health care in kerala essay

Sustainability

Reimagining health: A people’s manifesto for Kerala

Kerala has made significant progress against several leading causes of death and disease. Life expectancy has increased dramatically, infant and maternal mortality rates have declined, the under-five mortality rate has decreased significantly. But, has Kerala solved all its healthcare issues?

The Nipah outbreak or the Covid-19 pandemic may not test Kerala’s healthcare infrastructure, but the state is facing a health crisis that is rooted in its social transformation. Kerala society needs to develop a bipartisan vision and an appropriate praxis to ensure healthy lives and promote wellbeing for people of all ages. Kerala’s electorate will soon head to the polling booths to select their legislative assembly members. Perhaps, this is the right time to present a people’s manifesto on health to political parties, as health is not on top of their agenda.

READ I Back to basics: Kerala’s Covid-19 curve springs another surprise

A vision for health in Kerala

A broad-based political discourse involving bipartisan political leaders and all population segments is essential to achieve a vision for health in Kerala. A detailed analysis of Kerala’s determinants of health and wellbeing is an essential step towards developing a comprehensive action. There is a consensus on the need for good health as an essential component of sustainable development. A healthy population is an essential infrastructure for development. That reflects the complexity and interconnectedness of health and development.

The demographic, epidemiological, migratory, and environmental transition presents new challenges to Kerala’s health sector. Kerala’s demographic change can alter disease burdens, the health care system, its costs, family and social structure, economies, trade, and human migration patterns. Dr Nithya NR (2013) from the Department of Political Science, University of Kerala, India, listed some of the critical aspects of the present health scenario in Kerala as:

The privatization of medical care
Over hospitalisation
Over administration of medicines
Increasing number of specialists
Escalation of the health care cost
Marginalization of the poor
Large number of ill-qualified doctors
Decline in professional ethics in the health sector
Increase in medicine’s price
Lack of political commitment
Bureaucratic inefficiency
Corruption and
Lack of proper planning

It appears that Kerala’s political discourse is oblivious of the gravity of the present and imminent challenges to its citizens’ health and wellbeing. The structural changes needed to address these challenges are not in the political manifesto of any political parties or the popular discourse. Also, there is propaganda to project Kerala as a global leader.

READ I Covid-19: Busting the myth of herd immunity

Social determinants of health in Kerala

Reimagining health and wellbeing in Kerala needs to consider widening economic and social inequalities, rapid urbanisation, threats to the climate and the environment, the increasing burden of infectious diseases, and emerging challenges of noncommunicable diseases. Unwavering support for affordable Universal health coverage must be integral to achieving a healthy population in Kerala. The health and wellbeing of the population cannot be achieved without ending poverty and reducing inequalities.

The challenges of a high prevalence of comorbidity are yet another characteristic of Health in Kerala. There is a link between chronic diseases such as diabetes, CVD and TB. A 2012 study supported by the Kerala government found that 44% of TB patients had diabetes. Moreover, 21% of TB patients were found to have undiagnosed diabetes.

Kerala’s health gains are uneven in a closer analysis between districts, population groups, and age groups. The apparent impressive gains of overall averages hide that many are being left behind. One of the significant reasons for the perception of health in Kerala is a model derives from the hegemonical patterns of health policymaking. Health policymaking in Kerala is mainly done from biomedical models of health and practised by a few medical elites of the state.

READ I Scrappage policy: A big business opportunity awaits India

Lifestyle diseases major threat in Kerala

High prevalence of heart diseases, cancer, geriatric care challenges, the prevalence of high-risk factors, and an unacceptably high percentage of malnourished and underweight children cannot be wished away. The economic burden of ill health is high in Kerala, which could eat away some of the overall development gains. Catastrophic health expenditure requiring distress financing and out-of-pocket health expenditures will have severe long-term health and economics consequences. Uncontrolled Rapid privatisation of healthcare will make affordable healthcare a luxury.

All this should be read in the context of the government’s failure to agree on a comprehensive health policy for Kerala. Written policies do act as a tool for accountability and monitoring. The health policies in Kerala, influenced mainly by the biomedical models of health and wellbeing, has consistently rejected social-structural models of health which derives knowledge from a structural analysis of health and an enquiry into the social production of health and wellness.

Kerala is the most urgent candidate to explore the structural determinants of health and wellbeing and integrate health into its policies. A range of structural determinants of health, which can influence health equity in positive and negative ways:

Adequate housing, basic amenities and a healthy environment.
Access to Social support networks.
Decent Income, social status and social protection.
Education and literacy.
Employment status, working conditions and Job security.
Social environments.
Physical environments.
Food security and safe food.
Social support and social inclusion.
Personal health practices and coping skill.
Support for healthy early child development.
Exposure to conflict and violence, including domestic abuse.
Access to affordable health services of decent quality.
Gender norms in accessing health services.
Culture and health-seeking behaviour.

READ I 700MHz band spectrum sale: India loses opportunity to unveil affordable internet

Global healthcare commitments

Kerala also needs to meet the global commitment by 2030 to end the epidemics of AIDS, tuberculosis, malaria, neglected tropical diseases, combat hepatitis, water-borne diseases, and other communicable diseases. Kerala has a natural leadership opportunity to implement Health-related Sustainable Development Goals

TB is still an unfinished agenda in Kerala. It affects primarily young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the state TB cell shows. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10%.

To align with the National Sustainable Development Goals, Kerala needs to reduce, by 2030, one-third of premature mortality from noncommunicable diseases through prevention and treatment and promoting mental health. The state needs to strengthen substance abuse prevention and treatment, including narcotic drug abuse and harmful alcohol use.

Kerala is increasingly called the diabetes capital of India, with a prevalence of diabetes as high as 20% ─ double the national average of 8%. In a large multi-centre study involving nearly 20,000 subjects, the prevalence of diabetes in Thiruvananthapuram (Kerala’s capital city) was 17% compared with 15% in Hyderabad and New Delhi, 4% in Nagpur and 3% in Dibrugarh.

Alcohol abuse causes an increased level of the disease burden in youth in the state. The Kerala alcohol policy is motivated by revenue considerations rather than public health considerations or a balance between two. Support and treatment programs for alcohol abuse is far farm adequate.

READ I $1.9 trillion US stimulus package to boost India growth, nudge inflation

Need to curb road accidents

In 2019, Kerala had the fourth-highest number of road accidents in the country, adding to the state’s fragile trauma care system. The state was ranked fifth from 2015 to 2018 regarding the number of road accidents in 2019. The Kerala road safety authorities have identified a high number of 238 accident black spots in the state.

As per the Union ministry of road transport and highways protocol, an accident blackspot is identified when five accidents or 10 fatalities have been reported within an area of 500 m in length in three years. To achieve the UN Sustainable Development Goal related to health, by 2020, the state has to halve the deaths and injuries from road traffic accidents.

The state needs to ensure universal access to sexual and reproductive healthcare services, including family planning, information and education, by 2030. During NFHS- 5, The Total Fertility Rate (TFR) in Kerala stood at 1.8. Whereas at the National level, the TFR is 2.2, slightly above the replacement level of 2.1. Like many other states, In Kerala also, Family planning is the responsibility of women.

About 50 per cent of married women used some modern contraception method across the State of Kerala in India in 2016. Tubal ligation, the surgical removal or blocking of fallopian tubes, was the most common method used by women in Kerala, at around 46 per cent. Male sterilization remains 0.01% though it is a simple procedure than the surgical procedure of Tubal ligation.

Kerala is far away from achieving universal health coverage, including financial risk protection from ‘Catastrophic health expenditure’, access to essential healthcare services, access to safe, effective, quality and affordable essential medicines and vaccines for all.

Catastrophic out-of-pocket expenditure on health has become a critical element of the State’s health system. According to a 2011 KSSP’s study, on average, a person spends almost Rs Six thousand a year out of his pocket to seek medical care in Kerala.

By 2030, Kerala has to substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. As a first health risk assessment on the burden of outdoor air pollution in Kerala by Prof Myriam Tobollik and colleagues (2015) from the Department of Environment and Health, School of Public Health, Bielefeld University in Germany, and the Federal Environment Agency of Germany shows that many deaths attributed to ambient air pollution by PM2.5 are due to cardiovascular causes. In the baseline scenario (Cardiovascular Deaths (CD)_Baseline (6)), 51% of the male and 49% of the female cardiovascular deaths can be attributed to air pollution in Kerala.

Some of the comprehensive epidemiological data on the disease burden in Kerala is very sobering. Kerala is reporting diabetes 20%, high blood pressure 42%, high cholesterol (>200mg/dl) 72%, smoking (42% in men), obesity (body mass index >25) 40%, physical inactivity 41%, alcohol abuse 13%. Kerala also has a high per cent of malnourished children. 19% of Kerala children are underweight, every fifth child has stunted growth, and 15.3 per cent of children are underweight in Kerala.

About 14% of all deaths in Kerala are caused by coronary heart/artery disease (CHD/CAD). Approximately 60% of CAD deaths in men and 40% of CAD deaths in women occur before the age of 65, a young age as CAD in Kerala is premature and malignant. The high rates of premature heart disease in Kerala also results in a high economic burden as high as 20% of its state domestic product.

