198

M easles 7026 1 4942 1

C h ick en p o x - - 14920 8

A c u te R esp irato ry 3189579 130 813H 03 216

In fectio n

P n eu m o n ia 18955 28 29475 59

E n teric fe v er 8413 6 12996 3

V iral H e p atitis A 10489 11 7433 n

W eils D isea se - 2162 97

R ab ies 149 9 I 31 31

P u lm o n ary 39241 278 20836 187

T u b ercu lo sis

A ll o th e r D iseases 11165090 4336 2 3 258663 7889

T otal 15141482 4815 32024825 8528

T h e d a ta is tak en fo r ten y ea rs w h e re th e stu d y is en d in g . T h e n e x t ra tio is

n o t availab le. In th e tab le it is e v id e n t ab o u t th e m o rb id ity ra te d u e to d iffe ren t

d iseases. T h e m o rb id ity o c c u rre n c e o f th e co m m u n icab le illn ess in K e ra la fo r a

p e rio d o f n in e y e a rs in c re a se d to a g reat fro m 154.92 p ercen t in th e ca se o f acute

re sp ira to ry in fectio n , 5 5 .4 9 p e rc e n t in ac u te re sp ira to ry in fectio n , 55.49 on

p n eu m o n ia, 5 4 .4 7 p e rc e n t o n en teric fever, 108.3 p e rc e n t in th e ca se o f all o th e r

d iseases. T h e o v erall o c c u rre n c e o f c o m m u n ic a b le illness is m o re th a n b efo re. It

is ra ise d to 111.5 p e rc e n t fo r a p e rio d o f n in e years. A t th e sam e tim e ce rtam

d ise a se s su ch as ac u te d ia rrh e a d iseases, w h o o p in g co u g h , an d m easle s re c o rd e d a

fall o f f to 2 2 .7 5 p ercen t, 87.35 p e rc e n t an d 2 9 .6 6 p e rc e n t resp ectiv ely .

 Diseases 1995 2000 2004 2006

A c u te D ia rrh e a l d ise a se s 4 6 .3 0 2 4 .3 7 16.22 15.80

M ea sle s 0.46 0.1 9 0 .0 9 0.08

C h ic k e n p o x 0.43 0.45 0.49

A c u te R e s p ira to ry In fectio n s 210.65 2 5 3 .5 7 257.25 2 2 9 .3 0

P n e u m o n ia 1.25 0 .9 0 0.67 0.47

E n teric F e v e r 0.56 0.40 0.28 0.13
V ira l H e p a titis A 0.6 9 0.21 0.21 0.19

P u lm o n a ry T u b e rc u lo sis 2.5 9 1.38 0.62 0.3 6

T h e d a ta sh o w s th a t th e m o rb id ity p a tte rn in K e ra la in c e rta in cases

sh o w in g a d ec lin e . A t th e sam e tim e ce rtain d ise a se s is sh o w in g a tren d o f

in crease. T h e K e r a la S a s th r a S a h ith y a P a r is h a d c o n d u c te d a su rv e y in 2 0 0 6 an d

c o m p a re d its re s u lts w ith th e ir stu d ies c o n d u c te d o n 1987 a n d 1996.^ A c co rd in g to

th e stu d y th e m o rb id ity ra te in 1987 w as 206.3 an d in 1996 it w a s 121.9 an d in

2 0 0 0 it w a s 79.2.'*^ It w a s as a re su lt o f th e in tro d u c tio n o f v a rio u s v a c c in a tio n

p ro je c ts a n d o th e r s a n ita tio n sy stem s in tro d u c e d d u rin g th e tim e. It also p o in ted

o u t a n o th e r c o n c lu sio n th a t th e in fec tio u s d ise a se s ca u sin g d ea th is d e c lin in g w h ile

th e d e a th s c a u se d b y c h ro n ic d ise a se s are in c re a s in g ." In th e ca se o f ch ro n ic

d ise a se s th e m o rb id ity ra te a m o n g th e a g e g ro u p o f 15 to 5 4 is v e ry h ig h .’^

T h e m o rb id ity ra te o f K e ra la in c e rta in c a se s is h ig h e r th a n th e ra te s o f

o th e r states o f In d ia. T h e case o f tu b e rc u lo sis is o n e ex a m p le . T h e rate

tu b e rc u lo sis is 5 p e r 1000 p o p u la tio n in K e ra la w h ic h is h ig h e r th a n th e states o f

T am il N a d u , K a rn a ta k a , M a h a ra sh tra , R a ja sth a n , P u n ja b a n d H a ry a n a .'^ W hile

K e ra la re p o rts 5 ca se s th e n a tio n a l re p o rt is 9 fo r lOOO.''^ T h o u g h th e ra te o f

m o rb id ity is h ig h in K e ra la , b u t th e fa ta lity ra te is lo w as c o m p a re d to th e o th e r

states.'^ T h e fre q u e n c y an d o c c u rre n c e o f m a la ria an d ja u n d ic e is lo w in K e rala

th a n o th e r p arts. A d ia rrh o e a l d isease is th e n e x t p ro b le m c re a tin g te n sio n to the

h ea lth c o n d itio n s. In th e y e a r 2 0 0 5 a b o u t 285 c a se s w e re re p o rte d as a w h o le in

th e c o u n try .'^ A m o n g th is 19.0 p e rc e n t d e a th s w e re h a p p e n e d a t A n d lira P rad e sh ,

12.79 p e rc e n t in K am atalca, 6 .1 7 p e rc e n t cases w e re re p o rte d in K e ra la .’^ B u t in

K e ra la d u rin g th a t tim e n o d ea th s w ere re p o rted .'^

A n o th e r issu e s a re th e p ro b le m s o f a n a e m ia an d o b esity . T a m iln a d u carries

th e first p o sitio n in th e issu e in all o v e r India. It is c a lc u la te d in th e p e rio d o f

ce n su s p e rio d o f 2001 T a m iln a d u rep o rted th e ca se s o f 3.5 p e rc e n t o f acute

a n a e m ia w h ile K e ra la re p o rte d th e lo w e st w ith 0.5 p e rc e n t.'^ In th e case o f

m o d e ra te a n a e m ia , A ss a m p lace s th e first p o s itio n w ith 2 5 .6 p e rc e n t an d K erala

h as th e lo w e s t ra te o f 2 .7 percent.^^O n o n e sid e th e c o u n try is su ffe rin g from

p o v e rty , m a ln u tritio n a n d an a em ia. A t th e sam e tim e a n o th e r g ro u p o f p o p u la tio n

is su ffe rin g fro m th e p ro b le m o f o b esity . G e n e ra lly o b e sity is a re su lt o f ex cess

fo o d an d n u tritio n . In d ire c tly it h as a k illin g asp e ct. P u n ja b a n d K e ra la sh o w th e

in d ic a tio n s o f o b e sity h ig h ly .^' O b e sity re p o rte d am o n g w o m e n is 2 4 p e rc e n t in

K e ra la w h ic h is n e x t to P u n ja b , w h e re it is re p o rte d as 4 0 p e r c e n t . T h e n atio n al

av e ra g e o f o b e sity is re p o rte d as 12.8 percent.^^ T h e p ro b le m s o f a n a e m ia and

o b e sity a lw a y s re la tin g to th e o c c u rre n c e o f v a rio u s c h ro n ic d ise a se s. M o st o f the

ch ro n ic d ise a se s are o c c u rrin g as a re su lt o f v a rio u s life sty les.

Frequency of chronic diseases in Kerala till 2006 Table No. 13

Diseases Kerala India

H y p e rte n sio n 1433 589

D iab e te s 980 221

H e a rt D ise a se s 914 385

M e n ta l D ise a se s 283 132

T h e ta b le c o n v e y s th e freq u en c y o f c h ro n ic d is e a s e s till 2 0 0 6 . S tudies

re v e a l th a t th e c h ro n ic d ise a se s su ch as h y p erte n sio n , d ia b e te s, c a n c e r etc. are h ig h

as c o m p a re d to th e n a tio n a l lev el. T h e b u rd e n o f c o m m u n ic a b le d ise a se s an d the

ch ro n ic d is e a se s a ffe c tin g th e h e a lth c o n d itio n o f th e state. T h e cliro n ic d iseases

are h a p p e n in g d u e to th e lifesty le an d p attern o f life th e peoDie fo llo w in g . It’s a

s o cially d efin e d fa c to r fo r m o rb id ity .

A n o th e r m a jo r issu e ca n b e asse sse d fro m th e d em o g ra p h ic e x p e rie n c e is

in cre asin g p ro p o rtio n ra te o f aged g ro u p in th e p o p u latio n . T h e U n ite d N a tio n s

O rg a n isatio n h as tak en th e a g e o f 60 as the d iv id in g lin e b etw e en o id a g e an d

m id d le an d y o u n g e r ag e g ro u p s an d th e p o p u latio n as ag e in g w h e n th e p ro p o rtio n

o f eld erly re a c h e s sev en p e rc e n t o f total population.*^ D u rin g 1981-91 th e g en e ral

p o p u la tio n g ro w th rate w as 1.39 p e rc e n t an d th e g ro w th ra te o f th e aged

p o p u la tio n fo r th e p a rtic u la r p e rio d w as 3.36percent.^^ T h e in cre ased life

e x p e ctan cy re su lts in tro u b le s an d w e ak en in g o f o ld age. T h is is a s a se n o u s

so cial an d p u b lic h ea lth q u estio n , even in th e slo w ly d ev e lo p in g re g io n s o f th e

w o rld. In th e u rb a n iz ed n atio n s, ex p e rim en ts w ere siarted an d n u m ero u s

p ro g ra m m e s h av e b ee n im p le m e n te d for th e w elfare o f th e aged p eo p le, m o stly in

th e h ea lth c a re co n d itio n . In K e rala also, som e w e lfa re m easu res h av e b ee n tak en

by th e g o v ern m e n t an d p riv a te o rg a n isa tio n s fo r th e aged. T h e state g o v e rn m e n t

in tro d u ce d a n ew p o lic y fo r th e o ld aged p erso n s in 2008 b y an a ly z in g th e issues

th e y are facin g. T h is p o lic y aim s to p ro v id e th e fee h elpful an d su itab le health

c a re to th e eld erly people.^^ E v en th o u g h th e state h a d ac h ie v ed tre m e n d o u s an d

re m a rk a b le a c h ie v em en ts in th e d e v e lo p m e n t se c to r th e re are d iffe re n t issu es in

c o n n e c tio n w ith th e to tal h ea lth care. O n e o f th e m a jo r issu es is a s sta te d ea rlie r

th a t th e m o rb id ity ra te o f th e sta te is h ig h e r th a n th e ra te o f th e o th e r states o f th e

n atio n . K e ra la p o ssess a ra te o f 55 p e rc e n t w h ereas th e n atio n al av e rag e is

c a lc u lated as 16.^* T h e m o rb id ity o c c u rre n c e o f th e co m m u n ic a b le illness in

K e rala fo r a p erio d o f n in e y ea rs fro m 1995 to 2 0 0 4 is ca lc u lated b y th e S tate

P lan n in g B o ard and p u b lish ed its results. T h e results p e n n it a re a d e r to go

th ro u g h the re su lts an d it m akes to k n o w ab o u t the p ro b lem s really fa cin g to d a y ’s

c o n d itio n s. A ll th o se stu d ies re v eal th a t th e p re se n t d ay K e rala is facin g serio u s

h ea lth issu es ev e n th e sta te attain ed a g ro w th in th e carin g sy stem earlier.

O th er c a u se s fo r th e d e a th s are th e h ig h est ra tio o f su icid es an d accid en ts.

