Kerala Assembly Elections 2026: Health sector achievements and frailties on focus

Public health has been at the centre of many ongoing election-time debates in Kerala, with the Left hailing the achievements of the health sector over the past decade as unprecedented, while the Opposition has been quick to point out that the frailties of the system are remaining hidden behind the propaganda over the Kerala model of health as the number one in the country. 

Kerala has long been celebrated as a model of high health outcomes achieved at relatively low cost—strong maternal and child health indicators, low infant mortality, and high life expectancy. But the glaring paradox today is that despite high per capita government expenditure on health, the State today records the highest out of pocket expenditure (OOPE) in the country—59.1% of the total health expenditure—as per the last National Health Accounts.

In 2017 when the first Pinarayi Vijayan-led government launched the Aardram Mission, the aim was to bring in structural reforms in primary health care so that the public health system becomes people-friendly and efficient and to shift the focus from curative care to preventive, promotive and palliative care. 

Aardram Mission

The Aardram Mission brought visible improvements in infrastructure, essential diagnostics and consumables, human resources and service delivery at the primary care level, with 740 primary health centres being transformed as family health centres (FHC).

But the outcomes have been uneven. The Comptroller and Auditor General (CAG) audits and research studies show that provision of human resources did not keep pace and that the Mission did not fully achieve comprehensive primary care or disease prevention objectives. “There was a clear thought process and excellent planning behind Aardram in 2016-17. It gave a face lift to primary care facilities, outpatient hours were extended, lifestyle clinics started as well an improved range of services were offered at FHCs. But in the second phase (2021-26), the Mission lost its continuity. Massive infrastructural expansion at secondary level hospitals through Kerala Infrastructure Investment Fund Board (KIIFB) was not matched with adequate provision of human resources, leading to poor utilisation. Outpatient care went up from 34% in 2014 to 47.5% in 2017-18 but for in-patient care, people approached the private sector more,” a senior Health official said.

A fundamental driver of the high OOPE in Kerala is the State’s advanced epidemiological transition (elderly account for nearly 20% of the population) and the burgeoning burden of Non-Communicable Diseases (NCDs) whose care is long term and costly and which is not well served by the present primary care system. These persistent gaps in care in the public health system force people to approach private sector regardless of the affordability factor. 

According to a 2024 study, while the people generally preferred government hospitals for non-acute ailments, for emergencies and other acute-care requirements they chose medical college hospitals or private hospitals.

Policy for the elderly

“Aardram II failed to bring in a comprehensive care policy for the elderly, whose care involves regular hospital visits and specialised care, given the high proportion of those with chronic diseases and multimorbidities. It also failed to prepare and train the health system for geriatric care. This will have to be addressed on priority by the next government,” a public health expert pointed out. In its second term, the Left government seems to have focussed on high-profile health projects when several issues involving the improvement of basic care were crying for attention, he added.

Idling facilities in public health hospitals which could have been made operational 24×7 through the provision of adequate human resources or the long-term follow-up of pre-term infants with developmental delays did not receive any attention as the government went after high-profile projects such as robotic surgery and organ transplant institute. 

Issues with KASP

The second Pinarayi Vijayan government also chose to ignore the fundamental governance failure at the core of Karunya Arogya Suraksha Padhati (KASP), run without any checks and balances or cost control mechanisms that are crucial for the sustainability of a health insurance scheme. If KASP was meant to provide free treatment for all, without contesting any of the health insurance claims, then the government should have made adequate budgetary allocation for the same. KASP’s insurance payouts consistently stood at ₹1,500-1,700 crore, while the annual budgetary allocation was just around ₹700 crore.

While pushing the narrative about the free treatment given under KASP, the government chose not to see how the scheme was bleeding public hospitals dry. In fact, KASP indirectly contributed to OOPE because public hospitals were penniless to make local purchases of drugs and surgical accessories, all of which patients had to buy on their own.

The huge fiscal commitment that KASP has become and its fallout on public hospitals are something that call for structural changes, a task that the successor government cannot ignore.