Kerala’s public health sector in need of a booster shot

A few months ago, a young road traffic accident victim admitted to the ICU at Government Medical College Hospital (MCH), Thiruvananthapuram, needed an emergency interventional radiology (IR) procedure to control a life-threatening haemorrhage.

The hospital has had a full-fledged IR cath lab since 2019. But it was not functional round-the-clock. With no permanent IR faculty or supporting team to operate it 24×7, doctors were forced to shift the patient to Sree Chitra Tirunal Institute for Medical Sciences and Technology on the same campus for the procedure. The patient died en route.

“It is inexcusable that the oldest medical college in the State does not have a round-the-clock IR lab,” a senior doctor points out. “The cath lab now functions only three days a week with a contract radiologist. Two trained interventional radiologists left two years ago, largely because of poor entry-level pay, an anomaly only partly corrected after the doctors’ strike.”

There are cath labs aplenty across the State now, in the public health system. However, not many are operational round-the-clock to provide life-saving care to patients, who are often rushed in at the middle of the night, doctors say.

Some bright spots

At the same time, incidents narrated by people like K. Anilkumar of Vembayam in Thiruvananthapuram on social media, thanking the State-run Sree Avittom Thirunal (SAT) Hospital, stand out. His daughter, carrying twins, had been admitted to a private hospital for a C-section, three weeks ahead of her expected date of delivery. But he moved her to the SAT, where she had a normal term delivery.

In his post, Anilkumar said that in any private hospital, the family would have had to find lakhs to pay as neonatal ICU costs alone. These contrasting accounts capture the paradoxes within Kerala’s expansive public health system.

Over the past few weeks, the Health department has been in a roil. Allegations of negligence and treatment lapses have triggered public outrage and political attacks. The Opposition claims the health system is “on ventilator.” Doctors argue they are being made scapegoats while systemic deficiencies are ignored.

Incidents of negligence abound

Recent incidents of alleged medical negligence have intensified public scrutiny. A pair of artery forceps was recovered from a woman five years after her hysterectomy was done at the Alappuzha medical college hospital. A similar case had surfaced earlier at the Kozhikode MCH. A nine-year-old treated for a fracture at the Palakkad district hospital later required amputation following an infection.

Between 2016 and 2025, Kerala invested ₹2,583 crore on 102 major medical infrastructure projects through the Kerala Infrastructure Investment Fund Board (KIIFB), according to Economic Review, 2025.

The infrastructure expansion in the form of new hospital blocks, intensive care units, cath labs and diagnostic facilities has also led to a sharp rise in outpatient footfall in the public sector hospitals. Currently, over 45% of the State’s population is using the OP facilities of the public sector units against the 30% of 2014, according to government figures.

Yet, when it comes to hospitalisation, people continue to prefer the private sector. Around 72% of deliveries in the State now take place in private hospitals. The out-of-pocket expenditure (OOPE) remains among the highest in the country, despite increased health spending and insurance coverage under the Karunya Arogya Suraksha Padhati (KASP).

Many perils of staff shortage

“Huge buildings and equipment are not what make a public health system efficient. People do. Constructing huge buildings or purchasing hi-tech equipment without provisioning for human resources (HR) to operate these additional facilities strains the system. Naturally, quality of care suffers and human errors go up,” points out B. Ekbal, a public health activist.

HR shortage remains the central issue, a concern flagged in the Comptroller and Auditor General’s performance audit of Kerala’s health sector (2016–2022). While patient load has increased significantly, HR expansion has not kept pace proportionately. “It is impossible to restrict OP numbers, which range from 200 to 400 daily. We cannot even give 10 minutes to a patient,” points out P.K. Sunil, president of the Kerala Government Medical Officers’ Association.

“Shortage of HR, erratic supplies and cumbersome processes affect the quality of care. At the same time, some institutions with adequate staff are underutilised,” he says.

“What is needed is a rationalisation and redistribution of HR across institutions; standardisation of hospitals at various levels; and re-fixing the duties and responsibilities of various categories of healthcare workers. The General Hospital at Palakkad is quite different from the one at Ernakulam, which performs organ transplants,” Dr. Sunil explains.

Doctors in medical colleges say that nursing staff shortage often forces them to give a short shrift to essential surgical safety protocols. Anaesthesia faculty shortage is another serious concern, they point out.