More than 60% of the high income and more than 80% of low-income people hospitalized for heart attack result in catastrophic health spending, with 50% of these requiring distresses financing in Kerala.

The Prevalence of premature CAD in Kerala is because of increasing modifiable risk factors in teenagers. The contributing factors are high consumption of alcohol, unhealthy diet along with very high intake of saturated fat as part and parcel of cultural, lack of physical activity, sedentary lifestyle and air-pollution.

There are 974 female cancer and 913 male cancer patients per million in Kerala as per cancer registry data. In one year, Kerala has roughly 35,000 new cancer cases occurs. In this, 50% of cancers are in the throat, mouth and lungs in male & 15% in women caused by tobacco and alcohol habits. Actually, in Kerala overall, tobacco is responsible for 50% and diet for 10-20% of cancers.

Breast cancer is the most common malignancy among women in Kerala; about 30 to 35% is accounted for by breast cancer. According to the data available with the Thiruvananthapuram Cancer Registry, the prevalence rate in rural areas is 19.8 per 100,000, while in urban areas, it is 30.5 per 100,000.

The incidence of colorectal cancer in Kerala is about 5.5/ 100,000. Also, the incidence of thyroid and ovarian cancers is up among women in Kerala. Prostate cancer, the most common malignancy among men worldwide, is among the ten leading cancers in Kerala. Cardiovascular disease is the foremost killer of people with diabetes. 80% of diabetic patients die from heart disease.

People from Kerala have the highest cholesterol level in India, ranging from 197 to 229mg/dl than 157 to 180mg/dl nationally. Fat intake in Kerala is 30% of the energy, with 70% of that (20% of daily energy) coming from saturated fat. As a right step, Kerala Government has imposed a 14.5 per cent “fat tax” on foods such as burgers and pizza sold in specific locations such as cultural complexes and indoor stadiums.

Privatisation of healthcare escalates costs

One of the significant consequences of the unregulated rapid privatization of health care in Kerala is over-medicalization and escalation of healthcare costs. Kerala has the country’s highest caesarian rate of 30.5 per cent, which is three times higher than the national average. The World Health Organization’s recommended rate is (15 %).

Kerala needs to substantially increase health financing and the recruitment, development, training, and retention of Kerala’s health workforce, particularly nurses and community health workers. Nursing training in Kerala needs to reform, keeping in mind the nursing profession’s dual role in Kerala. Nursing professionals contribute to the local health care needs and the international health care needs of developed countries.

In the context of emerging and re-emerging diseases, there is a need to strengthen the State-specific capacity for early warning, risk reduction, and health risk management. Rajeev Sadanadan and his colleagues (2018) alerted us to the need for developing a global health security perspective while addressing the 2018 Nipah virus outbreak linked to Pteropus bats in Kerala.

Health is a public commodity, and it is a fundamental human right. The Covid-19 pandemic has robbed the civil society space in health response, and the governments gladly usurped space to a law and order frame of response. Criminalising health and disease is a disturbing trend.

A transparent health financing policy based on a cost budget should be mandatory from Kerala’s elected government. Lack of a costed health policy should be considered as criminal negligence of the government. Citizens’ right to life is compromised when a government fails to present a written, cost health policy. An annual report of the State of Health in Kerala must be a mandatory report from the next elected government.

A transdisciplinary, multisectoral, rights-based, gender- and eco-sensitive approach is essential to address Kerala’s health inequalities and to build good health and wellbeing. Investing in health do make solid economic sense as well. Health is a pressing issue in Kerala. Commitment to Kerala’s real health issues is the litmus test to the social commitment of political leaders of Kerala.

(Dr Joe Thomas is associate dean, faculty of sustainability studies, and head, School of Public Health, MIT World Peace University , Pune.)

References:

Nithya N.R. (2013), ‘Kerala Model of Health’: Crisis in the Neo-liberal Era, International Journal of Science and Research, ISSN No. 2319-7064, Volume 2 Issue 8, August 2013, pp.201-203. 14.

Sadanadan R, Arunkumar G, Laserson KF, et al. (2018) Towards global health security: response to the May 2018 Nipah virus outbreak linked to Pteropus bats in Kerala, India. BMJ Glob Health. . 2018 Nov 9;3(6):e001086. doi: 10.1136/bmjgh-2018-001086. eCollection 2018

Tobollik, M., Razum, O., Wintermeyer, D., & Plass, D. (2015). Burden of Outdoor Air Pollution in Kerala, India—A First Health Risk Assessment at State Level. International journal of environmental research and public health, 12(9), 10602–10619.

Dr Joe Thomas is Professor of Public Health, Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.

Joe Thomas https://www.policycircle.org/author/joe-thomas/ ICD-11 Inclusion of Ayurveda, Siddha, Unani reclaims global health narrative
Joe Thomas https://www.policycircle.org/author/joe-thomas/ Pharmacy Commission Bill seeks to empower pharmacists in primary healthcare
Joe Thomas https://www.policycircle.org/author/joe-thomas/ Kerala's NCD burden calls for social determinants of health approach
Joe Thomas https://www.policycircle.org/author/joe-thomas/ Lifestyle stigma for chronic diseases a drag on Kerala’s healthcare outcomes

The Kerala model in the time of COVID19: Rethinking state, society and democracy

Jos chathukulam.

a Ramakrishna Hegde Chair on Decentralization & Development, Institute for Social and Economic Change (ISEC) Bangalore, VKRV Rao Road, Nagarghavi PO, Bangalore 560 072, India

Joseph Tharamangalam

b Department of Sociology and Anthropology, Mount St. Vincent University, Halifax, NS B3M 2J6, Canada

• Kerala’s pandemic management has been a decisive test of the “Kerala model of development”.
• Behind Kerala’s relative success were robust public institutions, the legacy of the “Kerala model” built over many years.
• This pandemic shows that even a participatory social democratic state face tough challenge in managing crises and guaranteeing basic security.
• Adversarial politics and absence of consensus-based democratic approach led to the surge in Covid 19 in Kerala.

Kerala, a small state in South India, has been celebrated as a development model by scholars across the world for its exemplary achievements in human development and poverty reduction despite relatively low GDP growth. It was no surprise, then, that the Covid 19 pandemic that hit Kerala before any other part of India, became a test case for the Kerala model in dealing with such a crisis. Kerala was lauded across the world once again as a success story in containing this unprecedented pandemic, in treating those infected, and in making needed provisions for those adversely affected by the lockdown. But as it turned out, this celebration was premature as Kerala soon faced a third wave of Covid 19 infections. The objective of this paper is to examine Kerala’s trajectory in achieving the success and then confronting the unanticipated reversal. It will examine the legacy of the Kerala model such as robust and decentralized institutions and provisions for healthcare, welfare and safety nets, and especially the capacity of a democratic state working in synergy with civil society and enjoying a high degree of consensus and public trust. It will then examine the new surge of the virus and attempts to establish if this was due to any mistakes made by the state or some deficits in its model of “public action” that includes adversarial politics having a disruptive tenor about it. We will conclude by arguing that the Kerala model is still relevant, and that it is still a model in motion.

1. Introduction

The Covid-19 pandemic that descended upon us suddenly, rapidly spreading across the whole world, has been wreaking havoc on our lives and established habits. It is challenging us to interrogate and rethink many taken-for-granted ideas about our lives and institutions- the relationship between the individual and society, the meaning and value of sociality and communitas , of the common good, and perhaps above all the institutions that serve, govern and constrain us. Our focus here is on the institution of the state, the critical actor in dealing with this pandemic. An important fact that has emerged in the wake of this global outbreak is that different states and political regimes behind them responded to the pandemic in very different ways with clearly different outcomes. A seemingly counter-intuitive fact that has become clear is that some rich and powerful states (the US and the UK) have emerged as poor performers in effectively responding to the pandemic-in containing the infection by such timely measures as testing and isolating the infected, and in reducing fatalities by providing adequate health care in well-equipped medical centers. On the other hand, there are some relatively poor, so-called under-developed countries and regions, such as Vietnam ( The Economist, 2020 ), Cambodia and the small state of Kerala in India (a state within a state) which have emerged as success stories with a record of early and effective interventions, of controlling the spread of the virus, healing the infected and reducing the death rate. This is a notable and significant fact despite later reversals and second and third wave of Covid 19 infections in some of these cases, including that of Kerala.

This article focuses on the “Kerala model” of managing the pandemic. This small state in the south-west coast of India has been well known for nearly half a century for its “model” or pattern of development that achieved high levels of social and human development and rapid reduction in chronic poverty and endemic deprivations despite low economic growth and income ( CDS, 1975 ) 2 . The “Kerala model” 3 that has been studied by researchers since the mid-1970s, is once again in the news across the world as a relative success story in containing the pandemic despite economic constraints and other vulnerabilities such as its dense population 4 and constant exposure to foreign contacts 5 . Indeed, some of these observers see Kerala’s pandemic management as a decisive test of the Kerala model. However, this turned out to be a premature celebration 6 . Even the Kerala government and the vibrant media in the state played a pivotal role in the branding of Kerala model of Covid 19 management and containment as a “successful model” too early. While everybody expected a third wave of Covid 19 infections 7 following the return of Non-Resident Keralites (NRKs) 8 from various parts of the globe, no one foresaw the danger of community transmission and the unprecedented spike in Covid 19 case load in Kerala. This worrying trend has raised concerns regarding the effectiveness of the Kerala model of pandemic containment and management.