It is a c h a lle n g e to th e h ea lth se c to r o f th e state. T h e state h as a h ig h est su icid e

ra te s in th e world.^^ M en tal stress an d o th e r fam ily so cial issues are to th e reaso n s

fo r th e h ig h ra n g e o f su ic id e s in K erala. S tu d ie s reveal th at the su icid e ra te is high

in th e ru ral a re a s tlian in th e u rb an areas an d h ig h e st sh are o f to tal d e a th s am o n g

w o m en ag es 15 to 24.^^ T h e W H O m a stu d y ex am in es th e re aso n s fo r th e

su icid es as d ep ressio n , fa m ily stress, alco h o l d ep e n d en ce an d im p o v erish m en t an d

g e n d e r d iscrim in atio n . I f th e g o v e rn m e n ts h a v e tak en step s to so lv e th e issues

lead in g to su ic id e th e o cc u rre n ce o f su icid es can b e rem o v ed . E ven th o u g h th ere

are so m an y so cial c a u se s fo r th e su ic id e s i f th e society su p p o rts th e g ro u p s th e

d ea th ra te s can b e reduce.

F ro m th e a b o v e sta te m e n ts it ca n e stim ate ab o u t th e ch a n g es o c c u rre d in

th e h ea lth se c to r o f K e rala fro m its fo n n a tio n to th e p e rio d o f new m illen n iu m .

S o m e tim es th e d ata is g iv in g in fo rm atio n ab o u t th e in cid en ts ev e n a fte r 2000,

so m e o f th em a re e n d in g w ith 2 0 0 4 , 2 0 0 6 etc. It is used c lea rly fo cu sin g u p o n th e

re tu rn o f th e erad icate d h e a lth issu es, life style d isease s an d th e new d isease s

w h ich are fa m ilia r in th e K e ra la health ca re sy stem now . D u n n g th e p erio d o f

1960'‘s an d 1 9 7 0 's K e ra la 's life p attern an d d isease s w e re d iffe ren t A t th at tim e

th e d ise a se s c o m m o n ly found in K e rala w e re m ain ly in co n n e ctio n w ith

re sp ira to ry in fectio n s, d iarrh o el d iso rd ers, w o rm in festatio n , skin infectio n ,

n u tritio n a l d e fic ie n c ie s an d p o v e rty re la te d c a u se s and d iab ete s, h y p erte n sio n ,

d e g e n e ra tiv e h eart d ise a se s a n d can cer.^' T h is categor>' m an y ep id em ics w e re

th e o re tic a lly to h a v e b e e n e lim in a te d from K erala, b u t th e d iseases such as

M alaria, c h o le ra etc. are co m in g b a c k b e y o n d an y doubts. In ad d itio n , a d ise a se

like Jap a n e se e n c ep h alitis th at w as ra n d o m in K e rala h as ap p e are d in m an y p arts

o f th e state as an ep id em ic. In a d d itio n to th a t th e m o d e m sco u rg e o f A ID S h as

b e e n re p o rted w id ely . C o n sid e rin g th e p re se n c e o f stig m a an d d iscrim in atio n

to w a rd s th o se w ho su ffe r fro m H IV /A ID S th e re is ev e ry p o ssib ility o f A ID S

em erg in g as a m a jo r p u b lic h e a lth p ro b lem in K erala. D u e to u rb a n iz atio n , life

sty les h a v e u n d erg o n e ch a n g es. T h e re are m o re p eo p le w ith sed e n ta ry h ab its an d

th e y face m o re co m p e titiv e an d h a ssle situ atio n . A lth o u g h d ru g in tak e is n o t a

m a jo r p u b lic h e a lth p ro b lem e x c e p t am o n g th e rich y o u n g alco h o lism a m o n g m en

h as ru in ed th e liv es o f m a n y w o m en an d ch ild re n am o n g th e u rb an an d rural poor.

D e ath s on th e ro a d s are b e c o m in g a c o m m o n feature in K erala. A trem en d o u s

in crease in th e n u m b e r o f v e h ic le s o n n arro w and p o o rly m ain ta in e d ro ad s co u p led

w ith a lack o f ed u c atio n ab o u t ro ad tra n sp o rt safety an d p o o rly m ain ta in e d ro ad s

an d v eh icle s tak e a h ea v y toll o f life.

T h e h ig h e r in co m es led to sev eral ca se s o f u n n ec essary m ed ica tio n ,

e sp e cially o f a n tib io tic s re su lte d in th e lo w erin g o f n atu ra l im m u n ity an d led to

d ru g in d u ced diseases. "H e a lth see k in g behavior*’ b ecam e a status sym bol w hich

sp re ad a m o n g o th e rs also re su lte d in v a rio u s life sty le diseases.

In ad d itio n to th e c a se s d iscu ssed above, th e d ilem m a w h ich m a k e s a

d ep ressin g situ atio n in K e rala is th e in cre asin g rate o f c a n c e r creatin g d am ag es. It

n o t o n ly affectin g a p erso n , b u t also th e w h o le fam ily. I f it is n o ticed th at a p erso n

is a v ictim o f can cer, th en th e fam ily is lo sin g its h o p e and try in g to re c o v e r th at

p erso n from it at an y cost. N o w a d ay s K erala re p o rts n ea rly 35000 ca ses o f new

re g istered an d aro u n d o n e lak h p atien ts u n d e r tre a tm e n t ev ery year.^^ N u m ero u s

m a tte rs are th e re aso n s fo r th e in creasin g effect o f c a n c e r in K erala. A m o n g them

th e use o f to b acc o is th e b asic re a so n S o m an y o th e r en v iro n m e n ta l and

e c o lo g ic al facto rs alo n g w ith life style are also tran sm ittin g th e d isease. B ut th e

early d etec tio n o f th e p ro b le m s is still a q u estio n o f tu rm o il. E ven th e n th e re are

v a rio u s in stitu tio n s, such as th e R eg io n al C an ce r C en tre at T h iru v an a n th ap u ra m

an d M a la b a r C an ce r C en tre at T h a la sse ry an d K a n n u r are re sp o n sib ly b ea rin g th e

m a jo r ro le in fin d in g an d so lv in g th e issue. T h e fa cility o f g iv in g o u t th e p ro cess

o f ra d ia tio n is av a ila b le in th e fiv e g o v ern m e n t m ed ical c o lle g e s an d general

h o sp ital at E m a k u la m u n d er th e g o v ern m e n t s e c t o r . B u t th e p ric e s o f m ed icin e

and o th e r facto rs are trib u la tio n o f su rv iv al for th e co m m o n p eo p le. T h e fe ar o f

attac k o f c a n c e r to th e fu tu re g en e ratio n is an o th er te rro r to th e total fam ily. T he

g o v ern m e n t is in tro d u cin g e x c lu siv e m easu res for giving aw aren ess o n th e u se o f

c a n c e r c re a tin g su b stan ce s fro m th e b o tto m o f th e so ciety th ro u g h th e a n g a n a va d is

an d p rim a ry h ea lth ce n tres etc.

A n o th e r issu e to b e d eb a te d is th e m erg in g and R e-e m e rg in g Infections.

T h e state h a d ad o p ted d iffe re n t p ro b le m so lv in g p ro g ram m e s fo r th e erad icatio n o f

v a rio u s in fec tio u s d isease s. In th e first stage, th e step s an d m easu res ta k e n o n a

larg e so cio ec o n o m ic o u tlo o k p ro v id e d p re v en tiv e an d cu rativ e h ea lth ca re th ro u g h

p rim ary , sec o n d ary an d te rtia ry lev el h ea lth ca re in stitu tio n s. T h e p e rio d o f m o re

s o cially c o m m itte d p eo p le an d so ciety tried b est to e rad icate th e issues h ad b ee n

n o ticed . T h e g o v ern m e n ts w ere re ad y to su b stitu te a m a jo r p a rt o f its re v e n u e o r

b u d g et fo r en h a n cin g th e in fra stru ctu re an d o th e r needs. B ut th e p erio d fro m 1970

and 1980the state w itn essed a serio u s ec o n o m ic an d p o litical crisis. T h at p erio d is

o th erw ise k n o w n as th e fiscal c risis o f th e state. D u rin g th ai p erio d th ere can b e

seen a d e c lin e in th e sh a re o f th e ex p e n d itu re o n h ealth sector. B ut d u rin g th e

1990s th e g o v ern m e n t ag ain d em o n strate d its in te re st o n th e h ea lth affa irs b y

a d v o c a tin g th e id ea “ G o o d H e alth at L o w C o st.”^'* It m a y b e d u rin g th a t p erio d

started a rise o r th e K e ra la m o d el d ev e lo p m e n t th ro u g h d ec en traliza tio n o f

a d m in istratio n . Y e t th e last p e rio d s o f th e 1990s w itn essed a n u m b e r o f vario u s

in fec tio u s d iseases. D u rin g 1990s th e re w e re in cid en ts o f m alaria w e re rep o rted .

S in ce 2 0 0 6 Ju n e an d M ay in c o u rse o f tim e th e n ew issu es such as d e n g u e fever,

c h ik u n g u n ia, lep to sp iro sis etc. w e re reported.^^Incidence of dengue fe v er

in cre ased fro m 0.23 p e rc e n t fro m 100000 o n 2001 to 12.0 p ercen t on2003.^^in th e

p erio d o f 2 0 0 5 -2 0 0 6 th e ca ses o f tu b erc u lo sis w e re rep o rted 275 fro m am o n g

100000 o f p o p u latio n . ^^The ca se o f lep to sp iro sis ro se from 7 .4 p erce n t o n 2 0 0 0 to

16.8 p e rc e n t in 2 0 0 7 . In 2 0 0 6 , 7 0 0 0 0 ca se o f c h ik u n g u n ia w as reported.^^

T h e c o n tin u o u s re o cc u rre n ces o f th e e rad icate d in fec tio u s d ise a se s along

w ith th e n ew d ise a se s is a serio u s tro u b le as far as th e state is co n cern ed . The

p e rio d o f m o n so o n as d isc u sse d in th e first c h a p te r ag ain w itn essin g th e re tu rn o f

in fec tio u s d isease s in K e ra la a fte r it a c h ie v em en ts in th e h ea lth ca re sector. T h e

m ain re aso n s fo r th e o c c u rre n c e an d re o cc u rre n ce o f th e d isease s are d u e to th e

e n v iro n m e n ta l issu es. M alaria, C h o lera, d iarreh ea etc. are h ap p e n in g w ith th e new

issu es lik e c h ik u n g u n n ia, d e n g u e fe v e r d u rin g th e m o n so o n season. T h e ra p id

u rb a n iz atio n p ro c ess, lack o f w a te r re so u rces an d d ra in a g e facilities are

o v erw h elm in g ly in c re a sin g th e co n d itio n . H a rm fu l ag ricu ltu ral p ractices,

m ism a n a g e m e n t o f sold, liq u id an d m ed ical w aste are th e o th e r reasons."*®

E ffe c ts o f E n v ir o n m e n ta l iss u e s o n P u b lic H eaU h s e c to r

K e rala is th e lan d ly in g in b e tw e e n W estern G h a is an d A ra b ian Sea, g ifted

w ith so m an y rivers, b a c k w a te rs an d o th e r w a te r re so u rces w ith th e p re se n c e o f th e

tw o te n n m o n so o n is su ffic ie n t an d g ifted in th e m a tte r o f th e n atu ral resources.

T h a t's w hy the land is p o p u larly k n o w n as th e G o d s ’ o w n country. E co lo g ical

eq u ilib riu m is p la y in g a v ital ro le m th e socio cu ltu ra l stab ility an d h ea lth asp ects

o f a co m m u n ity . T h e e n v iro n m e n t a n d h ea lth o f a so ciety is c lo se ly co n n ected .

