Why Kerala’s PHCs can boast of being the best in the country

“The population is 1004; there are four pregnant women, 74 senior citizens, nine living alone; 109 people have blood pressure and 70 are diabetics.”

These are the details of people with health issues in the 12th ward of Varavoor Panchayat in Kerala’s Thrissur, and the Accredited Social Health Activist (ASHA) there, Bindu M Babu, has all these details on her fingertips.

She needs to only go through her diary once to get more details such as the number of APL/BPL families, Dalits, migrants, infants, adolescent children, cancer patients and even the number of wells and rain water harvesting ponds, till the day before. Overall, she maintains data of 215 households in her ward. (Wards with a bigger population have more than one ASHAs).

Bindu is relieved that the last COVID-positive person in her ward has tested negative a day before and the number of people under quarantine has come down to zero.

Her to-do list includes visiting every household once a month; meeting pregnant women and palliative care patients twice a month; calling up and visiting the elderly and those who live alone once a week so as to understand their requirements and supply necessary medicines; checking whether someone has communicable diseases; ensuring infants have been vaccinated at regular intervals and pregnant women are not missing Vitamin tablets.

This is the long list of duties that an ASHA worker has to do. And despite being quite unacknowledged, it is workers like Bindu who form the strong base in Kerala’s robust primary health care (PHC) network, an internationally acclaimed health care system.

From grassroots to awards

There are 26,000 ASHAs in Kerala, around 5,000 Health Inspectors and an equal number of public health nurses, doctors and anganwadi workers attached to PHCs.

Kerala has 848 Primary Healthcare Centres of which 168 function 24 hours. Attached to every PHC, there are 5-6 sub centres and Community Health Centres depending upon the population of the respective Panchayats.

Under the recently launched ‘Ardram Mission’, the PHCs are being converted into Family Health Centres. According to the Health Minister KK Shailaja, around 400 PHCs have been renovated, modernised and converted into Family Health Centres and the rest is under progress.

Over the last few years, Kerala has bagged a major share of national awards for the best performing PHCs. In 2019, seven PHCs in Kerala were ranked the best in the country and received the National Quality Assurance Standard (NQAS) by the Centre.

The Family Health Centre at Kayyur in Kasargod district which achieved a score of 99%, emerged as the top in the list as the best performing PHC in the country.

“Successful implementation of preventive healthcare with the participation of the people is the key to this achievement,” says Rajiv, the Health Inspector at the Family Health Centre in Kayyur. “There are sanitation committees at ward level. Jagratha Samithis and neighbourhood groups also act effectively paying attention to preventive care.”

As many as 23 hospitals in the state have achieved NQAS Certification, scoring 70% or above under various indicators. In 2018 too, the Primary Health Centres in Kerala were the top performing PHCs in the country.

The extensive fieldwork conducted by Health Inspectors, ASHAs and anganwadi workers plays a key role in Kerala’s achievement of the eradication of many deadly diseases like malaria and leptospirosis.

Such a coordinated effort is made possible due to the decentralisation of power and resources to the local self-governments.

“The vigilance and caution maintained by the health care workers at the primary level even in non-seasons of epidemics is our biggest strength. This factor has been a key in successfully containing the Nipah outbreak and Covid 19 in its initial phase,” says Dr Mohammad Asheel, the Director of Social Security Mission.

According to him, the watchfulness maintained at the primary level is a major factor in keeping the COVID death rate low in the state.

“Our circumstances are extremely challenging, more challenging than any other state, whether it be the population density, the flow of migrants and NRKs, or a high level of urbanisation. Despite all odds we could contain the death toll as low as possible,” says Dr Asheel.

Prone to viral attacks

Despite the robust healthcare network, Kerala has been constantly hit by new viral diseases every year. Besides the seasonal attack of communicable diseases such as Dengue, Chikungunya, Japanese Encephalitis, Avian flu and H1NI, there is an alarming trend of the return of the eradicated epidemics such as Malaria and Diphtheria.

In 2019, 656 malaria cases were reported but only one death was registered. On the other hand, a new variety of viral diseases like Avian flu, H1NI and Nipah has turned lethal over the past ten years.

Nipah virus claimed 16 lives in 2018 but Kerala’s health managers received international acclaim — even from WHO — for successfully containing the virus.

Kerala had the record of lowest death toll due to the virus which claimed hundreds of lives in Bangladesh and Malaysia. However, Kerala proved to be a fast learner from experience by containing the Nipah outbreak in 2019 by lowering the death toll to one.

Poultry farmers are often attacked by Avian flu. Massive culling of birds was the only way out to control the disease which resulted in heavy loss for the farmers. Around 2.6 lakh ducks were culled in 2014, when the state was worst hit by Avian flu.

Massive programmes have been launched to control viral diseases being spread by mosquitoes. “We start preparations well in advance to the rainy seasons. Environmental cleaning is a major activity. House visits to eliminate circumstances supporting mosquito breeding, awareness campaigns, collecting the fever data and ensuring proper medical attention are carried out regularly,” says Jobi, a health inspector in Thrissur district.

All this has borne fruit in the form of more people visiting PHCs. “Ten, twenty years back, only those who came by bus or bicycles used to access PHCs. Now, we can see people coming in Ferraris,” claims Jobi who has been in the service over the last 25 years.

The urban and the middle class accessing health service in the primary sector has been a tangible result of Kerala’s systematic and collective efforts in strengthening preventive health care.

The figures too prove the same. In 2017, 165 dengue deaths were reported. This reduced to 32 in 2018. Only 14 dengue deaths have been recorded in 2019.

History paves the way

The roots of Kerala’s robust health care system can be traced back to 19th century under the British rule. According to historians, the princely state of Travancore had paid special attention to public health.

Vaccination against small pox was introduced in 1813 during which the rulers set the model by taking vaccination for the members of the royal family. Vaccination against smallpox was made compulsory in 1879 by the then king of Travancore.

The London Missionary Society established a medical mission in Travancore in 1795. In early 1900, other missionaries like the Salvation Army and Lutheran Missionaries established clinics and dispensaries in Malabar as well.

“In 1928, the Government of Travancore with the help of Rockefeller Foundation did a survey of diseases. This might have laid the foundation stone of Kerala’s public healthcare system,” says M Kabir, public health expert and former professor with Centre for Development Studies at Thiruvananthapuram.

A public health unit was established in Neyyattinkara in Thiruvananthapuram which could perhaps have given birth to the concept of Primary Health Centre, according to experts.

Absence of a public health act

Despite its well networked healthcare system, Kerala does not have a unified Public Health law. The state is governed by legislations that have existed even before the formation of the state — the Travancore-Cochin Public Health Act of 1955 and the Madras Public Health Act of 1939.

“A draft proposal has been under consideration for long. There is a need to integrate waste management, food safety etc. A unified public health act would bring all these activities under an umbrella which would strengthen the public health system,” says Dr Aravindan, a public health expert and a member of the expert committee for COVID-19 management.

“There are confusions with regard to the change in powers. The apprehension that such a unified Act may curtail the powers being enjoyed by LSGs (local self governments) is one reason for the delay,” he says.

However, he adds that such worries are out of place. According to him, the LSGs play a vital role which will not be weakened.

On the contrary, the absence of a Public Health Act is a major reason for the state’s mishandling of garbage management.