The objective of this paper is twofold: to highlight the ways in which Kerala handled the pandemic and to analyze the structural and systemic factors behind the state’s success. We will especially focus on the state and Kerala’s model of an effective and vibrant democracy and “public action” in the words of Dreze and Sen. We argue that while Kerala was blessed with good and efficient leaders during this crisis, the more important factors behind Kerala’s success have been robust institutions of state and governance built over many years with the capacity to take timely and effective measures in handling the crisis. We further examine the unexpected reversal and the rise of third wave of Covid 19 infections in an attempt to identify what, if any, mistakes may have been made by Kerala and if so if these were due to any deficits inherent in the Kerala model. We argue Kerala may have made a mistake in relaxing—even abandoning—the rules for the entry of a large wave of NRKs returning to the state, and for isolating, testing and tracing these returnees, as Kerala had successfully done earlier. While recognizing the unknown and unpredictable nature of this new virus (still being studied by experts) we also identify what may be some deficits in the model such as its tradition of public action that includes adversarial politics having a disruptive tenor about it, especially at a time of impending and contentious election.

We argue further that states like Kerala which have handled the crisis well have generally been relatively effective models of social democracies in which the state and its institutions work in relative synergy with society and representative social institutions. The paper is organized in four parts. This introductory Part is followed by Part II which describes the trajectory of the pandemic crisis, timely and effective steps Kerala took in managing the pandemic, and then failed to anticipate and prevent a third wave. It also examines deficits in the model that may have been behind the state’s failure to prevent a third wave. Kerala’s adversarial and competitive politics gave birth to public action which in turn laid the foundation for Kerala model of development. However, competitive and adversarial politics may have its limitations especially when it comes to managing pandemics like the present one. Kerala should have adopted a healthy combination of competitive and adversarial politics and a consensus based democratic approach to tackle the pandemic.

Part III analyses the structural and systemic factors behind Kerala’s relative success, focusing especially on the capacity of the state and its institutions acting in synergy with society. Part IV concludes the paper by reflecting upon the Kerala experience and attempting to draw some generalizations about the capacity of “effective democracies” such as Kerala to eliminate endemic poverty and chronic hunger in contrast to India’s abysmal failure in making any serious dent into its record in these as it continues to be home to the single largest pool of chronically poor and hungry people in the world. We suggest that the roots of these lie in a major democratic deficit in the Indian system– failed or weak public action, including rational-legal social movements and popular organizations, the space for these increasingly filled by communal, caste and nativist movements (Tharamangalam, 2016). It also discusses about the dominance of adversarial and competitive politics as the reason of Kerala’s failure to contain the Covid 19 pandemic in its third wave.

2. What did Kerala do with Covid 19?

How did Kerala combat this virus better than India and many other countries? Through what means? Much of the answer to this question is public knowledge by now; for example, Italy and the UK were battered by Covid 19 in the earlier phase of the pandemic outbreak since they did too little and were too late to take measures to contain the virus by testing, isolating and treating those infected and it resulted in devastating consequences. Today, Italy, UK, Spain or much part of the Europe are slowly recovering from the onslaught of the pandemic. The US, the world’s richest and most powerful nation, was also confronting this crisis with early denials followed by confusing pronouncements and frequently changing policy initiatives by its authoritarian president even as the virus has spread rapidly turning cities like New York into epicenters of the pandemic. Brazil’s response to Covid 19 has also been a terrible one. India took some bold steps to contain the deadly pandemic by enforcing a stringent nationwide lockdown, but with little consultation, planning or provisioning in place to address the consequences of such a lockdown in a country with high levels of poverty, hunger, homelessness, weak health infrastructure and migrant laborers concentrated in its many urban centers. Despite three successive lockdowns, India failed to control the spiraling surge in new Covid 19 infections 9 . India which is slowly emerging from the lockdown in a phase to phase manner has overtaken Brazil and USA and has become the global epicenter of Covid 19 pandemic.

To see how and why Kerala has been effective, we describe a few of the steps it has taken in a short time, then examine the policy priorities and values as well as the institutional structures that enabled Kerala to act quickly to battle the pandemic—all of these the legacy of the “Kerala model” over a period of time. Although, Kerala flattened the infection curve during the first two phases of Covid 19 10 , it failed to contain the surge in infections in the third phase. Kerala’s strategies in containing the pandemic in the first and second wave of infections gave way to premature celebrations and it instilled a sense of false safety in the minds of people. The fear factor went completely missing and with the easing of the lockdown people paid little attention to observe physical distancing, hand washing and even wearing masks.

The Kerala model of containing the Covid 19 pandemic was a topic of discussion across the globe for a few months. National and international media 11 , healthcare experts, policymakers and intellectuals were showering praises on Kerala for its effective management of the deadly virus. On May 4, the Kerala Chief Minister (CM) Pinarayi Vijayan said that the state has flattened the Covid 19 infection curve. At that time Kerala had only 34 active Covid 19 cases. But soon praises were replaced with criticism as the state saw an increasing surge in the number of Covid 19. The political scandals and the arrival of NRKs changed the whole scenario. Kerala is a politically vibrant state. Politics in Kerala is dominated by two political fronts: The United Democratic Front (UDF) led by the Indian National Congress (INC) and the Left Democratic Front (LDF) led by Communist Party of India (Marxist). At present, the LDF government is in power and UDF serves as the opposition. The adversarial and competitive politics having a disruptive tenor forms the backbone of Kerala politics. However, in the wake of Covid 19, the political bickering took a backseat. The consensus put out by the ruling and opposition party leaders were evident in the first phase of Covid 19 infections in the state. However, that was too short lived, as a controversy erupted over the dubious deal by the ruling LDF government with a US based tech firm called Sprinklr. The Kerala government was embroiled in the controversy over allegedly breaching the privacy of 1.75 lakh people under quarantine in the state by striking a deal to collate and handle the health data of those quarantined 12 . The major allegation was that the data was collected without the informed consent of the people and the deal lacked strong data protection clauses 13 . The government version was that such an exercise was carried out to help medical officials and doctors to make a well-informed choice about possible hospitalization in the case of those quarantined. Since the confidential data was collected under the deal made with the US company, questions were raised as to why the government did not disclose any details in the public domain regarding the deal. Opposition parties 14 also questioned the rationale behind single handedly appointing the US based Sprinklr company that too without putting a global tender for the same. Since the CM also manages multiple portfolios including the department of information technology, the controversial deal was enough to rake up a political storm that too in the midst of the pandemic.

The logic behind approaching a foreign company when Kerala has institutions like Centre for Development of Imaging Technology (C-DIT) 15 and Kerala State IT Mission 16 which are capable of handling big data analytics also raised doubts regarding governments decision. Even the government at the Centre led by Bharatiya Janata Party (BJP) came down heavily on the state government for inking such a pact with a big data analytics company like Sprinklr, when the country has central agencies like National Informatics Centre (NIC) 17 which could easily handle the task assigned to the Sprinklr. Meanwhile, the Kerala government defended its position citing that it took the decision to effectively analyze the Covid 19 data quickly. The government version was that it resorted to such a deal as it feared Kerala might see an unprecedented jump in Covid 19 infection, following the easing of lockdown. It also stated that the ownership of the data lies with the Kerala government and not with the Sprinklr, which temporarily hosted the data in its server. The state government also said that strong data protection clauses were added to ensure the data privacy. However, the opposition parties weren’t satisfied with these explanations and the reluctance of the CM to address the controversy openly added more fuel to the fire 18 . Meanwhile, the government constituted a two-member committee to look into the matter. On April 22, opposition parties and privacy right activists 19 approached Kerala High Court to stay and cancel the controversial deal. The Court directed the state government to anonymize the data of the people placed under quarantine for Covid 19 in Kerala 20 . The Sprinklr controversy was a political setback for the government in the state and it also led to the erosion of consensus based democratic approach that was highly required to mitigate the pandemic. With the local government elections around the corner and assembly elections scheduled to take place on May 2021, the management of Covid 19 pandemic is a litmus test for the ruling party and the opposition.