E co lo g y is a p rin cip a l fa c to r th at d e te n n in e s th e h ea lth statu s o f an area. The

W o rld H e alth O rg a n izatio n c o n sid e r “E n v iro n m en tal h ealth co m p rises o f th o se

asp e cts o f h u m an h ea lth , in clu d in g q u ality o f life th a t are d eterm in e d b y ph y sical,

b io lo g ic al, so cial, an d p sy c h o so c ia l facto rs in th e en v iro n m e n t. It also re fe rs to

th e th e o ry an d p ra c tic e o f asse ssin g , co rrectin g , co n tro llin g , and p re v en tin g th o se

facto rs in th e e n v iro n m e n t th a t can p o ten tially affect ad v ersely th e h ea lth o f

p re sen t an d fu tu re g e n e r a t i o n s . N a t i o n a l In stitu te o f E n v iro n m en tal H ealth

S cien ce s co n sid er, “ E n v iro n m en tal H ealth S cien ces is th e stu d y o f facto rs in the

e n v iro n m e n t th at affect h u m an health . T h e se facto rs re p resen t ch em ical,

b io lo g ic al, o r p h y sical ag e n ts co n tain e d in air, w ater, soil, o r food, and are

tran sp o rte d to h u m an s v ia in h alatio n , in g estio n , o r skin ab so rp tio n . T h e n et effect

is p ro d u c tio n o f a d v e rse h ea lth effec ts/'^ " E n v iro n m en tal d e p n v a tio n is

c o n sid e re d to b e th e m a jo r re a so n o f illness. E n v iro n m en t m ay b e d efin e d as an

ag g reg ate o f all th e ex tern al circ u m sta n c e s an d in flu en c es affectin g th e life and

im p ro v e m e n t o f a creatu re.

W a te r is a m a jo r d e te m iin a n t in th e en v iro n m en tal realm w h ich d eterm in e s

th e h ea lth o f a society. A s stated ea rlie r g o o d d rin k in g w ater, air, clea n lin e ss an d

o th e r re so u rces p la y a p ro m in e n t ro le in th e sh ap in g o f th e h ea lth co n d itio n s o f a

so cial g ro up. T h e re so u rc e s are d irec tly o r in d irectly in flu en cin g th e co n d itio n s,

in m a jo r c o n d itio n s, v /ater b o rn e d ise a se s are h ig h ly sp re ad in g an d m ak e a ca u se

fo r th e d e a th o f so m an y p eo p le. R apid u rb a n iz atio n , in cre ased d em an d and

co n su m p tio n o f w ater, lack o f h e a lth y an d g o o d d rin k in g w a te r reso u rces, h y g ien ic

a tm o sp h e re etc. creates serio u s issu es in th e h ea lth sector. A s th e seco n d h ig h est

state h a v in g th e rain fall in a y e a r and th e p re se n c e o f o th e r w a te r b o d ie s it h as th e

3 0 0 m m o f w a te r su p p ly . C o m p a n n g to R ajasthan, th e d ese rted land o f th e

n atio n , th e w a te r re so u rc e s o f K e ra la is sh o w in g a d efic ien cy in its w a te r

a v a ila b ility now . S o it s h o u ld p o sse ss th e w a te r su ffic ie n cy m o re th a n th e

av a ila b ility o f w a te r reso u rces. B ut n o w K e rala h as 1250Q m w a te r su ffic ie n cy as

co m p arin g to R a ja sth a n th e y h av e 1650Q m . In d ia h as an av e rag e o f 1550. U S A

h as th e su ffic ie n cy o f 9 2 7 3 Q m . '‘^At n atio n al level 4.3 p e r ce n t o f rural p o p u latio n

an d 11 p e rc e n t o f u rb a n p o p u la tio n u se b o iled w a te r fo r d rin k in g , w h ile fig u res are

49.3 p e rc e n t a n d 65.3 p e rc e n t fo r K e rala respectively.'^'*

T h e ab se n c e o f p e rfe c t solid, liquid, m edical a n d o th e r w a ste s c reates issu es

in th e co n ta m in a tio n o f w a te r b o d ies. T h ey are d isc h a rg in g th ro u g h th e n atu ral

w a te r b o d ie s lead in g to its co n tam in atio n , E v e n th e re is v ario u s aw aren e ss

p ro g ra m m e s are co n d u c tin g , a larg e p o p u latio n still u se s w a te r d ire c tly fo r

d rin k in g w ith o u t m ak in g an y p re c a u tio n s such as tre a tm e n t o f b o ilin g o f th e w ater.

In fectio u s d ise a se s ca u sin g b y p a th o g e n ic b ac te ria, v iru ses an d p a ra site are th e

m o st c o m m o n ly sp re ad in g h e a lth issu es in re la tio n w ith w ater.

N e x t to w a te r th e e n v iro n m e n ta l fa c to r th a t a sse ssin g th e h ea lth statu s o f a

s o ciety is th e c o n d itio n s o f th e s o i l In K erala, it is d eg rad in g a s a y ard fo r

d u m p in g all ty p e s o f w a ste su ch as d o m estic, in d u strial an d ag ricu ltu ral. T h e rate

o f so il d a m a g in g is in c re a sin g y early . P o te n tia lly to x ic su b stan ce s m a k e h a rm s to

th e h u m an h e a lth co n d itio n s. C h em ical su b stan ce s an d m etals d isch arg ed fro m the

in d u strial zo n e s to th e soil n ea rb y , m ix in g w ith th e air, w ater, v e g e ta tio n etc.

c reates h a rm fu l g ase s an d o th e r p o llu tio n s. T h e h ig h ly p o llu te d soil ca n n o t

p ro d u c e an y a g ric u ltu ral p ro d u c ts fo r lo n g years.'^^ T h e serio u s re su lt o f th e soil

p o llu tio n is th e lack o f n o n -to x ic v e g e ta b le s a n d crops. T h is w ill finally re su lt in

th e sto p p in g o f a g ric u ltu ral a c tiv ities in th is land. I f th e farm ers a re n o t getting

e n o u g h p ro d u c ts fo r th e ir e ffo rt th e p ro c e ss w ill g ra d u a lly declin e.

In d u strializa tio n an d u rb a n iz a tio n are th e o th e r m a jo r re aso n s fo r the

s ca rcity o f a g ric u ltu ra l lan d s in th e state, w h ich in d irec tly in flu en c in g th e

e n v iro n m e n ta l stru c tu re o f th e state. In K e ra la su ch a d e c lin e o f th e p ro p o rtio n o f

a g ric u ltu ra l lan d is v e ry high. T h e a g ric u ltu ral se c to r o f K e ra la is facin g serio u s

issu e s o f o v ere x p lo ita tio n an d c o n v e rsio n o f a g ric u ltu ral fields. A g ric u ltu ra l lan d

c o n v e rsio n e sp e cially th e p a d d y field s re su ltin g in th e sca rcity o f fine crops.

D u rin g th e p e rio d o f 1960s th e re w e re ab o u t 19.06 lakhs ag ricu ltu ral h o ld in g s in

K erala. It w as n ea rly for o n e p e rc e n t fo r 10 h ectares. D u rin g 1971 th e n u m b e r o f

h o ld in g s in cre ased to 2 0 .2 2 lakhs. In th e y ea rs a fte r th e h o ld in g s w e re d iv id ed and

o n th e b asis o f th e ag ricu ltu ral c e n su s co n d u c te d o n 1990-1991 th e re w e re o v e r

5 4.18 lak h h o ld in g s in K e ra la o f w h ich n early 84 p c rc e n t w e re o f less th an h a lf a

47
h e c to r in size w ith th e p o p u la tio n grow th.

T h e d e c lin e o f a g ric u ltu re in K e rala is in d irectly affectin g th e h ea lth sector.

E v en th e re are sce n es o f d ire c t a ttac k in g th e p ro b lem s are som e m o re indirect.

W h e n th e a g ric u ltu ral in tere sts b e g a n to d ec lin e th e re aro u sed a d ec lin e in th e

su p p ly o f d o m e stic a lly p ro d u c e d rice, food g rain s, veg etab les, fruits, fish, egg,

m ilk etc. It g av e a c h a n c e to th e p ro fit m o tiv e su p p liers from th e o th e r states to

su p p ly m o re item s at low c o st b y u sin g d iffe ren t h arm fu l p esticid es. N o w K e rala

w itn essin g d iffe re n t ty p es o f can cers, ty p e I d iab etes, cereb ral p alsy an d o th e r

p ro b le m s am o n g th e ch ild re n .'’^ T h e u se o f b a n n e d an d h a n n fu l c h e m ic als an d

p e sticid es is h e a v ily affec tin g ev e n th e new b o m b ab ies and th e p re g n a n t lad ies

ex c ep t th e o th ers. T h e m a jo r re aso n b e h in d it is th e ab se n c e o f g o o d fo o d an d

h ea lth y liv in g conditions,'*'^ P esticid es usin g in th e state in clu d e c h e m ic als su ch as

en d o su lp h an , m eth y l p arath io n , lindane, m eth o x y ethyl m ercu ry ch lo rid e etc. are

b an n e d in m an y countries.^^ T h e use o f p esticid es is n o t o n ly affectin g th e

p ro d u c ts b u t also affec tin g th e air, w a te r an d soil.

T h e a ir o f th e state is p assin g th ro u g h a state o f p o llu tio n . A ir p o llu tio n

c a u se s m o re d e a th s th a n o th e r risk facto rs like m aln u tritio n , ob esity , alco h o l and

d ru g a b u se etc.^' It is an in v isib le k ille r o f the g en eratio n s. P o llu tio n creatin g from

c o n stru c tio n secto r, in d u strial an d a u to m o b ile secto rs an d o th ers are th e m ajo r

re aso n s for th e air p o llu tio n in K erala. The m ajo r citie s like C ochi,

T h iru v a n a n th a p u ra m , K o zh ik k o d e. T h rissu r, K o llam etc. are m u ch su ffe rin g from

it. A ir p o llu tio n c a u se s d ea th s o f p re m a tu re, re sp irato ry p ro b lem s like lung

can cer, h ea rt d isease s etc.^“

M in in g , q u arry in g etc. are th e o th e r en v iro n m e n ta l issues. T h e se tw o

e n v iro n m e n ta l tro u b les are d irec tly affec tin g th e w ater, soil an d a ir am b ian c e o f

th e area. T h e e sc alatin g e x te n sio n o f p o llu tio n p ro d u c in g from m in in g an d

q u a rry in g , d irectly lead in g to th e re sp irato ry d isease s am ong th o se w h o are

re sid in g n earb y . In a d d itio n to th e re sp ira to ry d ise a se s it ca rries o u t th e elem e n ts

o f c a n c e r re la ted d iseases.

D e fo restatio n is th e n e x t e n v iro n m e n ta l issu e facin g b y th e state. K e ra la is

b o u n d ed b y th e W e ste rn G h a ts in th e eastern side c o n sid e re d as o n e o f th e g lo b al

b io d iv ersity h o tsp o ts. It h as 3 3 5 7 9 sq .k m o r 35.3 p e rc e n t o f th e to tal forest.

W e ste rn G h a ts ac co u n t for 6 4 .9 5 p e rc e n t o f I n d ia 's account, startin g from T apti to

K a n y ak u m ari a n d co v e rin g an a re a o f 1500 k m length. It h as th e su ffic ie n t ra in y

fo rests, d w e llin g as a re so u rce fo r th e fo rty four riv ers and a n u m b er o f o th e r w a te r

b o d ie s in K erala. *'^ T h e larg e n u m b e r o f flo ra an d fa u n a o f th e G h a ts h o ld u p it to

b e c o m e a m e m b e r o f th e h e rita g e sites o f U N E S C O . D e fo restatio n is an o th er

c a u se fo r th e e c o lo g ic al u n b a la n c in g o n th e h ea lth c o n d itio n s o f a land. A s stated

earlier, h ea lth o f a g ro u p is d e term in in g b y v a rio u s e n v iro n m e n ta l factors. The

ra te o f d e c lin e in th e d e n sity o f ra in y fo rests c a u se s th e w e ak en in g o f th e natural

reso u rces. T h e len g th an d d ep th o f th e m o n so o n s are d ec lin in g yearly.^'^K erala’s

fo rest co n d itio n s are d im in ish in g in th e fifty y e a rs in a h ig h extent. It is ad v e rsely

affectin g th e clim a te o f th e state.^^ T h e w e ak en in g o f th e natural re so u rc e s is

g ra d u a lly affec tin g a p o p u la tio n an d th ere b y th e h ea lth se c to r o n d iffe re n t

d im en sio n s.

