The Left Democratic Front made a promise in its election manifesto of 2016 – that it would draft a new health policy for the specific needs of the state. In mid-February, the state cabinet approved such a policy prepared by a 17-member panel constituted by the health department comprising eminent medical practitioners and health activists.

Dr KP Aravindan, convenor of the policy drafting committee and professor emeritus at the Government Medical College at Kozhikode, said that a state health policy was long overdue as the central government’s policies cannot address state-specific health problems. “Kerala has high human development indices and a comparatively better healthcare system,” he said. “Our problems are different from other states. That is the main reason for formulating our own policy.”

Among the many problems that the policy seeks to address are rising incidence of lifestyle diseases, recurrent outbreak of infectious diseases, ill-health in an ageing population and among marginalised communities, and inadequate trauma and mental healthcare.

Reducing healthcare expenditure

The policy points out that the biggest public health problem is enormous out-of-pocket expenditure on healthcare – the predicament for patients across India. The policy notes that medical expenditure has increases because of privatisation and commercialisation of the health sector, advances in diagnostic technology, rise in prices of essential medicines, a backward public health sector, no comprehensive free medical care to the poor, a tendency among patients to seek super specialty healthcare for all ailments, and a rise in diseases like cancer that need long-term treatment.

“Private health care has become expensive,” said Aravindan. “Members of middle class and aspiring middle class cannot afford to it. So we want to strengthen public healthcare.”

The aim is to increase state government expenditure on healthcare from the current 0.6% of the Gross State Domestic Product to at least 5%, by increasing it by 1% every year. The panel suggested measures to increase revenue that can be used for public health expenditure, such as “sin taxes” on liquor and tobacco.

On the other hand, the policy proposes regulating private healthcare facilities by ensuring that they are all registered. The panel expects that the Clinical Establishments Act passed by the Kerala assembly in the beginning of February will also help rein in errant private healthcare facilities.

Treatment protocols

Another major provision of the Kerala health policy is to have standard treatment guidelines binding on all medical professionals that the panel feels will help reduce treatment expenses. The aim is to curb unnecessary laboratory tests and clinical procedures.

“We put forward the suggestion to control irrational treatment practices,” said Dr AK Jayashree, head of community medicine at the Pariyaram Medical College and member of the committee that drafted the health policy. “It cannot be done quickly. The government should convince medical practitioners and their organisations before going ahead with it.”

However, some doctors in the state feel that such a move is impractical. “We can have a treatment guideline, but it should also be institutional specific,” Dr KA Rauf, state president of Kerala Government Medical Officers’ Association, an organisation of all doctors working with the state health services department. “How can we have common guidelines for primary health centres and medical college hospitals as there is a huge gap between the facilities and availability of doctors?”

The policy also suggests a separate antibiotic policy drafted by an expert antibiotic guideline committee to prevent the indiscriminate use of antibiotics that is currently leading to a crisis of antibiotic resistance across the country. Dr N Sulphi, Kerala secretary of Indian Medical Association, welcomed the move to have a state-specific antibiotic policy despite the existence of a national policy. “Antibiotic use is much higher in Kerala compared to other Indian states,” he said. “The proposed policy can ensure rational use of antibiotics.”

Referral system

The policy noted that the absence of a functional referral system is affecting the quality of healthcare, noting that patients are going to superspeciality hospitals for ailments that can be treated at primary health centres. The panel has suggested classifying public health facilities into three categories – primary health centres, community health centres and family health centres as tier one hospitals, taluk and district hospitals into tier two and selected district hospitals and medical college hospitals into tier three category. Arvaindan emphasised the need for the government to educate the public about approaching tier 1 health facilities first and that they can be referred up the chain, when needed.

Patients with fever line up outside the out-patient ward at the Thiruvananthapuram General Hospital in May 2017.
Patients with fever line up outside the out-patient ward at the Thiruvananthapuram General Hospital in May 2017.

Apart from strengthening public health institutions, the policy suggests tax exemptions for small private hospitals. “They give cheap or affordable medical care,” said Aravindan. “The arrival of corporate multi-specialty hospitals is threatening the existence of hospitals run mainly by doctors. So the government has to support them.”

Not surprisingly, this provision has been welcomed by doctors in the state. “A lot of people depend on small hospitals thanks to the low treatment expenses,” said Rauf. “Tax exemption can further reduce the cost of treatment.”

Dr Sulphi of IMA said small private hospitals need government support as they play an important role in Kerala’s health sector. “An IMA study has found that around 500 small hospitals (run by one or two doctors) were closed down in Kerala in the last 10 years with the advent of big corporate hospitals. These hospitals provide affordable health care to patients and the government should provide sops to them.”

Spending on medicines

Only 3% of India’s population lives in Kerala, but people in the state consume 10% of the medicines produced in the country. The state spends between Rs 6,000 crores and Rs 8,000 crores on medicines every year. High medicine prices result in higher overall cost of healthcare. “It is time the state took responsibility for distributing quality medicines at affordable rates,” Aravindan said.

Aravindan says it is not difficult for the government to distribute cheaper medicines. “A majority of the medicines are being produced from 600-odd molecules. Only 50 medicines have got the patent protection.”

The state plans on setting up public or co-operative drug production centres that can manufacture generic drugs that can be sold at lower prices.

“Kerala State Drugs and Pharmaceuticals Limited, the public sector company, is currently manufacturing medicines worth Rs 40 crore. Our aim is to make it a 100-crore production centre. We are also planning to set up a pharma park to set up [public sector] pharmaceutical units,” said Aravindan.

Infant and maternal mortality

The policy also warns that the state must not get complacent about its infant and maternal mortality rates, which are far better than the rest of India. Kerala’s infant mortality ratio is 10 deaths per 1,000 births and maternal mortality ratio is 66 deaths per one lakh live births. Kerala has had difficulties getting over the last mile problem in bringing infant mortality into single digits, which requires micro strategies to get antenatal and neonatal care to the the few communities that still do not have such access.

“Infant mortality rate has to be brought to 8 by 2020,” the policy notes. The state plans to ensure that all clinics offering obstetric care are licenced and open through the day and night.

The policy also highlights the rising rates of breast cancer in the state and the need for a proper study of the disease burden and creation of a state cancer registry. It also recommends setting up additional tribal health centres in districts like Palakkad and Wayanad.

Aravindan says implementing the policy requires political will. Though the panel has put in a lot of effort to prepare the policy, Aravindan said the document should not remain static. “It needs reassessment every two years to make it a dynamic document. Pressure groups and patient groups should read the policy and question the government about non-implementation of the suggestions,” he said.