Meanwhile, the Covid 19 infections continued to surge with the arrival of NRKs and people stranded in various parts of the India. Starting from May 7, under Vande Bharat 21 and Samudra Setu Missions 22 , nearly 5619 persons from Gulf and Maldives returned to Kerala. Nearly 59,945 Keralites staying in various parts of the country also returned to Kerala till May 21, 2020. At that time, one in every hundred NRKs were testing positive for Covid 19. Then by June 17, a total of 84,195 NRKs and 1,79,059 Keralites living in various parts of the country returned to Kerala. As per the latest figures released by the Ministry of External Affairs (MoEA), a total of 94,085 NRKs have returned to Kerala. (till July 3, 2020). Majority of Kerala’s Covid 19 positive cases were from the returnees to the state from abroad and other states within India. Total Covid 19 cases in Kerala jumped nearly nine times from 499 on May 4 to 4465 on July 4. However, the spike in Covid 19 infections after the arrival of expatriates was something that the government expected. Kerala has a large population of expatriates and the government wanted those who wish to return to their home state to conduct Covid 19 tests before boarding the plane. It was aimed at segregating the infected and non – infected people. But it did not happen due to various reasons. Then came the controversy surrounding the mandatory Covid 19 negative certificates for the expatriates who wish to return to India. The first directive came from the Central government, two weeks before nationwide lockdown was imposed in the country. It was on March 5, India issued a travel advisory that insisted on Covid 19 negative certification for evacuation of citizens stranded in countries like China, Italy and South Korea 23 . Later Ministry for Civil Aviation on March 14 issued a circular directing the same. At that time, the Kerala government passed a resolution in the Kerala Assembly which termed the directive demanding mandatory Covid 19 negative certificate for expatriates as “fundamentally inhuman decision” 24 . The MoEA at that time said that the norm was put in place as a safety measure to prevent Covid 19 infected people passing on the virus to others on the flight. In the wake of Covid 19 pandemic, NRKs 25 , settled in various parts of the world, expressed their wish to return to their home state 26 . Above all Kerala government was ready to welcome expatriates without the requirement of a Covid 19 negative certificate. But Kerala government which went on to pass a resolution against the “mandatory Covid 19 negative certificate” order of the Central government in March, suddenly changed its official stand 27 on April 22. The Central government which was demanding mandatory Covid 19 negative certificate also changed its official stand and came up with the explanation that testing all those coming back to India and Kerala on repatriation flights was impossible.

The Kerala government said that it came up with the new directive to avoid fresh overseas cases after successfully containing Covid 19 in the state. However, the new directive from the part of the state government irked the NRKs and the opposition parties alike. The unhealthy face of the adversarial and competitive politics having a disruptive tenor came out in the open following the state government’s decision to adhere to mandatory Covid 19 negative certificates for expatriates.

There was an outpouring of resentment over Kerala government’s stand. This unexpected move was dubbed as reluctance to accept more people coming by repatriation flights since the government feared that it will lose control over the fight against the pandemic. The opposition parties including Congress, Indian Union Muslim League (IUML) and BJP capitalized the public resentment against the stand of the governments. The opposition parties knew anything involving NRKs would be a highly sensitive issue in the state since it has been surviving with the support of the remittances 28 by overseas workers. It gave the opposition parties an opportunity to exploit the public anger and position themselves as true advocates of NRKs. Kerala will go to assembly elections next year and keeping it in mind, the ruling LDF, has been trying its best to turn the health crisis into an incredible opportunity to revive its political fortunes. The UDF have dubbed the Covid 19 management as a mere public relations stunt with an eye on the forthcoming assembly elections. The opposition parties including BJP have accused the LDF for the spike in the infections as the government was too busy with marketing its Covid 19 story to international media and conducting debate series called Kerala Dialogue . The opposition parties in the state have always been skeptical about the Kerala model of handling Covid 19 pandemic.

The criticism by the opposition parties even had misogynistic undertones 29 . The opposition accused that the health minister was not interested in saving lives and mocked her with misogynistic epithet. 30

However, the segregation of the infected and non – infected returnees from abroad did not happen due to technical difficulties and reluctance of the Central government to conduct testing on expatriates boarding aircrafts from overseas. So, state government had no other go but to come up with an alternative strategy, where multi-layer screening facility was set up in airports for returnees 31 . Again, on June 11, the CM wrote to the Prime Minister to seek the help from the Central government to provide facilities for conducting Covid 19 test for expatriates returning to Kerala via chartered flights. But this move was also met with stiff opposition and criticism from opposition parties and NRKs 32 .

In July, a new trend emerged where Covid 19 infections through “contact” and local transmission 33 started to surge in the state with more cases of community spread than imported cases. On July 9, Kerala confirmed its first “Covid 19 super spreader” 34 incident in the coastal village of Poonthura and Pulluvila in Thiruvanthapuram, the capital of Kerala 35 . In Poonthura and Pulluvila, people blocked vehicles of police and attacked health workers. The residents in Poonthura and Pulluvila alleged that due to stringent lockdown measures they were not even allowed to venture out of their house to buy essential items from shops nearby. The residents complained that no shops in their vicinity were allowed to open and the men in uniform allegedly went around threatening and using bad words against the fishermen coming out of their homes. In addition to that a team of 25 commandoes were deployed in Poonthura coastal village as the Covid 19 infections continued to surge. Such stringent measure didn’t go down well with the coastal villagers. The presence of commandoes in uniform provoked the resistance among fisher folk. The law enforcement agencies’ failure to understand the ecology of politics 36 ( Kurien, 1994 , Kurien, 2001 ) in coastal areas of Kerala including Poonthura also led to the fall out between the authorities and the residents of coastal villages.

Government implemented stringent lockdown in these coastal hamlets since nearly 81 per cent of the Covid 19 cases reported during this time period through local transmission occurred in these coastal areas. On July 17, the Kerala government admitted that community transmission of Covid 19 had occurred in the coastal hamlets of Poonthura and Pulluvila in Thiruvanthapuram. It was the first time a state government in India officially admitted that community transmission of Covid19 has taken place. The total number of Covid 19 cases surged from 6166 on July 8, 2020 to 16,995 on July 24, 2020.

But first, a brief overview of Kerala and its specific characteristics will be helpful in providing a better context for this discussion. Kerala is one of 28 states in India, one of the smallest, but the most densely populated with 35 million people nestled between the Arabian sea and the hill ranges of the western ghats 37 . Kerala is the only state in India without the nucleated village system characteristic of India; its villages are revenue divisions, sometimes called dispersed villages because of the pattern of dispersed houses and settlements. Its relatively small cities and towns interspersed across the state create a rural–urban continuum ensuring very little rural–urban differences as regards such features as literacy, readership of books and magazines, and social and political consciousness. Having achieved the demographic transition by the 1990s, it now has a high proportion of aging population which currently stands nearly 16 per cent 38 ( Rajan & Mishra, 2020 , Kerala Economic Review, 2019 ), on par with many developed countries. Another notable feature of Kerala is the legacy of a matrilineal system that was prevalent among a few castes, especially the dominant caste of Nairs ( Jeffrey, 2004 ).

Historically, Kerala has had close trade and cultural links with the outside world across the Arabian Sea; Christianity and Islam made their substantial presence here in the very early centuries of the founding of these religions making the state one of the most multi-religious and multi-cultural. The past few decades saw a mass exodus of Kerala’s young people seeking employment outside the state, especially in the Arabian Gulf, but also in Europe and North America. The remittances sent by these workers amount to about one third of Kerala’s state domestic product 39 ( Krishnan, 1994 ). Note also that there is a substantial number of migrant workers from other Indian states (called “guest workers” by the Kerala government) who fill local vacancies at the lower levels of the labor market, attracted by the higher wages and better social security in Kerala. In addition to all this, unprecedented income growth and easily available bank loans in recent years have also spurred an exodus of Kerala students seeking technical and higher education abroad, not only in the west but even in some remote parts of China and Central Asia, new destinations for those seeking medical and other degrees at relatively low cost. It is noteworthy that this small state now has four international airports facilitating the high volume of international travel. It is not surprising, then, that Kerala was the first state to experience the Covid-19 infection. Indeed, the virus was initially brought by Keralites returning from Wuhan and Italy 40 .

How, then, did Kerala react to the sudden crisis? The first point to be highlighted here is that Kerala may have been among the best prepared states/regions in the world to face this crisis. One reason for this is that it had the experience of successfully handling three crises in the past two years, a very serious Nipah epidemic in 2018 and two outbreaks of unprecedented floods, the first in 2018, the second in 2019 41 . The experience of effectively harnessing and coordinating a variety of social players 42 in all the three crises, and the accumulated social capital and networks became useful again. Even more important in this regard is the capacity of the state in terms of infrastructure facilities for public provisioning of essential services and basic security including its robust health care system, universally accessible and free for all. However, the spike in infections has exerted pressure on the healthcare system in the state. Till August 31, 2020 Kerala had a total of 71, 071Covid 19 cases, 48,079 recoveries and 280 deaths 43 . The surge in infections is also taking a toll on the state’s health workers. Health workers at all levels are experiencing fatigue 44 . One of the major reasons for this is the situation in which health workers are contracting the virus while treating Covid 19 patients. More than 500 health workers including 98 doctors and 148 staff nurses have been infected with Covid 19 till August 1, 2020 45 .