Lack of anaesthesia support

“Procedures like endoscopies and fracture reductions in casualty are now done without anaesthesia support, causing much pain and discomfort to patients. As a teaching hospital, we cannot even teach students the standard protocols,” confides a faculty member of MCH, Thiruvananthapuram.

“The decade-old Government Medical College Hospital, Kollam, still does not have a neurosurgeon 24×7. All trauma cases still get shunted to us. The hospital does not have round-the-clock cardiology services either, which is why Venu, the auto driver from Chavara, had to come all the way here for “emergency care”, after suffering a heart attack and eventually die here,” he says.

Every State Budget adds more fancy infrastructure or projects in hospitals without making provisions for posts to run them, rue doctors.

“Creating more idling infrastructure sans posts becomes a burden on hospital administrators. Cath labs are there in every district but none of the secondary hospitals has enough doctors, ICU-trained nurses or even posts of dialysis and Cath lab technicians,” says a senior Health official.

1,400 posts sought, 202 approved

Last year, the Directorate of Health Services reportedly proposed 1,400 new posts, including specialist and super-specialist doctors. After prolonged discussions with the Finance department, only 202 doctor posts were approved, says Dr. Sunil.

However, P.K. Jameela, State Planning Board member and former Director of Health Services, Kerala, disputes the perception of neglect. Between 2016 and 2025, general doctors increased from 4,613 to 6,171; specialists from 2,317 to 3,185; nursing staff from 9,869 to 13,575; and other staff from 5,022 to 7,609, she argues, quoting the Economic Review 2025.

“Additional HR is also deployed through the National Health Mission, local self-governments and hospital development societies. The influx of patients into public hospitals shows trust in the system,” she says, adding that the narrative of the collapse of the public health sector is a politically motivated one, with an eye on the ensuing Assembly election.

Why they choose private hospitals

However, V. Ramankutty, a renowned public health expert, feels that a serious erosion of people’s trust in the public health system is evident. Creating huge infrastructure and facilities may not be the best way to earn that trust back, he says. “The key question is, how many of us in the “paying category,” including the Ministers and senior officials, will choose to seek medical care in the public health facilities than in a private hospital? The perceived quality of care delivered and the hospital experience are important for people, which is why they go to the private sector, despite the high cost of care. The government should choose institutions to develop and upgrade, where high-quality care and hassle-free services are offered to people, rather than spread the resources thin,” Dr. Ramankutty feels.

Decentralisation was expected to bring about many positive changes in the health sector but sadly, the gains have not been uniform, he says. Financial strain is compounding operational challenges. Since 2021-22, Hospital Development Societies (HDS) have struggled due to delayed reimbursement of dues under KASP. Without timely payments, HDSs cannot make local purchases of drugs and consumables, points out Dr. Sunil. KASP beneficiaries thus end up paying from their own pocket for equipment and services which are unavailable in hospitals.

Health Minister Veena George feels that a vicious campaign was on to vilify the State’s public health system. In the last five years, the Health department received around 600 complaints of alleged negligence/treatment lapses in private sector hospitals, while only 57 were reported from public hospitals, she argues.

Regular medical audits needed

Doctors say complaints must be examined through systematic clinical audits rather than political reaction. “Other than maternal death audits, regular medical audits do not happen in the system in other specialities. Unless we do this exercise systematically, vulnerabilities will remain and mishaps will continue. Instead, the doctor is punished and the rest, ignored,” a senior Health official says.

Another dimension is the changing nature of medicine itself. Treatment today is more intensive and life-prolonging than it was a decade ago. ICU stays are longer and interventions are more complex. It is true that HR provisioning has not reckoned with these evolving realities, says Dr. Jameela.

“One solution would be to give functional autonomy to medical colleges, allowing moderate user fees from the paying category. The neonatal ICU at SAT is among the finest. Instead of private-sector rates of ₹40,000 per day, why not charge a reasonable ₹2,000 per day from those who can afford it?” argues the official.

Professional administrators

Dr. Ekbal believes that major hospitals like medical colleges require professional hospital administrators, who can streamline processes, establish protocols and checklists, conduct audits and improve patient experience. There should be clear protocols as well as facilities created for referral and back referrals – just issuing a GO will not cut it, he argues.

“There is no ‘public’ in public health anymore. Hospitals have become high-tech, but the patient experience remains unchanged. People still run from pillar to post to get things done in our hospitals,” he says.

“People choose private hospitals because they receive good service and convenience. Unless public facilities focus on service delivery and patient experience, Kerala’s OOPE will continue to rise,” says a senior Health official.