T h e m a n g ro v e s are su p p le m e n ta ry ty p es o f forest h av e a n u m b e r o f special

p la n ts an d o th e r creatu res. It is o th e rw ise know n as th e re sp irato ry o rg a n s o f the

earth. B eca u se th e m a n g ro v e s h a v e th e ab ility to ab so rb a larg e q u a n tity o f

in to x ic ab le g ase s an d can p ro d u c e larg e q u an tity o f oxygen.^^ T h e p re se n c e o f

m a n g ro v e s su p p o rts th e g ro w th a n d sp re ad in g o f v ario u s ty p es o f flo ra and fa u n a

w h ic h h av e th e ca p acity to so lv e so m an y h arm fu l issu es o f th e n atu re. Ju st like

th e d e fo re sta tio n th e n u m b e r an d d e n sity o f th e m a n g ro v e s are also r e d u c i n g . I t

ad v e rsely a ffe c te d th e c o n c e rn e d areas in re d u cin g th e u n n atu ra l issu es created .

A fte r th e tsu n am i o n 2 0 0 4 th e state realized th e im p o rtan ce o f th e m a n g ro v e s and

n o w th e state try in g to p ro te c t this.^^

A s a state w ith h ig h d e n sity a n d p o p u latio n th e d ra in a g e sy stem s and

san itatio n m e asu res fo llo w in g b y th e state n o w is in ad eq u a te to m eet th e

co n d itio n s. T h ere w ere b e tte r san itatio n and d ra in a g e existed before th e 1 9 8 0 ’s.
A fte r th at th e p o p u la tio n g ro w th is in an in cre asin g ratio. T h e m o re u rb a n iz atio n

p ro g ra m m e s an d d e n sity in th e u rb an areas create m u ch m o re serio u s issu e in th e

field o f san itatio n , h y g ie n e an d d ra in a g e system . T h e citie s are m o re p o p u lated

th an th e rural reg io n s. T h e ca n als and d ra in sy stem is n o t su fficien t to ca rry the

w a ste from th e city to th e o u te r r e g i o n s . A s a m o re p o p u la te d state th e re are n o t

en o u g h co n d itio n s to so lv e th e w a ste s. D ifferen t ty p e s o f w a ste s are in creasin g

d ay b y d a y an d th e w id th o f th e state is n o t e n o u g h to m eet th e p ro b lem s surely.

W a ste p ro c e ssin g ce n tre s started in d iffe re n t p arts o f th e state in v ite d m ass

m o v e m e n ts ag a in st su ch ce n tres as th e in h ab itan ts n e a r to th e ce n tres h a d to su ffe r

difficulties.^'^ T h e in cid en ts an d m o v em en ts h a p p e n e d at V ila p p ilsa la n e a r

T h iru v a n a n th a p u ra m w a s a liv e e x p e rie n c e b efo re n in e years.

L a trin e fa c ility in K e rala is h ig h e r th an th e o th e r states. It is a visib le

e x a m p le as w e are tra v e llin g from o n e en d o f th e n atio n to th e o th e r end, can see

n early h a lf o f th e p o p u latio n d o n 't h av e th e latrine facilities o r they are not using

it. M ajo rity o f th em are u sin g th e p u b lic p lace s fo r th e ir u se an d th e to w n s an d

rural ce n tres are a lik e o n this m atter. B ut in th e case o f K e rala is som ew hax

d iffe re n t an d th e re are b e tte r facilities in d iffe ren t types. T h e ro le o f th e G ram a

P an ch a y ath s an d L o cal S e lf G o v e rn m en t sh o u ld b e ap p lau d in g fo r a s s u n n g such

facilities to th e p ublic.

In f lu e n c e o f N e o -L ib e ra l p o lic ie s o n P u b lic H e a lth S e c to r

.After th e c a te g o ry o f en v iro n m e n ta l issu es th e n e x t is th e ec o n o m ic c n sis.

T h e p e rio d from 1990 In d ia w itn e sse d serio u s ec o n o m ic crisis. T h e crisis b ec am e

a d ee p o n e in Ju ly 1991, w h e n fo reig n c u rre n c y re serv es h a d d eterio rated to alm o st

$1 b illio n . In fla tio n h ad ro a red to an n u a l ra te o f 17 percen t. F isc al d efic it w as

v ery h ig h an d h ad b e c o m e u n su stain ab le. F o reig n in v esto rs an d N R Is h a d lost

c o n fid e n c e in Indian ec o n o m y . T h e w id en in g g ap b e tw e e n th e re v e n u e an d

e x p e n d itu re o f th e g o v e rn m e n t re su lte d in g ro w in g fiscal deficits. A s a re su lt th e

g o v e rn m e n t o f In d ia w as fo rced to ch a n g e the ec o n o m ic p o licies o f th e co u n try . It

fin ally re su lted in th e n ew ec o n o m ic re fo rm s o f lib eralizatio n , p riv atiza tio n , an d

g lo b alizatio n . A s a re su lt th e ec o n o m y w itn essed trem e n d o u s im p act o n the

o v erall ec o n o m ic d e v e lo p m e n t in alm o st all sectors. E co n o m ic ch a n g es led to the

n e w p o lic ie s o f n e o lib era lism an d fu rth e r issues.

N e o -lib e ra lism ca n o th e rw ise b e tag g ed as th e n am e fo r E co n o m ic

lib eralism . It su p p o rts free tra d e an d o p en m ark ets, p riv atiza tio n , d ereg u latio n ,

d ec rea sin g th e size o f th e p u b lic se c to r an d re d u cm g th e social p ro g ram s. T h e

im p o rtan t ch a rac te ristic s o f neo liberalism on health in K erala are; “ the

p riv a tiz a tio n o f m ed ical an d h ea lth ca re sector, o v e r h o sp italiz atio n , o v e r

a d m in istra tio n o f m ed icin es, in creasin g n u m b e r o f sp ecialists, e sc alatio n o f th e

h ea lth ca re cost, m a rg in a liz a tio n o f th e p o o r, large n u m b e r o f ill-q u alified d o cto rs,

d e c lin e in p ro fe ssio n a l eth ics in th e h ea lth sector, in cre ase m m e d ic in e 's price,

lack o f p o litic a l co m m itm e n t, b u re au cratic in efficien cy , co rru p tio n , lack o f p ro p e r

p la n n in g ” ^'

T h e w e alth re lo c a te d from th e G u lf reg io n an d o th e r p lace s in d irectly

in flu en c ed th e h ea lth ca re se c to r o f K e rala. W h a t th e ec o n o m ic p ro sp e rity th e slate

h a d ac h ie v e d in th e first fifty y e a rs o f its tim e w as m ain ly c o n trib u ted b y th e

m ig ra n ts o f K erala. In th e first sta g e th e K e rala m ig ra n ts arriv ed at a b ro ad in

sea rch o f g o o d jo b facilities. A s w e k n o w th at b efo re th e p assin g o f th e L an d

R e fo rm s A c t o f K e ra la th e m a jo r sh are o f the w ealth an d lan d w as m ain ly

co n c en trate d a m o n g a m in o rity o f th e total p o p u latio n . T h e lack o f jo b

o p p o rtu n itie s an d th e e x isted social co n d itio n s forced th e o th ers to go aw ay from

th is lan d in search o f g o o d jo b an d earn in g s. It c re a te d w h at is ca lle d th e G u lf

m ig ratio n . A s a re su lt o f th e g u lf m ig ratio n and th e av a ila b ility o f in co m e alo n g

w ith th e n ew lan d re fo rm s g av e them an o p p o rtu n ity to p u rc h ase lands, co n stru c t

g o o d h o u ses, ch a n c e s o f ed u c a tio n an d o th e r m o d ern ities. In th e first stage, th e

jo u rn e y o f th e m o n ey m ain ly re ach e d here w as sp en t for th e co n stru c tio n o f b ig

h o u ses an d o th e r su ch constructions.^^T he 2001-2011 cen su s re p o rts the

p o p u la tio n g ro w th is d e c re a sin g b y 4 .8 6 % w h ile th e co n stru c tio n o f h o u ses

in cre asin g b y 16.7% . T h e 3 .4 % o f th e to tal h o u ses o f In d ia an d 10.6% in K e rala

is c lo se d w ith o u t using.^'* G ra d u ally th e sp en d in g o n co n stru c tio n in d u stry ch a n g ed

to o th e r interests. O p p o rtu n itie s w e re o ffered on g o o d h ea lth care sy stem s, w h ich

su p p o rted th e p e o p le to go to h o sp ita ls w h e th e r th o se are p riv ate o f p u b lic i f th e

c o st is h ig h o r low . T h ereb y in d irec tly th e g u lf m ig ratio n c o n stru c te d a n ic e space

fo r th e u p ii ftm en t o f th e h ea lth ca re sy stem in K erala.

N o w a n u m b e r o f h o sp ita ls an d o th e r h e a lth ca re in stitu tes a re co n d u c tin g

by th e g u lf m ig ra n ts in K erala. T h e aw aren ess o f g o o d h ea lth a n d th e p ro fit

g ain in g from this se c to r p a v in g th e g u lf m ig ran ts to start b u sm ess in th e h ea lth

sector.

C o m m o d itiz a tio n o f H ealth is th e next pro b lem o f K e ra la ’s h ea lth sector.

C o m m o d itisa tio n in a serv ice se c to r m e a n s co n sid erin g th e serv ic e as c o m m o d ity

and fin d in g m ark e ts fo r th e p ro d u ct. H en ce, h ea lth is th e c o m m o d ity an d in co u rse

o f th e c lo su re o f th e 20'^ ce n tu ry a n d b eg in n in g o f th e 21®' c e n tu ry w itn essed the

m a k e o v e r o f th e h ea lth se c to r fro m th e stan d ard o f fu n d am en tal rig h t to a m ere

co m m o d ity . It w as as th e re su lt o f th e w o rld w id e c o m m o d itisa tio n and

p riv atiza tio n o f th e d iffe re n t serv ice secto rs. P riv atisatio n d efin itely aim s at ‘fo r

p ro fit se c to r.” W ith p riv ate p ra ctice by d o cto rs an d d isp en satio n o f m ed ical care

as a p ro fit m o tiv e h ea lth ca re se c to r p a ss e d th ro u g h th e p ro c e ss of

co m m ercializatio n , c o rp o ra tiz a tio n an d m ark etisatio n . In th e p ro c ess of

g lo b alizatio n m u ltin atio n al c o rp o ra tio n h av e sy stem atically d ecid in g an d targ e tin g

o n th e p o lic y m ak in g , d efin in g p rio ritie s and d ec id in g to th e in tro d u c tio n o f

m ed ica l c a re o n a b u sin e ss p latfo rm . T h ey are d ec id in g fo r d isease control

p ro g ram m e s, p ro v isio n in g o f health care and m ed ical research at th e vario u s

levels. T h e p o licy o f m ak in g h ea lth ca re as a m ark e tw ise p ro d u ct U n ited S tates is

th e lead e r an d is g ro w in g sp ee d ily in th e d e v e lo p e d and d ev e lo p in g co u n trie s. T h e

g o v e rn m e n t h as a m in im al ro le in p ro v id in g p u b lic in su ran c e to its p eo p le. A fte r

th e in tro d u ctio n o f n ew ec o n o m ic p o lic ie s In d ia c rep t into th e w itch ed h an d s o f

th e c o rp o ra tio n s w h o are d e c id in g n o w ab o u t th e m ed ica l ca re an d d isease s to b e

trea ted . I f th e re is n o d irec t so u rc es to estab lish th e arg u m en ts h u m an th o u g h t

alw a y s re a liz in g th e w o rld th e y a re g o in g thro u g h . A n u m b e r o f lite rary w o rk s,

d o c u m e n ta rie s an d film s d isc u sse d th e p ro b lem in a d etailed m anner. F o r e x a m p le

th e sh o rt film s an d film s lik e O rg a n T rafficking, L o v e D onation, The Han>est,