Following community transmission, government opened First Line Covid Treatment Centers (FLCTs) 46 at the Panchayat level. The opening of FLCTs added more workload on the existing healthcare system. As of July 20, nearly 10,000 doctors are entrusted with the duty to treat Covid 19 patients. Though Kerala has one of the best doctor-patient ratios in the country, that is one doctor for 400 people, but for dealing with a pandemic like Covid 19 that is not at all proving to be sufficient. Occasional ostracization and attack on healthcare workers have affected their morale. For instance, in the coastal village of Poonthura in Thiruvanthapuram where community transmission was first confirmed, a medical team that went to the coastal area for Covid-19 swab collection was surrounded by angry mobs, who threatened them with abusive words and even coughed at their faces. 47

Then, keeping the private hospitals away was yet another strategic error. Nearly 65–70 per cent of the population in Kerala depends on private hospitals. Sensing the gravity of the situation, in June the government asked the private hospitals to keep aside at least 20 beds per hospital for Covid 19 patients by July first week. Finally, on August 7, 2020, Covid 19 treatment in private hospitals started. In Kerala, treatment for Covid-19 is provided completely free of cost in government hospitals. Covid hospitals and FLCTs for also provide meals at free of cost to the patients. The government fixed the tariff for Covid 19 treatment at private hospitals to prevent opportunistic exploitation of patients.

Kerala also failed to make use of the vast potential of alternative medical streams like ayurveda and homeopathy in treating Covid 19. Meanwhile, as the Covid 19 infections have alarmingly increased, the government has started promoting ayurveda as a way of boosting the immunity of the population 48 . However, government has made it clear that diagnosis, medication and treatment of Covid 19 will only be done through scientifically-backed modern medicine. Another criticism against Kerala was that it was not testing enough. Critics point out that Kerala was testing less and thus it had relatively few cases earlier. In fact, whether Kerala was testing enough was a cause of concern. However, in the beginning Kerala, in March, the state was testing the most, followed by Maharashtra. Kerala with a population of 35 million people conducted 137 tests per million and Maharashtra at that time conducted 27 samples per million people. But in mid – April, when Covid 19 infections were slowing down in Kerala, the aggressive testing strategy was relaxed. There had been allegation that Kerala started testing asymptomatic and people with mild symptoms at a later stage. But as on September 3, 2020, Kerala has ramped up its testing from 20,000 to 30,000 tests per day. Critics also argues that Kerala invested its energy more in contact tracing than in testing which led to the drastic situation the state is facing now.

Second, Kerala took early steps in monitoring and enforcing the rules of isolation. It has also harnessed and deployed modern technology such as surveillance by drones identifying locations of social gatherings, use of “geofencing” 49 to enforce quarantine, and location tracking devices to create spatiotemporal maps for re-tracking movements of those infected. Government resorted to surveillance technology to track the spread of the Covid 19 and to monitor people placed under quarantine. Government was forced to resort to technology-based monitoring as the number of lockdown violators and those evading quarantine were increasing in the state. Geofencing technology was one among them. Cyberdome 50 , developed a software based on geofencing technology to track the movement of people in quarantine.

On March 17, in Kottayam, a district in central Kerala, police first made use of the geofencing technology software. It had helped the police official to catch a total of 13 people who stepped out of their houses during their quarantine period in the district 51 . Geofencing based monitoring was implemented in Kasargod and Wayanad districts where 50 per cent of quarantine violators were caught red – handed. To make sure people were observing physical distancing during the lockdown period and to aid police in effectively implementing the lockdown, Kerala police launched Project Eagle Eye , under which drones were used to catch those violating quarantine and lockdown. Police used 350 drones to track those violating the lockdown rules and physical distancing norms 52 . However, the technological surveillance didn’t deter people from violating the lockdown and quarantine rules. In addition to that, the technical glitches and the laidback attitude from the part of law enforcement agencies weakened surveillance-based monitoring of those suspected to have contracted the novel coronavirus in the state. There have also been instances where police personnel got infected with Covid 19 while performing their duties 53 . As per the government records, nearly 20,000 cops are directly involved with Covid 19 related works, that is almost one third of their workforce. With more and more police personnel getting infected has led to shortage of adequate police force and increased their workload. On August 4, Kerala government decided to give the police a large role in contact tracing, in ensuring greater compliance of quarantine and physical distancing at public places, functions and total control over containment zones and clusters. In the first two phases of Covid 19, these tasks were entrusted with local governments, health inspectors and accredited social health activists (ASHA). So, it is clear from these that government has distanced itself from the earlier participatory mode of governance to contain the spread of the pandemic and resorted to converting Kerala into a surveillance state 54 in the midst of the pandemic. The medical fraternity was also upset with government’s decision to give more powers to police in the management of Covid 19 pandemic.

The Kerala government also made a controversial decision to collect call details of Covid 19 patients. It has been criticized as an infringement on the privacy of the people and a brazen move to convert Kerala into a police state. Meanwhile, the Kerala government on August 19 submitted 55 before the Kerala High Court that the police required the mobile tower details in order to find out only the location of the Covid-19 patients and the calls they make or receive. The government informed the Court that the police are collecting the tower location details only to identify the location and stated that it is not collecting call detail records (CDR).

Third, the government during the second wave of Covid 19 infections made use of effective communication system that included daily evening press briefings by a team led by the CM. These widely attended briefings share with the people the latest facts, figures, plans, concerns, challenges, and cautions.

However, the row over the controversial deal with Sprinklr, the political blame game over the mandatory Covid 19 negative certificate for NRKs, gold smuggling scam 56 and the alleged links of the smuggling suspects to Chief Minister’s Office (CMO) and corruption allegation against government’s flagship housing scheme – Livelihood, Inclusion and Financial Empowerment (LIFE Mission) 57 have diverted the attention from the Covid 19 pandemic in Kerala. The administrators and politicians have forgotten that in a pandemic situation, a consensus based democratic approach is required to get things under control. The competitive and adversarial politics having a disruptive tenor about it have gained upper hand over the fight against Covid 19. The highly popular press conferences of the CM have turned into a war of words between the government, opposition parties and media. This has caused a dent in the popularity of CM’s press briefing 58 .

The vibrant media in the state is now less bothered about the Covid 19 and is busy hosting prime – time TV news debates in Kerala on gold smuggling and the involvement of the CMO. In short, the over dominance of adversarial and competitive politics has shifted the focus of public attention from Covid 19. Following the controversial gold smuggling scam, the opposition parties were carrying out protests across the state by disregarding rules relating to physical distancing. The protests saw participation of a massive gathering of party workers violating physical distancing and wearing of masks. The Kerala High Court on July 15 said that all parties and associations must strictly abide by the Covid 19 guidelines 59 . The reckless behaviour of the people also contributed to spike in infections. Following the easing of lockdown towards the end of May, people started stepping out of their homes feeling reassured by Kerala’s handling of pandemic, the effectiveness of public health system and the low mortality rate at that time. A section of people thinks that this overconfidence that the public authorities displayed created a false sense of safety among people leading to their irresponsible behaviour from the part of people, where physical distancing norms and wearing of masks 60 were flouted. Misleading information and advertisements in the name of Covid 19 pandemic was also reported in Kerala. 61 The CM on August 4 said that “laxity and complacency” were the reasons for the surge of Covid 19 infections in the state. The government said that people were complacent in taking precautionary measures against the Covid 19 and it has resulted in the spike in infections. Then law enforcement agencies and local authorities did not pay much attention to unregistered entry of people from neighbouring states through hidden forest roads and porous borders of Idukki, Wayanad, Kannur, Kollam and Thiruvanthapuram districts. 62

Fourth, the government lost no time in making adequate provisions for the vulnerable groups adversely affected by the lockdown 63 –causal laborers, guest workers, the very poor and the homeless– efficient and well-organized provision of food and shelter for all those in need. In sharp contrast to the heart-rending scenes of migrant workers in Delhi walking to far away homes with their babies and meagre possessions on their back, being beaten up by the police on the way, some even dying on the road, the scenes in Kerala were of free shelters, community kitchens and volunteers delivering food to the needy 64 . On March 26, the government of Kerala launched the community kitchen initiative to stave off hunger and to ensure no one goes hungry in the wake of pandemic and lockdown. The government entrusted the responsibility of managing the community kitchens to the local self-governments and to Kudumbashree 65 ( Mukherjee-Reed, 2015 ). On April 1, 2020 there were 1316 community kitchens and on May 22, the number came down to 1097. Through these community kitchens, 2.50 lakh to 2.80 lakh food packets were distributed on a daily basis. Food was provided at free of cost to the needy, migrant workers, and those under home quarantine. Due to the easing of lockdown, those stranded including guest labourers started going back to their homes and as a result the demand for food came down and this in turn has reduced the number of community kitchens operating in the state. However, with the surge in Covid 19 infections, the demand for community kitchens has increased. As per the latest figures provided by the Kudumbashree , there are 1145 community kitchens functioning in the state as on August 1, 2020. 66

It also observed strict protocols avoiding assembling of people and delivering food packages to those in need at their shelters. A “hub and spoke model” of food distribution has been developed for sourcing food from existing networks such as the canteens run by Kudumbashree , and sending these out as parcels to multiple destinations. 67 It is noteworthy that these services are available to all the needy completely free of cost. Apart from community kitchen, Kudumbashree also ran Janakeeya hotels 68 to serve budget meals for Rs. 20 (US $ 0.27).

Fifth, a theme to be discussed further below, is the capacity of the state to harness and coordinate the high levels of social capital in the state including governmental and non-governmental organizations and associations 69 . Then, transparency has been a key feature of Kerala model of handling the Covid 19 pandemic. But with the surge in Covid 19 cases and deaths have allegedly led to fudging of Covid 19 data, especially when it comes to the death toll due to pandemic. One of the major allegations is that the government has left out many legitimately probable Covid 19 deaths out of its official Covid 19 death list. It began on July 20, when the state decided not to include the death of Covid 19 patients with comorbidities in its official death tally. 70 The state government denied allegations of data manipulation and insist they are following the guidelines prescribed by WHO and ICMR. The Covid 19 expert committee formed by the Kerala government has asked the government to follow the WHO or ICMR guidelines in counting the death 71 . Government version is that Kerala has one of the lowest fatality rates in the country with 8 deaths per 10 lakh population. Overall, 68.85 per cent of patients who died of Covid 19 were aged 60 years and above 72 . The risk of death from Covid 19 is also higher in people with comorbidities 73 and in the case of Kerala it stands true. For instance, till July 27, state had a total of 61 Covid 19 deaths and out of it 47 of them had comorbidities 74 .

3. Behind the success: The legacy of the Kerala model

What is behind Kerala’s success, some unique factors specific to Kerala, a Kerala exceptionalism? This is a complex question, and it is possible to highlight some unique historical and social factors, mentioned above. But our focus here is on institutional and cultural factors that are comparable and amenable to empirical investigation. From this perspective we will highlight the legacy of the “Kerala model of development” that has created what some political scientists have called an effective or vibrant democracy ( Heller, 1996 , Heller, 1999 , Heller, 2000 ), itself the legacy of “public action”, as explained by Dreze and Sen 75 . This latter concept includes a proactive and interventionist state that responds to popular demands for basic social security, and a mobilized and politically conscious society that puts pressure on the state and holds it to account.

3.1. A proactive and interventionist state

How Kerala evolved into such a state, at least close to this ideal, has a relatively long history. When Kerala was born as a new state in India in 1957 by combining the two princely states of Travancore and Cochin and the British ruled region of Malabar, all the three regions, especially the first two, had a half century old history of anti-caste and social reform movements followed by trade union and socialist movements, these resulting in a mobilized, and a socially and politically conscious population. The new state’s first democratically elected government was formed by the Communist Party of India (CPI), the first time a communist party came to power in a free and multi-party election anywhere in the world 76 ( Desai, 2006 ). This government did not last long in a highly contentious political environment and with an unsympathetic, if not hostile, central government in Delhi which dismissed it in response to a “liberation struggle” unleashed by landed interests and dominant religious and caste groups 77 . However, within a very short time Kerala settled into a vibrant, if still contentious, democratic system governed alternatively in every five years by two coalitions: LDF and UDF. Strong popular demand led to the enactment and implementation of various welfare measures, especially under the LDF governments, and these have come to stay, with occasional modifications by a succeeding government. Especially noteworthy here is a free and robust health care system with a special focus on primary healthcare. As happened everywhere else in and outside India, both the education and health care systems came under threat from a process of mindless privatization unleashed by the neoliberal reforms of the past three decades. Nevertheless, these have survived, and the latter in particular seems to have become more efficient and accessible to people as a result of the policies of decentralization implemented since the mid 1990s. While this was an all-India initiative launched by the Central government, Kerala seems to have taken this more seriously, launching its own campaign for “people’s planning” and implementing what seems to be the most extensive and efficient decentralization program anywhere in India ( Chathukulam and John, 2002 , Moolakkattu and Chathukulam, 2007 , Oommen, 2007 ). Kerala’s progress in achieving social well-being by all measures, ranging from the Human Development Index (HDI) to the Multi-Dimensional Poverty Index (MPI) and the Global Hunger Index (GHI) are not only decades ahead of India, but on par with the middle level developed countries.

3.2. Social mobilization and public participation

If the state is such a critical institution in the provision of such public goods, it still needs to be explained how and under what conditions the underprivileged classes in a society, including vast numbers of the rural poor, are able to influence state policy and make it respond to their needs. High HDI indicators, which are statistical averages, underscore the fact that development here has been more inclusive with a wider spread than elsewhere in India. This raises the critical political question of how these classes become mobilized, incorporated into relatively stable organizations with universalistic ideologies and programs, and integrated into the political process. Kerala throws considerable light on this question and shows how and why the mobilizations of these classes—the nature of their organizations and the mode of integration — are critical for the provision of such public goods and services.

Policy experts and development economists are also of the opinion that an orchestrated decentralized response system comprising the state government, local government, Kudumbashree , public health system and people demonstrated solidarity and social capital at its best helped a great deal in controlling the pandemic in the first two waves of Covid 19 infections in the state. 78

Kerala has a long history of social mobilization and struggle. The trajectory began in the southern part of Kerala, the princely state of Travancore and later that of Kochi (formerly Cochin) with the well-known anti-caste and social reform movements in the latter part of the nineteenth century—combining a unique Kerala model of renaissance, enlightenment, and reformation, all in one. In British Malabar, where rack-renting and predatory landlordism were more prominent, nineteenth and early twentieth century social movements focused more on agrarian issues( Herring, 1983 , 2003, Radhadrishnan, 1989 and Panikkar, 1989) One of the fascinating facets of this history in Travancore is that even the Maharajah, the kingdom’s Hindu ruler, was himself transformed from protector of Varnashrama Dharma , the caste-based social and moral order (regarded as the most oppressive in India at the time) to supporter of lower-caste struggles and changer of caste oppression ( Devika, 2010 , Woodstock, 1967 ). Eventually the Maharajah threw open to all castes’ educational institutions and Hindu temples, formerly the exclusive preserves of the higher castes. Some of these movements were later joined by, and even absorbed into, trade union and political movements that led to the establishment of strong political parties. Especially noteworthy here is a well-organized Communist Party with a universalistic and class ideology that remained purposive and programmatic and retained its mass base across caste and religion over a period of time in one of the most pluralist societies in the world. The Communist Party’s decision to function within a multi-party democratic system involved not only abandoning its orthodox doctrine of armed revolution, but compromising class struggle in favor of class accommodation, in effect transforming it into a well-organized social democratic party of the European vintage 79 . It can be argued that such a class compromise may have been facilitated by the upper caste/class origins of the top leadership of the left parties. On the positive side, this strategy succeeded in influencing the right-of-center parties and traditional conservative forces to accept some basic social programs of the left parties. On the negative side, it is important to note two points here. First, the left parties abandoned such critical radical programs as land redistribution. They did enact and implement tenancy reforms that successfully abolished predatory landlordism. The traditional landless classes, of whom the vast majority were (still are) the Dalits, received only their house sites or Kudikidappu land leaving them where they had been for centuries, landless laborers, now turned into modern types of casual wage laborers 80 ( Tharamangalam, 1981 ).

Second, even the limited distribution of house sites, the most radical among Indian states, required organized struggles and intense participation of mass organizations, especially of landless workers. The newly gained home ownership, however limited, did succeed in bestowing a certain sense of dignity to the former hutment dwellers who could no longer be evicted from their houses at the whims of the landlords.

3.3. State–society synergy

We have argued above that the two key elements in the Kerala model are (1) an interventionist state committed to pro-poor policies, and (2) a mobilized society that engages the state through well-organized mass organizations and parties. In this section we discuss the way in which these two elements have interacted to create and maintain a certain synergy, a “virtuous” relationship. We suggest that this may be critical in understanding why Kerala has succeeded where many others such as Guatemala, Nicaragua, and Sri Lanka have not been so successful.

In examining state–society relations, scholars use different analytical lenses such as “equilibrium,” “balance,” “synergy,” and “state-in-society.” We find Joel Migdal’s concept of state-in-society is particularly useful for it shows the state as embedded in society and constructed by social forces, on the one hand, yet enjoying relative autonomy and the capacity to mold and even manipulate social forces and social groups, on the other ( Migdal et al., 1994 , Migdal, 2001 , Houtzager and Moore, 2003 , Evans, 1995 , Evans, 1997 , Evans et al., 1985 ). While the state can enjoy relative stability over a period of time, being a system of institutionalized practices, beliefs, and rules, every state is ultimately precarious and vulnerable as an arena in which contesting and changing social forces are continuously at play. We argue that Kerala has been successful in maintaining a balance between state and society and among a variety of social groups and organizations. By this we do not mean an equilibrium imposed by some invisible hand, but a synergy created and maintained by institutionalized mechanisms capable of accommodating differences and resolving conflicts. As noted above, in Kerala the process involved accommodation and compromise among various interest groups, mediated by rational-legal, modern institutions of the state as well as political parties and other organizations. This is not to suggest that this “virtuous” relationship has been unproblematic, or without dilemmas, strains, or contradictions or that it will be sustained indefinitely and can now be taken for granted. In fact, such a relationship is always precarious and a delicately negotiated one since democratic participation involves and requires critics of a given regime and even political opposition, and states and societies must negotiate inevitable conflicts of interests among social classes and groups.