N irn n a ya m , A va liim N ja m tm Tham m il, E zh a m A rivii, M e r c e l etc. d ep icts h ea lth

and right to live as p ro d u c ts o n o n e sid e and as h u m an rig h ts o n th e o th e r side,

B ut th e se so m etim e s c o n v e y th e in tere sts o f th e c o rp o ra te o f th e s e c to r

S am e as co m m o d itiz a tio n p riv a tiz a tio n is th e n e x t m a jo r an d w o rst issu e

th a t is ex istin g th e h e a lth sce n ario o f K erala. P riv atisatio n is u n a v o id a b le now , y et

it c reates d a n g e ro u s c o n se q u e n c e s in th e w h o le co u n try . In 1954, A .D . S hroff, a

B o m b ay e c o n o m ist started a F o ru m o f F ree E n terp rise. B y in sp irin g and

an a ly z in g th e d e fe c ts o f th e P lan n in g C o m m issio n o f G o v e rn m en t o f In d ia ne

w ro te ab o u t fo r m o d ificatio n s. H e a rg u ed th at i f th e ‘'g o v e rn m e n t is read y to shed

so m e o f th e ir im p ractical id e o lo g ie s an d ex ten d th e ir ac tiv e su p p o rt to th e p riv ate

se c to r rapid ly in d u strializ atio n w ill tak e p lace in India w ith in ten y e a rs .'’ The

ru in o f U S S R d u rin g 1990s created a w o rld w id e ec o n o m ic crisis. T h e a b se n c e o f

U S S R su p p o rted th e c a p ita list co u n trie s to d iscu ss an d o p erate p o licies o f th e ir

o w n m terests. 1990s w itn essed th e m a jo r p o licy ch a n g es su ch as th e new

ec o n o m ic re fo n n s p o p u la rly know n as L ib era liz atio n , P riv atisatio n and

G lo b alisatio n (L P G ). In d ia b e c a m e a p art o f this p ro c ess o f w o rld ly in tro d u ce d

n ew ec o n o m ic policies.^^ G lo b alisa tio n aim ed to m ak e th e In d ian ec o n o m y as

fastest g ro w in g ec o n o m y an d g lo b ally co m p etitiv e. T h e series o f re fo n n s

u n d e rta k e n w ith re sp e c t to th is ch a n g e w e re in th e in d u strial sector, trad e, fin an cial

a n d serv ic e se c to r etc.^’ It aim ed to m ak e the ec o n o m y m ore su ccessfu l. “ W ith the

o n set o f re fo rm s to lib era lise th e In d ian ec o n o m y in J u ly l9 9 1 , a n ew e ra has

d aw n ed fo r In d ia an d h er b illio n p lus p o p u latio n .” T h e tran sitio n to o k p la c e as a

re su lt o f th is p ro c e ss m ad e a tre m e n d o u s im p act o n th e o v erall ec o n o m ic

d e v e lo p m e n t o f th e n atio n . T h e tre n d s to w ard s p riv atiza tio n o f th e serv ice sec to r

d a te s b ac k to th e sam e p erio d . A c co rd in g the fam o u s w rite r it w as as a re su lt o f

th e ab se n ce o f ac u te k n o w led g e o f th e au th o rities o n this m atter. It p u rsu e d “th e

h ea lth sy stem o f In d ia as o n e o f th e leading p riv atised health se c to r o f th e

w o rld ..,th e p riv itisa tio n o f h ea lth an d m e d icin e is a serio u s th rea t as fa r th e

c o u n try lik e In d ia is c o n c ern e d . T h e p riv atiza tio n o r lib era liza tio n o f h ea lth is tied

w ith th e p o lic y o f sim p lify in g th e p ro c ess o f a ttra ctin g fo reig n ca p ita l and

te c h n o io g y .’*^^ M o re o v e r th e p riv a te h o sp itals k eep a clean, h y g ien ic an d serv ice

o rie n te d m a n n e r th a n th at o f th e p u b lic sector.

 B eing a p art o f th e federal fo rm o f th e g o v e rn m e n t o f In d ia, K e ra la p asse d

th ro u g h th e sam e ex a m p le s o f p riv a tiz a tio n o f health . It b ec am e p o p u la r fro m

1990s o n w ard s. A c c o rd in g to C .R .S o m a n it created a crisis in K e ra la h ea lth care

scene. P riv ate h o sp ita ls w e re p ro fit m o tiv e an d th e y c h a rg in g m o re m oney,

th ro u g h o v e r in v estig atm g p a tie n ts in th e ir o w n lab o ra to ries th an p ro v id in g them

care.^'^D octors in th e p u b lic se c to r w e re also g ain th ro u g h th e co n n e ctio n b etw e en

th is in d u stry an d p ro fessio n . E v en th e g o v ern m e n t is aw are ab o u t th e situ atio n

w o u ld n o t tak e an y serio u s step s ag a m st th is m ove. T h e y d id n o t tak e an y attem p t

to reg u late the health care m d u stry an d it's affectin g situ a tio n s.’ ’

D r.V .R a m a n k u tty p o in ts o u t th a t th e p riv a tiz a tio n o f the health ca re in d u stry w ill

re d u ce th e q u ality an d serv ic es o ffe re d by th e sec to r p rev io u sly . A sto n ish in g

e n c o u ra g e m e n ts in th e fo rm o f gift, m o n ey an d o th e r m cen tiv es w ill te n d this

se rv ic e se c to r to an u n eth ica l, p ro fit m o tiv a te d v en tu re .’^ P riv ate h o sp itals

d e fin ite ly w ill su rp a ss th e g o v e rn m e n t facilities o n th e ir service. T h e y w il!

in cre ase th e n u m b e r o f b e d s alo n g w ith th e s ta ff p erso n n el. H e c o n c lu d e d th a t i f

th e p o litica l p artie s an d th e g o v ern m e n ts are n o t re ad y to d ev e lo p a n ew v isio n o n

K e ra la h ea lth c a re sy stem , a n ew K erala ‘m o d e l’ w ill merge.^^

P riv ate s e c to r is flo u rish m g p rim a rily b e c a u se o f th e failu re o f th e p u b lic

secto r. T h e g ro w th o f p riv a te h o sp ita ls an d d iag n o stic cen tres also en c o u ra g e d by

th e ce n tral and state g o v ern m e n ts b y o fferin g tax e x e m p tio n s an d lan d at

co n c essio n al rates, in re tu rn for p ro v isio n o f free tre a tm e n t fo r th e p o o r as a

ce rtain p ro p o rtio n o f o u tp atien ts an d mpatients.^'* T h e p u b lic h ea lth sy stem is

g ettin g alien a te d from th e p eo p le an d o n ly fifty p ercen t o f th e p o p u latio n e v e n

fro m th e lo w e r in co m e g ro u p seek s m ed ical h elp from th e g o v ern m e n t hospitals.

T h e p riv itisa tio n o f m ed ica l field cre a te d serio u s issu es in th e p u b lic h ea lth

a d m in istra tio n o f K erala. T h e re w e re p riv ate p ra c titio n e rs in K e ra la b e fo re it

fo rm atio n . T h e p riv a te p ra c tic in g o f th e govt, d o c to rs an d o th e r p riv a te

p ra c titio n e rs su p p o rted th e p riv a tiz a tio n o f th e h e a lth w ing. P riv ate h ea lth ca re

ac co u n ts fo r 4.2 p e rc e n t o f G D P , ra n k in g In d ia am o n g st th e to p 2 0 co u n trie s in the

w o rld a c co u n tin g for 80 p e rc e n t o f o u tp atien t an d 60 p e rc e n t o f in p atien t c a re .’^

In th e p o st lib era lize d era th e re is a b o o m in g in th e e sta b lish m e n t o f p riv ate

h o sp itals in th e u rb an an d th e u rb a n p erip h e ries of K eraia. In th e rural areas there

ai'e so m an y c lin ic s w h ich g o b ey o n d lim itatio n s. W ell eq u ip p ed w ith ex p en siv e

d iag n o stic m ach in es, special co n su ltan ts, th ese in stitu tio n s are n o w lead in g th e

h ea lth affairs o f th e rural areas.

W h e n h e a lth b e c o m e s a p ro d u c t th ere is a m ark e t o f h ea lth centres. H ere

th e ro le is p la y in g by th e p riv a te h o sp ita ls an d clinics. T h is se c to r u tilize s th e

d istin c tio n b etw e en th e rich an d poor. W h e n th e p o o r o p tin g p u b lic sec to rs d u e to

th e a b o v e said facto rs tre a tm e n ts is n o t u p to th e ir needs. So tn e p o o r b eg a n to

th in k ab o u t o p tin g o f p riv ate h o sp itals. T h a i sen tim en tal a p p ro ach is ad v ersely

u ses b y th e m u ltin atio n al h o sp itals. T h e lack o f aw aren e ss ab o u t d iseases am ong

th e p o o r is m isu sin g b y th e p n v a te h o sp itals

M ajo rity o f p o p u la tio n in this lan d k now s th e a c h ie v em en ts and

a w aren e ss th ey g o t w e re th ro u g h th e m terfe ren c e an d ac tiv e p artic ip a tio n o f the

d iffe re n t g o v ern m e n ts even th o se w e re e ith e r left w ing o r rig h t w ing. T h e role o f

serv ice sec to rs in th e p u b lic a re n a is n ec essary for th e co m m o n p eo p le. T h e roles

p la y e d b y su ch p u b lic o rie n te d sec to rs are visib le to th e c o m m o n m an. Y et. afte r

th e in tro d u c tio n o f th e p riv a te h o sp itals esp e cially m u ltin atio n al in feature th e y are

selectin g th e p riv a te h o sp ita ls tn a n th e p u b lic h o sp itals. T h ere a re d istin c tiv e

re a so n s b e h in d th is option. L ack o f b asic facilities an d p o o r in frastru ctu re, o v e r

p o p u la te d serv ic e see k ers and u n d e rsta ffe d h o sp itals, d e tlc ie n c y an d sh o rtag e in

th e life serv in g an d esse n tial m ed icin es etc. c re a te d serio u s ch a lle n g es in th e

e x istin g h ea lth ca re d e liv e ry sy stem o f p rim a ry , se c o n d ary an d te rtia ry lev els o f

g o v ern m e n t d riv in g h o sp itals. L ack o f p o litical co m m itm e n t, b u reau cratic

in effic ien cy , co rru p tio n at v ario u s levels, lack o f p ro p e r p la n n in g etc. h as

c o n trib u te d to th e larg e r p riv a tiz a tio n o f h ealth in K erala. T he a c c e ssib ility of

p riv ate c lin ic s o r h o sp ita ls o n ev ery ten k ilo m e te rs o ffe rs th e p eo p le an easy access

on a sh o rt tim e. T h e p u b lic h o sp itals m a v illa g e in K e rala are ca lle d as p rim a ry

h ea lth cen tres. T h e re are m ere ly o n e o r tw o su ch ce n tres in a v illa g e o r

p an c h ay ath . T h e p u b lic sec to r d o e s n ’t have th e cap acity to acco m m o d ate a large

n u m b e r o f p atien ts w ith in a sm all sp ac e w ith m in im u m s ta ff an d d o cto rs. Y o u n g

d o cto rs are n o t in tere ste d to d o jo b s in th e g o v ern m e n t se c to r w ith m e a g re salary

an d p o o r w o rk in g a tm o sp h e re in th e serv ice p lay s a n o th e r cru cial ro le in th e

in cre asin g o f p riv atiza tio n . A n o th e r ca u se b e h in d this is th e p riv ate h o sp ita ls treat

th e ir p a tie n ts w ith a p o sitiv e fe elin g th a t th e y are g iv in g m u ch co n c e rn s to th e

p atien ts. T h e n u m b e r o f th e p u b lic h o sp itals is ra th e r h ig h i f co m p ared to th e

p riv a te h o sp itals. S o th e s ta ff an d d o cto rs are n o t in a m o o d to k ee p a g o o d

relatio n w ith th e p atien ts w h o are th e stak eh o ld e rs here. T h e y tre a t th e p atien ts and

th e ir b y sta n d e rs in a h arsh m an n er. S o m e d o cto rs an d o th e r s ta ff are n e v e r

co n sid erin g th e ir p ro fe ssio n as a serv ic e o rien te d o n e and th e y h av e a d ig n ified

p o sitio n in th e society. E v en th o u g h th e p riv ate h o sp ita ls are sm all in size th e y are

g iv in g m o re am en ities. C o rru p tio n , u n clea n lin e ss o f th e govt, h o sp itals fo rces the

m a sse s to go to th e p riv a te sector. T h e n o n -a v ailab ility o f m ed icin es are an o th er

re aso n fo r o p tin g th e p riv a te sector. T h e free at th e p o in t o f m ed icin al sy stem s

p re v a ilin g in th e g o v e rn m e n t h o sp ita ls in K e rala is n o t at ail free e x c e p t fo r the

a c c o m m o d a tio n an d c o n su lta tio n at th e h o s p ita l T h e p atien ts h av e to b u y th e

m e d ic in e s from th e o p en m a rk e t a n d are forced to u se th e p riv ate facilities for

m o st o f th e d iag n o stic p ro c e d u re s an d to m ak e u n d e r th e tab le p a y m e n t fo r b e tte r

a tte n tio n an d treatm ent.