Our argument has only been that Kerala has not only been successful in maintaining a healthy balance but has, in fact, enhanced the “virtual relationship” between state and society in the context of confronting the four successive crises of floods and epidemics, and that the state’s response to the latest and more ferocious Covid 19 pandemic, may have been a final test of the “Kerala model”. Unlike the earlier crises, which were of short duration, the Covid 19 pandemic is likely to take longer time to resolve. It is therefore a crucial test of resilience of the Kerala model.

3.4. A ‘Navodhanam”: Kerala’s own century old renaissance

“Sapere Aude” (dare to know or be wise) is a famous phrase used by Emmanuel Kant in defining the motto behind the European enlightenment ( Kant, 1784 ). A daring critique of hegemonic ideologies and beliefs that imprison our minds is a prerequisite for liberating our minds from their hold and for imagining an alternative world of freedom. As mentioned earlier, Kerala had its own model of renaissance, a navodhanam that began in the late 19 th century. This “awakening” and the critical thinking spawned by it played a major role in the making of the Kerala model. It brought about a transformation in beliefs, values, ideals and norms, in people’s conception of and commitment to social and distributive justice and human rights, and in people’s aspirations for themselves and their children. To be sure, prominently figured in this revolution were such radical philosophers and cultural leaders such as Sri Narayana Guru, Ayyankali, and EMS Namboodiripad, and there were “battles of ideas” and “revolutions in ideas”. What is more important in the transformation of Kerala society, however, is the process by which such ideas became part of the popular cultural movements and were internalized in the collective consciousness of the people. This process was also facilitated by a spurt of growth in popular literature and drama starting in early 20th century, 81 joined also by popular cinema by the 1940s– all of these with critical social themes. Libraries and reading rooms spread all over the state in tandem with rapidly increasing literacy. In 1989–90, Kerala launched a campaign for 100 per cent literacy; by the 1990s the state had achieved 100 percent literacy ( GOI, 2008 ).

Kerala’s navodhanam was, indeed a revolution in hope —giving new hope to people who formerly lived without hope, accepting their fate as inevitable and/or unchangeable. Kerala historian Robin Jeffrey ( Jeffrey, 1992 ) has noted, for instance, that by the 1930s large numbers of people in Kerala had enthusiastically embraced the belief that they had “entitlements”, a concept that figures prominently in the writings of Amartya Sen. The social reform movements campaigned vigorously for the rights of the lower castes to education. An early associate of Sree Narayana Guru, Padmanabhan Palpu 82 said on the subject: “We are the largest Hindu community in Kerala. Without education no community has attained permanent civilized prosperity. In our community there must be no man or woman without primary education” 83 ( Ramachandran, 1998 ). It is not accidental that universal access to education (first primary and then secondary and even post-secondary) became an issue of high priority in Kerala both in terms of public demand and public policy. A notable aspect of mass participation, especially important in health care, has been the pivotal role of “women’s agency” (women’s empowerment in terms of literacy, education and health, promoting general achievements in human development indicators such as IMR, child nutrition and health), as explained by Amartya Sen ( Sen, 1999 , Sen, 2006 ) and ( Dreze and Sen, 1998 , Dreze and Sen, 2002 , Dreze and Sen, 2013 ).

4. Concluding remarks

The unprecedented Covid19 pandemic has shaken our taken-for granted “common sense” in many respects. Kerala which successfully contained the Covid 19 in the first two waves of infections is now struggling to contain the pandemic in its third wave. The Kerala model of managing and containing Covid 19, which was lauded once across the globe is now looked upon with skepticism. It is also a cautionary tale for the government, media and public at large against celebrating Covid 19 success models. Kerala’s biggest advantage was its robust healthcare system and participatory mode of governance or social democracy when it came to handling the pandemic. However, the pandemic has showed that even a participatory social democratic state face challenges in managing crises and ensuring basic security to all. Kerala is a politically vibrant state. The competitive and adversarial politics forms the very basis of the political landscape in the state. At the time of a deadly pandemic a consensus based democratic approach was highly required or at least a balanced proportion of competitive and adversarial politics and a consensus based democratic approach was required. But the state failed to do so. In Kerala, the unhealthy face of adversarial and competitive politics took the front seat while mitigating the spread of Covid 19 pandemic took the back seat. This led to the current surge in Covid 19 infections in the state. In Kerala, the pandemic has got a political hue. The handling of Covid 19 pandemic is now used as a tool to gain political mileage and dividends. Meanwhile, despite all the political turmoil and controversies, Kerala has managed to control the pandemic from going out of control when compared with other states in India.

Life after Covid may not be the same again, as the media and the chattering classes are reminding us daily. The project of neoliberal globalization and the accompanying New World Order may be nearing its end, even liberal capitalism may not be the same again. As the US, the world’s greatest power and the self-appointed leader of the this World Order , proved to be among the worst performers in managing this crisis, scapegoating other countries and even global institutions such as the WHO, whatever trust there may have been in the US-led world order seems to have eroded quickly. In this global context, and drawing especially on the example of the small state of Kerala we now return to our main question in this article: what is the role of the state in dealing with crises such as the present one, and in protecting its citizens and their well-being and providing them security—and ideally also in cooperating with other courtiers and global institutions?

We will conclude with a brief reflection on the concept of entitlement, made famous by Nobel Laureate Amartya Sen in many of his writings but especially in his classic study of famines (Sen, 1983). His now famous, but somewhat unexpected conclusion was that famines in the modern world are not caused by shortage of food, but by “entitlement failure” 84 . As a corollary to this he also argued that self-governing democracies in the modern world have no famines for the obvious reason that such a government, responding to the needs of the people who elected them, and working in synergy with its citizens and civil society organizations has the knowledge, capacity and the will to take timely and effective steps to obtain and move food to the needy.

One of the notable successes of India’s sovereign democracy has been the elimination of the periodic famines that had been a recurring feature of colonial India. The country has been free of famines since the 1960s; for the past few decades India has been not just self-sufficient in food supply, but has a substantial surplus, some of it often rotting or eaten by rats in ill-equipped public storages. But here comes India’s famous paradox of “hunger amidst plenty” in contrast to Kerala, a food deficit state which has eliminated such hunger. The facts about India’s endemic and chronic hunger to which over 250 million people are victims are documented in several national and international reports, the most notable of which is the latest GHI (2019) 85 presents a devastating picture of India, now ranked 102 among 117 countries ( von Grebmer et al., 2019 ). According to the report India is suffering from “a serious hunger problem’’. Yet another point to be highlighted about India’s paradox is that such endemic deprivations such as hunger and poverty are disproportionately concentrated in India’s peculiar underclass, those at the bottom of the caste system, especially the Scheduled Castes or Scheduled Tribes 86 . India’s historically excluded classes who make up about 1/3rd of the country’s population. Following Sen’s logic, it is clear that 70 years after independence these groups are excluded from entitlements to adequate food and nutrition.

As cogently argued by Patrick Heller, effective democracies put re-distributive pressure on the state. If so, it should be obvious that India fails this test; India is just not an effective democracy –in sharp contrast to Kerala which is. Atul Kohli, who has extensively studied these issues in India supports this conclusion ( Kohli, 2004 , Kohli, 2009 , Kohli, 2010 , Kohli, 2012 ). He addresses the class basis of the Indian state even better. According to him the redistributive capacity of the Indian state, always low, declined even further during the post-reform period. This latter period, he says, has been marked by a shift in the character of the Indian state from “a reluctant pro-capitalist state with a socialist ideology to an enthusiastic pro-capitalist state with some commitment to inclusive growth” ( Kohli, 2009 ). He asks if and how democratic politics can counter class power and if “…democracy and activism of the poor (can) modify this dominant pattern of development “( Kohli, 2009 ). He sounded an optimistic note as he was writing at a time when popular demands had led to such beneficial legislative measures such as the MGNREGS 87 and the National Food Security Act 88 which were beginning to show some success. But the Indian state has shifted once again under the BJP which combines even more right-wing economic policies with the ideology and project of Hindutva, a militant form of majoritarian Hindu nationalism that moved from the fringes of Indian society and politics to its mainstream in a short period of time ( Tharamangalam, 2006a , Tharamangalam, 2006b ). No wonder the figures for poverty and hunger are showing no decline as has happened in other southern countries, especially India’s own poorer neighbors such as Nepal and Bangladesh. 89 Meanwhile, it is indeed encouraging to see that a few states such as Kerala, Goa and the so called tribal states mentioned above have continued to follow more promising paths with easily visible outcomes in terms of their social development. We can only hope that the lessons learned from Kerala and other states and countries for their best practices during the Covid 19 pandemic will continue to resonate with the people of India and the world as they may be re-thinking and re-imagining a better world for the post-Covid era.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We are grateful to John S Moolakkattu, Professor of International Relations & Politics, Central University of Kerala, (Kasaragod) and Manasi Joseph, Faculty Member, Centre for Rural Management (CRM), Kottayam, Kerala for feedback on an earlier draft of the article. We are also thankful for reviewer comments.