P o litical o rg a n iz a tio n s and em p lo y m en t issues create d ifficu lt strik es in th e

p u b lic h o sp itals: d o c to rs ' strike, n u rs e s ’ strike, ra d io lo g is ts ’ strike etc. It in ju res

th e h o p es o f th e p o o re r sectio n s o f th e society w h o are w aitin g fo r th e life o f th e ir

b e lo v e d s. In a d eq u ate m o d e rn iz e d in fra stru ctu re lei th em to o p t th e p riv ate

d iag n o stic ce n tres to id en tify th e ir p ro b lem s.

E v en th o u g h th e m asses are su fferin g from v a rio u s h a rd sh ip s th e y are

o p tin g p riv ate h o sp itals in ca se o f trea tm e n t o f acu te illness. A s w o rk in g p ro fit

o rie n te d th e p riv ate h o sp ita ls are read y to k eep th e p atien ts o n th e ir m ain stream .

W h e n h e a lth b e c a m e a c o m m o d ity th e p eo p le w e re re ad y to p a y an d b u y

th e ir fu n d am en tal rig h t o n h ig h cost. H e alth is n o m o re seen as a rig h t b u t as a

rig h t b u t as c o m m o d ity to b e p u rc h a se d by m o n ey . T h e h u g e re m ittan ce o f

fo re ig n ex c h an g es fro m g u lf co u n trie s fu rth e r re in fo rce d th is attitude. A ll this

te n d e n c ie s are lead in g to a v irtu al u n co n tro lled g ro w th o f th e p riv ate m ed ica l care

fa c ilitie s in th e state.
 S olv in g p riv a tiz a tio n is n o t an easy task on today. T o re d u ce th e

c o n se q u en ce s, g o v e rn m e n t sh o u ld u n d erta k e ce rtain serio u s steps. It sh o u ld

in cre ase th e in fra stru ctu re an d o th e r lim itatio n s ex istin g in th e p u b lic h o sp itals. It

sh o u ld in cre ase th e w a g es an d salarie s o f th e s ta ff ac co rd in g to th e ir w ork, it

sh o u ld re d u ce th e re a so n s lead in g p e o p le lo th e p riv ate sector. G o v e rn m en t

sh o u ld in cre ase th e a m o u n t fo r th e im p ro v em en t o f th e h o sp itals in th e budget.

M o st p ro m in e n tly th e re sh o u ld b e a m o n ito rin g ag e n cy to m o n ito r th e b e h a v io r o f

th e s ta ff an d sh o u ld k ee p in to u ch w ith th e p eo p le ac cessin g w ith p ro b lem s.

T h e p riv a tiz a tio n p ro c e ss o f m ed ica l an d h ea lth ca re ed u c atio n an d th e

re d u c tio n o f th e p a rtic ip a tio n o f p u b lic sec to r o n th is issu e w ill g en e rate so m an y

so cial in eq u alities. T h e d iffe re n c e b e tw e e n th e h av e s an d h av e -n o ts w ill in crease

in a w id e level. T h a t c h a n g e w ill o c c u r in th e field s o f ed u catio n , em p lo y m en t

o p p o rtu n itie s an d ev e n in th e ec o n o m ic a n d social w ell b eings. K e rala a s a state

m o tiv a te d b y th e co m m u n ist an d so c ia list ideas and created p o licies in co n n ectio n

w ith th e so cialist o u tlo o k . T h e p riv a tiz a tio n o f m ed ical ed u c atio n w ill lead to th e

w ith d raw al an d e x c lu sio n o f th e d isad v an ta g ed social g ro u p s w h o d o n 't have

m o n e y to c o m p ete w ith th e rich ones. T h e m ore su ffe rers w ill b e th e trib al groups.

D alits, fish e r fo lk an d su ch o th e r alien a te d co m m u n ities. A fte r fifty y e a rs o f th e

state fo rm a tio n so m e o f th e social situ atio n s ex ists sam e in c e rtain a re a s o f th e

state. T h e ex c lu sio n o f th e stu d en ts fro m th e alie n a te d c o m m u n itie s in th e p riv ate

c o lle g e s an d th e ab se n c e o f th e p u b lic s e c to r w ill c re a te a serio u s g u lf b e tw e e n th e

rich an d poor. O n th e b asis o f th e co n d itio n s an a ly z ed th e p eo p le are try in g to

g iv e b e tte r h ea lth an d m ed ica l su p p o rt to th o se w h o are su fferin g in a situation.

B u t i f th e p riv a tiz a tio n h o sp ita ls in cre ase th e co st o f m ed ical c a re w ill also

in crease. H en ce, it is n o t easy to th e p o o re r sec tio n s o f th e so ciety to b e a r the

ex p e n se s o f the m ed ical care an d ed u c atio n al ac tiv h ies. “ In g en eral, th e

p riv a tiz a tio n p ro v id e s n o h o p e fo r th e p o o re r stra ta o f th e society. T h o se w h o are

a d m itte d to a g o v ern m e n t h o sp ital are g e n e ra lly fro m p o o r an d lo w e r m id d le -class

fa m ilies an d th e y are u su ally at th e w h im s and fan cies o f th e h o sp ital au th o rities.

I f th e d o c to r h as to a tte n d to a p a tie n t h e/sh e h a s to b e b n b e d o th e rw ise the

p atien ts' c o n d itio n is bound to tu rn fo r th e w orse.

 T h e issu e o f b e c o m in g a c o n su m e r stale is th e n e x t p ro b lem o f p re sen t day

K erala. K e rala is d esc rib in g in th e ec o n o m ic m ap o f In d ia as a c o n su m e r state.

T h e state d e p e n d th e o th e r states o r o u tsid e In d ia fo r all o f its su b ject m atters.

D u rin g th e p e rio d o f 1970s an d 1980s m ajo rity o f th e u n em p lo y ed y o u th w e n t

a b ro ad esp e cially to th e G u lf co u n trie s for b e tte r jo b s and salaries. A s d iscu ssed

ea rlier th e G u lf b o o m re su lt w a s th e d ec lin e o f th e agricultiarai sec to r o f th e state.

P la n tatio n cro p s w e re b e g u n to c u ltiv a te in ea ch an d ev e ry sp ac e p o ssib le .

E sp ec ia lly ru b b e r p la y e d th e p ro m in e n t ro le in th is category. C u ltiv atio n o f

p la n ta tio n c ro p s re d u c e d th e cu ltiv a tio n o f o th e r cro p s an d item s. P a d d y fields

g ain ed afte r th e lan d re fo n n s act w e re n o t cu ltiv ated larg ely and p ro p erly . R ich

p eo p le w h o ca m e b ac k from th e g u lf re g io n s w e re n o t re ad y to c u ltiv a te in th e

p a d d y fields. T h is b ig o ted an d m en tality affected th e ag ricu ltu ral se c to r o f th e

state. T h u s th e slate b ec am e a c o n su m e r state b y g ettin g re so u rces im m e d ia tely

n ec essary for d aily life. T h e ten d en c y o f co n su m erism o f the state is re su ltin g in

th e e m erg en ce o f d iffe re n t ch ro n ic diseases. T h u s, d irec tly an d in d irec tly the

ten d en c y o f co n su m erism d e g e n e ra te th e ad v a n ta g es o n ce th e state h a d gained.

In c rea se in p o p u la tio n in ce rta in areas an d lack o f facilities is a n o th e r th rea t

to th e h ea lth se c to r o f K erala. T h e co u n try o f In d ia is re ach e d th e stag e o f h ig h est

p o p u la tio n g ro w th w ith m e re re so u rces. K e rala is o n e o f th e p o p u lo u s states in

In d ia facin g th e th reat o f p o p u latio n . It is th e sec o n d h ig h e st d en sity lan d in India.

T o so lv e th e issu e th e g o v e rn m e n t o f India o u tlin e s a lo n g term o b je c tiv e for

attain in g a stab le p o p u latio n b y 2 0 4 5 , w ith c o n sisten t levels o f re q u irem en t an d

so cial an d ec o n o m ic developm ent.^^ T h e p ro g ra m m e is k n o w n as th e N a tio n al

P o p u la tio n P o lic y o r N P P 2 000.'* It w as add ressed issu es o f en su rin g u n iv ersa l

access to h ea lth c are o p tio n s an d stab iliz in g population.^^

H e alth in su ran c e a co m m o n m o d e o f m ed ica l secu rity is d o m in a n t m th e

co u n try an d h ig h ly cu sto m ary in K erala. T h e g o v e rn m e n t em p lo y ee s an d w o rk e rs

in th e o rg a n iz ed an d o th e r sec to rs h av e th e fam iliarity and re sp o n siv e n ess in th e

field. E n su rin g g o o d h e a lth fo r all an d h ea lth in su ran ce su p p o rts th e p o p u la tio n to

face th e se v e re h e a lth issu es w ith r e lie f

 K erala is th e G o d 's o w n co u n try w orldly re n o w n ed fo r its space o n to u rist

sp h ere. T h e to u rist from d iffe re n t re g io n s o f the w o rld is u sed to c o m e to th e stale

fo r to u rist p u rp o se s. In c o u rse o f tim e o f th e p riv a tisa tio n o f th e h ea lth se c to r and

th e n ew ly d e v e lo p e d to u rist m ap created a new arena. It is k n o w n as m ed ical

to u rism . W id ely it is u sin g b y th e to u rist o p erato rs in co n n e ctio n w ith h o sp itals.

T h ey in au g u ra ted p ro je c ts o f to u rism an d m ed ical trea tm e n t o n th e sam e lo catio n

w h e re th e to u rist are w ish in g to go.^‘ A large n u m b e r o f to u rists are c o m e here

fo r trea tin g d iffe re n t d isease . L o w cost, c o m b in a tio n o f th e trea tm e n ts lik e

ay u rv ed a, sid d h a, a c u p u n ctu re, n a tu re th era p y an d y o g a create a re sto rativ e

h e a lth y feelin g to th e p atients.

T h e K e ra la m o d el d e v e lo p m e n t can b e re g ard e d as th e b asic re aso n fo r th e

la b o u re r m ig ra tio n to K e ra la in a d d itio n to th e o th e r d iffe ren t ca u ses fo r the

m ig ratio n . T h e lack o f sk ille d lab o u re rs, h ig h w a g e d em an d s, an d m in im u m

w o rk in g h o u rs p ro m p te d th e n ativ e em p lo y ers to lo o k fo rw ard fo r g ettin g sk illed

lab o u re rs w ith m in im u m wage.^" T h is tem p ted the o th e r sta te ’s lab o ru e res w ho

w e re in se a rc h o f jo b re ach e d K erala. H ere th e social and ec o n o m ic co n d itio n s

w e re g o o d an d a m p le fo r th e group. B e tte r ed u c atio n al facilities fo r th e ir ch ild ren ,

g o o d h ea lth c o n d itio n s, tra n sp o rta tio n facilities, b e tte r a tm o sp h ere an d clim atic
fl1
c o n d itio n s te m p te d th em to re ach th is lan d an d settle here.

T h e m ig ratio n o f lab o re rs is ad v e rsely affectin g th e h ealth sp h ere o f K erala.

T h e u n h ea lth y liv ing c o n d itio n s in th e cam p s, lack o f san itatio n , lack o f h y g ie n e

a n d th e ab se n ce o f o th e r d e term in in g facto rs are p re v a le n t in th e ca m p s w h e re

th e se m ig ran t lab o u re rs are settled.^'* It is th e ro o t ca u se for th e e m e rg e n c e an d re -

e m e rg e n c e o f ce rtain c o m m u n ic a b le d iseases like, m alaria, ch o lera, d ia rre h e a etc.

T h e se a re h ap p e n in g at a n y ca m p s w h e re th e y are living.*^ T h e m ix in g u p o f

c u ltu re an d o th e r facto rs w ill d e fin ite ly d eterio rate th e co n d itio n s o f th e state.

C o n c lu s io n

H ealth is th e to tal w ell - b ein g o f a p e rso n s’ m en tal, physical an d em o tio n al

p erfec tio n . It is o th e rw ise m ean s a state free fro m all ty p es o f d isease s o r to

p re v e n t d isease s. A g a in it is to create c irc u m sta n ces to m ak e an in d iv id u al from

affec tin g all ty p e s o f d isease s. T o g et n d from all ty p es o f h u rd les in th e w a y o f

total d ev e lo p m e n t o f h ea lth it is th e d u ty o f th e state to m ak e n ec essary step s to

so lv e it. E v en th o u g h th e state h as ac h ie v ed high p o sitio n s m th e h ea lth sector,

n o w th e state is su rro u n d e d b y th e issues. T h e ab o v e m en tio n ed p ro b le m s and

ch a lle n g es are in creasin g d a y b y day. S o lv in g th e issu es is a serious task a s it is

co n cern ed . It is th e d u ty o f th e state to e n tru st d iffe ren t stak e h o ld ers to so lv e th e

issues. P ro p e r g u id a n c e an d m ix in g up o f d iffe re n t m e asu res is n ec essary to solve

th e p ro b lem s. It is th e d u ty o f th e g o v e rn m e n ts to g iv e p ro p e r aw aren e ss o n the

p rim a ry issu e o f p o p u latio n grow th. It is th e in cre asin g level o f p o p u latio n

d e fin ite ly m a k e s issu es o f m a ln u tritio n , p o v erty , a b se n c e o f g o o d d rin k in g w a te r

an d in a c c e ssib ility o f h ea lth ca re m easu res. T he g o v ern m e n ts are facing th o se

serio u s th rea ts to its n atio n al an d state g ro w th ratio. T h e fam ily p lan n in g

m e asu res ev e n o n ce attain ed a lev el in th e state, now a d ay s th e state is facin g an

a la n n in g lev el o f p o p u la tio n g row th. T o av o id su ch situ atio n th e g o v ern m e n t

m u st tak e steps. A n o th e r issu e o f alien a tio n o f ag ein g p eo p le, th e g o v ern m e n t

sh o u ld start sh elters to p ro te c t th em . A n o th e r issu e o f h esitan c e to d iffe re n t ty p es

o f v ac cin atio n s, th e g o v e rn m e n t h as to in itiate aw aren e ss p ro g ram m e s to th e

p eo p le. By re d u c in g p riv itisa tio n public se c to r sh o u ld be stren g th en ed .

In frastru ctu re o f th e p u b lic se c to r is th e o n ly re m e d y to th e c o m m o n a n d a lien a te d

o r p o o r sec tio n s to g et r e lie f from th e ir h ealth issues. It sh o u ld b e tak en as a

c h a lle n g e fro m th e g o v e rn m e n t th a t it w o u ld su p p o rt th e p eo p le w ith free o r low

ra te m ed ical o r h ea lth su p p o rt to th e m ajo rity o f its g en eratio n s.

 M ichael F oucault, P o w er/K n o \\'led g e: Selected Interview s a n d W ritings 1972-

1977, C olin G ordon (ed.), (N ew Y ork, P antheon Books, 1980), p. 166.

Ibid.

E. C handra S ekharan N air. K erala Vikasana M athruka -P ra th isa n d h iyu m

P arihara M argangallum (m al), (T hiruvananthapuram . P rabhath B ooks, 2003),

pp.7-8.

F rom A lm a - A ta to the y e a r 2000 R eflections a t the m idpoint (G eneva: W orld

H ealth O rg anisation 1998), p .U 2 .

P .G .K .Panikar, and C .R .S om an, H ealth status o f K erala, op. cit., p.47.

O xford D ictionary English.

P .G .K .Panikar, op. cit.

E conom ic R eview 2005, op. cit., pp.470-476.

H a ndb o ok o f the D epartm ent o f H ealth Services, (T hiruvananthapuram :

G overnm ent o f K erala, 2009).

K .P.A ravindan, K erala A rogya M athruka p u th iya N oottandilekkii fTvlal),

(K ochi:K erala S astra S ahithya Parishad, 2001), pp.46-53.

10
Ib id

Ibid.

12
I b id

13
K.P. A ravindan, (et.al). H ealth Transition in R u ra l K erala 1987-1996,

(K ochi: K erala S astra Sahitya Parishad, 1991), pp.l7*-39.

K.P. K annan (et.al). H ealth and D evelopm ent in R ural K erala,

(T hiruvananthapuram : integrated R ural T echnology C entre o f the K erala

S astra S ahithya P arishad, 1991), p p .55-69.

 Ibid.

Ibid.

19
K.P. A ravindan, R. V. G. M enon, A Snapshot o f K erala L ife a n d Thought o f

the M alayaJee People, (T hrissunK erala Sastra Shithya P arishad,2010), pP-72-

20
p p .59-72.

21
Ibid.

Ib id

23
Ibid, pp.72-86.

24
B. Eqbal, K erala H ealth Success to crisis, op. cit., pp. 280-29L

25
Ibid.

26
A nu.S.N air, H ealth System in K erala: A n O verview . In Introduction to K erala

Studies, J. V V ilanilam (et.al.) (U S A ' Inlem ational Institute for Scientific and

A cadem ic C ollaboration, 2002), p.946.

27
Ib id

28
T.D . Sim on, H ealth care a ccessibility a n d socio-econom ic groups: A stu d y o f

K erala, (U npublished Ph. D T hesis, D epartm ent o f E conom ics, Dr. John

M atthai C entre, U niversity o f C alicut, 2007), p p .55-58.

29
V, R am an K utty, The K erala H ealth M odel: Time f o r R e-assessm ent, Joseph

T ham aram angalm (ed.), K erala the P aradoxes o f P ublic action and
D evelopm ent, {New Delhi: O rient L ongm an P rivate Ltd., 2006), p p .3 0 9 -3 11.

30
K.P. A ravaindan, op. cit.

31
P.G .K . Panikar, op. cit., p .102.

32
Ib id

33
 Lakshm i.S, (et.al) D evelopm ent a n d E m erging issues in P ublic a n d P rivate

H ealth C ave System s o f K erala, (D elhi; International Journal o f P harm acy and

P harm aceutical Sciences, V ol.6. suppl.2, 2014) p.93.

35
C. U. T hresia and K.S. M ohm dra. Public H ealth C hallenges in K erala and S n

Lanka, (EPW . July 2011). op. c/r.,p.lOO

36
Ibid.

37
S.A bdul A ziz, D engippani, C hikim giinia k a ra n a n g a h m

p rathiro dha m argangalum , (Thiruvananthapuram : K erala L anguage Institute,

2007), pp.1-21.

Ibid-

Ibid. p p . 22-40

Jeevithasailiyum A rogyaviim (^ a l), (T h riss u r K erala S astra S ahithya

P arishad, 2010), pp.5-15.

41
E nviron m en t R eport-K erala 2001, L a n d E nvironm ent, W etlands o f K erala a n d

E n vironm ental H ealth, (T hiruvananthapuram ; M inistry o f E nvironm ent and

Forests, 2002), p.31.

42
Ibid.

43
Dr. K. R. S uresh K um ar (et.al) op. cit., pp.32-33.

44
T. D. Sim on, op. cit., p .67.

45
J.R adhakrishnan, C hikistsa R angathe M attam (M ai), V .K .N anda K um ar,(ed.),

K eralathinte m arunna M ughachaya (M al),(E m akulam : K urukshetra Prakasan,

2000), pp.258-264.

B eena.K .N and Jaya D .S, E valuation o f so il contam ination in the surrounding

o f K erala M in era ls a n d M etals L im ited (K M M L) industrial area in K ollam

D istrict, (Journal o ff Social S ciences and E nvironm ental M anagem ent,

A cadem ic jo u rn als, V o .7(7) July 2016,

http://w w w .academ icjournals.org/JSSE M ), pp. 1-7,
 S haharban K .P and Shabana T .P, A g riciiltn ia l land decline in K erala; an

Investigation, A n investigation, (N ew Delhi: International journal o f scientific

and research publication, V o l.5 June 2015) p. I

Indira D evi. P esticides in A griculture- A boon or a curse? A case study o f

K erala, E conom ic and P olitical W eekly, op. cit.. p p l9 9 -2 0 3 .

49
Ibid.

50
Ibid.

5!
The H indu, (T hiruvananthapuram ; 20 O ctober 2017).

52
Ibid.

53
A. Sreedhara M enon, A Survey o f K erala H istory, op. cit., p .393.

54
T h e H indu, (T hiruvananthapuram : 4 M arch 2015).

55
Ibid.

56
K allel Pokkudan, K andalkkadukalkkidayile E nte Jeevitham , (M ai.) (C alicut:

G reen B ooks, 2010), p. 47.

57
Ibid.

58
Ib id

59
The H indu, (K ozhikkode: 25 M arch, 2015).

60
Ib id

61
N ithya N. R., K erala M o d el o f H ealth: C risis in the N eo-liberal Era, op. cit.,

Ib id

B eena K.N. and Jaya D.S. op. cit.

64
Ibid.

R am achandra G uha, India after G andhi, (London: Picador, 2008) p.692.

Ibid.
68
Ibid.

69

70
C.R. S om an K erala's C risis in P ublic H ealth, op. cit.

Ibid.

72
V .R am ankutty, K erala 'M odel' in H ealth, in M .A . O om m en (ed.al),

R ethin kin g D evelopm ent: K e ra la 's D evelopm ent Experience, (N ew Delhi:

C oncept P ublishing, 1999), p p .1-4.

73
Ibid.

75
A nu. S. N air, op. cit., p.

76
Ib id

77
M ahendra K. Prem i, P opulation o f India In the new M illennium : C ensus

2001,( N ew Delhi: N ational B ook T rust India. 2006), p p .3-5.

78
Ibid.

79
R.K. Patel, op. cit., p. 14.

Ibid, pp. 59-60.

81
Joseph. M. C hrukara and Dr. Jam es M analel, M edical Tourism in K erala-

C hallenges a n d Scope, (R esearch G ate, 15 M ay, 2008), p p .370-371.

82
The H indu, (T hiruvananthapuram : 23 A ugust 2015).

83
Ibid.

84
Ib id

85
Ib id
 CONCLUSION

Kerala has been described as ‘unique’ among developing States,

a society where the ‘health and demographic transition have been achieved

within a single generation’ after the formation of Kerala State at a relatively

low public cost. There was a surprisingly increasing trend in the health

infrastructure like hospitals, health centres, laboratories, research centres,

doctors, paramedical personnel, medical and nursing colleges, etc.

Kerala’s achievement in health in spite of its economic

backwardness and its very low spending on health has prompted many

analysts to talk about the unique ‘Kerala Model of Health’ worth emulating

by other developing nations of the world. The seeds of infrastructure of the

health delivery system were sown in the State in the early days of the

princely rulers itself. The health strategy during the earlier phase was

directed against the control of infectious diseases like cholera, plague,

smallpox and malaria. This yielded impressive results in terms of changes

in the pattern of morbidity as well as mortality rates. Expansion of curative

medical care facilities also received its emphasis in due course of time. The

missionaries who came to this land not only imparted education on modern

lines but also contributed much in augmenting health standards of the

people by providing health care services. There are many socio-economic

conditions like female literacy, political climate, agrarian reforms and public

distribution system which is unique to Kerala and which has been

postulated to make this health model possible.

215
 Apart from these socio-economic factors outlined, the three-tier

system of health care also contributed to the high health status of the

people. The Primary Health Centres (PHC) and the Community Health

Centres (CHC), Taluk and District Hospitals and the Medical Colleges are

evenly distributed both in the urban and the rural areas. Apart from modern

medicine, Ayurveda, Homeopathy and other alternative systems are also

available to the people in Kerala.

The administrative service has developed and carried out crucial

programmes in family planning, health and housing that focus on the

community needs. The earnest efforts put in by the Government in building

up a sound health infrastructure, capable of delivering health care at

different socio economic levels even in remote rural areas have been

significant in raising the health status of the State and in enabling the State

to play a leadership role. It can be expected that the innovative schemes

adopted in Kerala and the leadership role played by the State in the

implementation of various health and family welfare programmes will serve

as a model for other states.

Kerala stands out as a beacon in health not only for India but also to

the rest of the world. It demonstrates the overriding importance of non-

medical factors and of the people’s active involvement in their own health

even within the limitation of severe economic constraints. Kerala devotes a

large percentage of its budget to health and education, female education

and employment which are emphasized with striking results.

216
 The State has achieved all the major health indicators targeted for

“Health for all by 2000 AD”. It would be worthwhile to look at this juncture

beyond 2000 AD in the context of the global discussion of ‘Zero Population

Growth’. Kerala may attain birth rate of about 10 per 1000 in another 20 to

25 yrs. The death rate has almost stabilized around 6 per thousand.

The health care programmes emerge as the main factor contributing

to the improvement in health status. The National health care programmes

are carried out throughout the State. Coupled with the achievements

gained in these programmes aimed at the control and eradication of killer

diseases, the MCH activities contributed very much in the reduction of

infant mortality and maternal mortality and in raising the life expectancy at

birth especially of females to over seventy years. The successful

implementation of the Family Welfare programmes reduced fertility rate to

the lowest in the country and the couple protection rate was recorded over

fifty. The implementation of IPP III covering four districts had brought in

impetus and momentum to the whole health care system of the State. All

attempts are being made to ensure people’s participation in the

programmes and to achieve inter sectoral co-ordination from the village to

state level with the hope to bring forth an era of better health standards.

The State will thereby be a model of health care delivery with complete

community backing, people’s participation and social commitment.

In primary health care centres, the acceptance and awareness about

health are comparatively high among the people in the State. Besides the

spread of literacy among females, climatic and topographical conditions,

217
availability of safe potable drinking water, hygienic and clean habits of the

people, sanitary facilities and above all a sound health infrastructure

directed towards curative, preventive, promotive and rehabilitative aspects

of public health have played significant roles.

The State has probably achieved its optimum level and it requires

fresh set of policies to take the State further ahead. The State’s health

system is so typical that it requires a comprehensive approach to tackle its

current problems and to fulfill the desire to hold on to its lead over other

Indian states. Population ageing, dual disease burden, cost escalation, high

out-of pocket expenditure, indebtness, co-existence of unrelated illness,

over medicalisation and distress selling of assets are some of the major

health system issues of Kerala. All these indicate that the State at present

does not enjoy similar advantages as it had in 1950’s.

The widely acclaimed Kerala Model of Health has started showing a

number of disturbing trends recently. It was clearly pointed out that, the

widely acclaimed Kerala Model of Health can be described as ‘Good health

at low cost based on social justice which is passing through a period of

crisis and if unchecked this may lead to an American model of health based

on privatization and marginalization of the disadvantaged. The important

aspects of the present health scenario in Kerala are :

 The simultaneous presence of the diseases of poverty and the

diseases of affluence or life style diseases.

 The slow decay of public health system.

218
  The uncontrolled growth of the private sector.

 Escalation of health care cost.

 Marginalization of the poor.

A look at the profile of the health services infrastructure in Kerala

would show that there are several institutions ranging from century old

ones to recently built ones. Majority of these old buildings have been

transformed to meet the need of the hour.

Various individual facilities have been built during these last few

decades using the resources from the State Government and various other

funding agencies. The Indian population project, reproductive and child

health programme are all examples of such endeavours.

In recent times the welfare funds available to the members of

Parliament and the Legislative Assembly have been made available for the

use of building such infrastructure. However it can be seen that sometimes

political and regional consideration have exerted an influence upon the

manner in which the resources and funds which were made available had

been spent by the haphazard manner these buildings in several institutions

have been built.

Though this kind of development of infrastructure was accomplished

a situation in which there is no standardization of the institutions has arisen.

There is a great need for evolving a logical sequence to narrow down the

gap in the inadequate provision of health care.

219
 The Government Health Service in the State is to be re-oriented to

meet the new challenges faced by Kerala today. Kerala has to create a

forum to meet the disparity in the health sector in the Malabar regions on

par with the health sector in other areas.

Kerala is now witnessing the emergence of an epidemic of chronic

diseases like diabetics, heart diseases, hypertension etc. Therefore various

community level prevention programmes have to be devised to enlighten

the people about prevention and management of these diseases. This can

be effectively carried out by strengthening the Public Health Centre.

The Public Health Centre has been a critical component for the

success of the ‘Kerala Health Model’. This can be seen from the fall in the

incidence of infectious diseases, falling birth rate etc. However the success

of these programmes does not diminish the need to revitalize the Primary

Health Sectors to meet the needs of the public in the present global

scenario. The health workforce is critical to the reforms of Primary Health

Centers. Significant investment is needed to empower the health staff to

learn and adapt combining the biomedical and social perceptiveness today.

Commercializations of the health services have eroded the value in taking

the time to create and foster the trust in an individual. But the health

workers in the primary health centre constantly interact with the individuals

in the community they serve in. This allows them to understand their health

and social issues. This type of people centered care is necessary in rural

areas. Hence it is highly important that proper preparation and an interface

220
between the population and the health services of the State needs to be

redesigned to make it more effective.

The coordination between the primary, secondary and tertiary care

systems have to be made more integrated. More resources should be

made available for this type of infrastructure. The trend towards the hospital

centric policy formation has to be stemmed and policies which are more

people centered at their community itself have to be framed.

The area specific programmes launched in the State have brought

in encouraging results promising the attainment of the designed goals.

Government expenditure on healthcare has been steadily rising over the

years. During 1957-58 and 1980-81, the Government expenditure on health

care increased at an annual rate of 13.04 per cent. Now the State is

spending 15% of its budget for health. It is a very high percentage and it is

doubtful whether the State would be able to increase this percentage of

expenses any further as it is finding difficult to tap fresh sources of income.

The Kerala health situation should be analyzed in detail with

generation of primary data regarding morbidity pattern, etc. with the help of

a periodic health survey and a people oriented health policy for Kerala

should be formulated.

Though the Department of Health and Family Welfare in the State

has a glorious past of development and progress in the provision of health

care it is an alarming fact that this Department too need reformation and

structural changes to provide the State with health care facilities more

221
efficiently than in the past. Toning up the health care system in the State

and making it capable of taking on the burden of providing equitable,

efficient and good quality health care needs concerted action. Concrete

steps need to be taken in the present which could take the glorious past to

the future generation also.

SUGGESTIONS

Through the study a list of suggestions to preserve the legacy of

Health and Family Welfare Department of the State is given below :

Re-instating the primacy of the Government Health service is the

need of the hour with its emphasis on primary health care. This would

necessitate upgrading the facilities in most institutions and ensuring that

these are available to most of the people.

IMPROVEMENT OF NON HEALTH SECTOR

The goal of better health has to be brought through development

of the non-healthcare sectors including food, housing, water supply and

sanitation. There is the need for a synergistic approach embracing all the

factors affecting the health status. All these basic needs have to be met for

attaining the health goal.

FINANCIAL AVAILABILITY

There is a felt need to strengthen the financial availability of

Government institutions. This means greater flow of funds to the peripheral

level hospital so that quality care can be adequately maintained. Finding

222
enough funds for the health sector is a challenge that has to be taken up

immediately. There are several possible ways of improving the health care

financing situation in the public hospitals and health centers.

i) Proper planning, prioritization and efficient utilization of the health

budget.

ii) Re-organizing the allocation of resources in the health sector more

efficiently by eliminating wasteful expenditure.

iii) Raising resources within the health sector with people’s

participation and consensus decision making.

iv) Tapping resources from other sectors like the co-operative sector,

banks, etc.

v) Health improvement is a complex phenomenon and cannot occur

just by isolated inputs. It is mediated by a number of factors which

co-exist and need to the tackled by an action programme. The

inter-sectoral action needs to be recognized for achieving any

health improvement.

COMMUNITY FINANCING

There can be a community or Panchayat (village) level tax

specifically collected to fund health care. This amount can be set apart

specifically for running the local level health institutions such as the Primary

heath centre. The present atmosphere of decentralized planning through

local bodies with people’s participation shows that the hospital

223
development committees can play a major role in resource mobilization. A

differential charging system as envisaged by the hospital development

committees by a consensus decision rather than as policy decision

enforced from above may be acceptable to the people. The panchayat raj

system rooted in community involvement is well poised to change the

scenario in the State. This is likely to conceive a new decentralized and

participatory ‘Model of Health care’ in the State.

COST CONTAINMENT

Another option for better performance of the health sector is to see if

costs can be contained, without affecting the level of services. By

streamlining the purchase of equipment and drugs, the transfer, posting

and recruitment of the staff and by other administration procedures, a lot of

efficiency could be introduced into the functioning of the health services.

Financial and administrative decentralization and reforming and

rationalizing the archaic administrative procedures should be considered

seriously for improving the present system.

RECOGNIZING THE ROLE OF THE PRIVATE SECTOR

In Kerala, in terms of infrastructure, the private sector has grown par

with the government health services. Policy making in health has to

acknowledge private sector’s contribution also. Expansion of facilities in

both the government and private sector should follow a need-based plan.

There should be guidelines for introducing newer technologies both in the

224
private and government sectors. Meanwhile the need for greater control of

the private sector should be emphasized.

LINKING UP WITH OTHER SECTORS

There is now a strong need for an intersectoral approach to meet the

health challenges in the State. The Community Medicine Departments

should be reorganized to spearhead such a multifactorial approach. It

needs concerted action from the Government working in close collaboration

with the people through Panchayat Raj institutions, for the State to ward off

these challenges and scale even greater heights in health achievement. A

meaningful co-operation of the different systems of medicine should also

be encouraged.

The study has its own limitation in the availability of relevant data.

The only firm data available is on mortality rates and there is a yawning gap

on data relating to morbidity. This is an area of priority which needs

emphasis in future research as assessment of health status in the absence

of data related to the incidence and prevalence of disease and variation

across social classes is bound to be incomplete. Even the trends in the

number of visits to hospitals and primary health centres may be used as a

proxy for measuring changes in health trend. Non-Health care variables like

housing, environmental sanitation, status of women, educational and

cultural levels which are proposed as a set of indicators proposed by WHO

can be used to measure the change in health trends.

225
 The programmes initiated by the Health and Family Welfare

Department and the people who are benefited from such initiatives have to

be recorded properly. The Department has to maintain statistics regarding

the beneficiaries of all the programmes year-wise so as to derive a clear

picture on the steady progress of the Department over year. Data regarding

services rendered by the sub-divisions of the department, community

participation, and inter-sectoral co-operation also need to be recorded. It is

also suggested that the Health and Family Welfare Department could

initiate an integration of the Allopathic system of medicine and Ayurveda

and Homeopathy of Indian System of Medicine to reach all the people of a

fast growing population.

226