2 There is a rich literature on the Kerala model of development. Also See, Franke & Chasin, 1994 ; Kannan, 1995 , Kannan, 2000 ; Dreze and Sen, 1998 , Dreze and Sen, 2002 ; Ramachandran, 1998 ; Tharamangalam, 1998a , Tharamangalam, 1998b , Tharamangalam, 2006a , Tharamangalam, 2006b , 2010; George, 1999 ; Isaac & Franke, 2000 ; Tornquist, 2002 ; Harris,2003 ; Tharakan, 2004 ; Thomas, 2006 ; Heller, 2007 ; Gurukkal & Varier, 2018 ; among others.

3 Note that the term “model” is used here to denote, not an exemplar for imitation—although there are some useful lessons that can be learned from Kerala’s experience—but in the scientific sense of a pattern of socio-economic and political development characterized by such notable features such as public action, support-led security, and state policies that prioritize general social well-being—features that are empirically identifiable and amenable to empirical investigation.

4 Kerala is the third most densely populated state in India. Based on the latest Census, Kerala’s density of population is 860 persons per sq. km. India’s population density is 382 persons per sq. km.

5 The first three Covid 19 cases in India were reported in the state of Kerala. The first patient was a medical student at Wuhan University, who returned to Kerala following the pandemic outbreak in China. The first case of Covid 19 was confirmed on January 30, 2020. Two more medical students from Wuhan, who returned to Kerala tested positive for Covid 19 in the following days.

6 See for example Biswas (2020a) , Biswas (2020b) in the BBC and Pandey (2020) in the BBC, Anandan (2020) in The Hindu.

7 The Third wave of Covid 19 infections in Kerala began on May 13, 2020 and is currently underway. The first wave of Covid 19 infections in Kerala began on January 30, 2020 and ended on February 20. It ended after the first three Covid 19 patients who tested positive for the novel coronavirus recovered. After that Kerala didn’t had any Covid 19 cases until March 7, 2020. On March 8, the second wave of Covid 19 infections began in Kerala with three Keralites, who had returned from Italy tests positive for Covid 19. The second wave ended on May 4, 2020 with Kerala flattening the infection curve.

8 According to Non-Resident Keralites Affairs (NORKA), in a state of 35 million population, one out of six Keralites work abroad. Following the easing of lockdown, nearly 4 lakh expatriates have registered with NORKA, stating their wish to return to Kerala. See NORKA, 2020 .

9 See Kumar (2020) in The Wire.

10 See Nowrojee (2020) in The Diplomat.

11 See for example Biswas (2020a) , Biswas (2020b) in the BBC, Fisher and Taub (2020) in the New York Times, Heller (2020) in The Hindu and Spinney (2020) in The Guardian.

12 To explain it further, those placed under the quarantine were asked by health workers to answer a questionnaire of 41 questions. The government collected these data from health workers and handed it over to the US based Sprinklr.

13 See John and Toms (2020) in The Economic Times.

14 The authors of this paper interacted with a few leaders of ruling and opposition parties in the state on April 30 and May 20, 2020 and discussed the Sprinkler controversy. Total eight interviews were conducted, four each from the ruling and opposition parties. Also See Chandran (2020) in The New Indian Express.

15 C-DIT, established by Government of Kerala in 1998 for the advancement of research, development and training in imaging technology.

16 It is an autonomous nodal IT implementation agency under Department of Electronics & Information Technology, Government of Kerala.

17 National Informatics Centre (NIC) is a science and technology institution for providing e-governance solutions, integrated services and global solutions in the government sector.

18 See Special Correspondent (2020, May 22) in The Hindu.

19 A batch of five writ petitions were filed before the Kerala High Court challenging the breach of confidentiality of data collected for the Sprinklr. The petitioners argued that the contract made with Sprinklr lacked strong data protection clauses to prevent commercial and unauthorised exploitation of Covid 19 data. Also see Jacob Jeemon (2020) .

20 Balu Gopalakrishnan Vs. State of Kerala and Ors The interim order was issued by a Division Bench comprising Chief Justice of the Kerala High Court. Though the Court refused to stay the deal or agreement, it reminded the government that medical data is sensitive and government should ensure it remains confidential. The government informed the Court that the database of the Covid 19 patients has been transferred to the government owned cloud web space in Amazon Web Services managed and controlled by C – DIT. Owing to sharp criticism from the opposition and privacy rights activists, Kerala government cancelled the deal with Sprinklr.

21 The Indian government launched Vande Bharat Mission (VBM) in May 2020. It is the country’s largest expatriation exercise to bring back stranded Indians from foreign countries. The first phase of the Mission was carried out from May 7 to May 15, 2020, the second phase of the Mission was from May 17 to June 10, 2020 and third phase from June 11 to July 2, 2020. Fourth phase was from July 3 to July 15, 2020. The VBM is currently in its fifth phase.

22 The Indian Navy launched ‘Operation Samudra Setu’ (OSS) on May 5, 2020 as a part of national effort to repatriate Indian citizens from overseas. OSS concluded on July 8, 2020.

23 Sinha (2020) in Times of India.

24 See, K M Nideesh (2020) in The Mint.

25 According to official estimates, there are least 33 lakh NRKs are residing in various countries.

26 The Kerala government was keen to bring back those with expired visas, pregnant woman, children, senior citizens, critically ill patients who have gone abroad for receiving treatment.

27 The order came in the wake of Central government decision to launch the repatriation exercise under Vande Bharat Mission to rescue Indian citizens stranded in various parts of the globe.

28 Migration experts and leading economists in the state said that the remittances by NRKs have played a significant role in the growth of Kerala’s economy. During a conversation with S Irudaya Rajan, Professor, Centre for Development Studies, Thiruvanthapuram and a member of a high-level Covid 19 committee set up by the state government to study the ramifications of the Covid 19, said that Kerala receives close to Rs. 85,000 crore (US $ 11,641 Million) annually as foreign remittances. Migration experts are pointing out that Kerala could lose nearly Rs. 13,000 crore (US $ 1780 Million) in annual foreign remittance as it is expected that more than 4 lakh Keralites who live abroad would eventually return to the state due to the pandemic by the end of September. Also See, Swamy (2020) in The Print.

29 A senior leader of the opposition party called the health minister K K Shailaja ‘Covid Queen’. The ill remarks were in response to government’s decision for making Covid 19 negative certificates mandatory for NRKs hoping to return to the state.

30 See Koshy (2020) in NDTV.

31 Those with Covid 19 symptoms were shifted to Covid 19 hospitals and rest of them to state run quarantine facilities or home quarantine in the case of pregnant women.

32 See Babu (2020a) , Babu (2020b) in Hindustan Times.

33 Local transmission means that the source of infection is from within a particular area.

34 Super Spreader is a person who spreads the disease to a greater number of people than an average infected person would. A typical Covid 19 patient is capable of infecting 2–3 persons. However, certain individuals or group of individuals are capable of infecting a large group of people and epidemiologists call them super spreaders.

35 In the following days, the “Super Spreader incidents were reported in Manikyavilakam and Puthenpally, in Thiruvanthapuram district. This eventually led to a spike in infections through local transmissions and Covid 19 clusters were formed in Puthukurichi, Anchuthengu, Beemapally, Vizhinjam, Adimalathura, Pozhiyoor, Parassala, Perumathura, Poovar, Kulathur and Karode in Thiruvanthapuram.

36 It is a known fact that under certain social circumstances, religion and cultural factors play a pivotal role in the political and social mobilization as in the case of the fishing community in Kerala. The apathy of political parties towards this community gave the opportunity for Catholic priests and social workers to empower these marginalized communities politically and socially. This has eventually led to the formation of fishers’ cooperatives and unions that has helped the fisher community to launch organized actions to defend their interests and causes.

37 It has a fragile, but unique and rich ecosystem that contains tracts of backwater areas known for wetland rice farming, hill and mid-land areas that have been historically famous for its expert crops such as pepper and other spices and more recently other export crops such as coconuts and rubber.

38 In the year 1961, Kerala’s 60 plus population was 5.10 per cent, which was at that time just below the national average of 5.60 per cent. From 1980s onwards Kerala began to overtake the rest of the India. In 2001, the proportion of the old age population in the Kerala rose to 10.50 per cent as against the national average at the 7.50 per cent. As per the latest (2011) census, 12.60 per cent of Kerala’s population were above 60 years compared to the national average of 8.60 per cent. A study ( Rajan & Mishra, 2013 ) showed that the elderly population in the state is growing at a perpetual rate of 2.30 per cent. It also found that the growth rate is high among the elderly aged 70 or 80 years above. In 2015, Kerala’s 60 plus population rose to 13.10 per cent while all India average stood at 8.30 per cent (Sample Registration System Statistical Report ( SRS, 2015 )). As per the SRS Report 2018, Kerala’s 60 plus population rose to 13.30 per cent. The Economic Review 2019 also asserted that Kerala is aging faster than India. It stated that 48 lakh people of Kerala are 60 years and above. Rajan and Mishra have created a population projection about elderly population aged 60 years and above in Indian states and union territories ( Rajan & Mishra, 2020 ). One of the authors of this research paper interacted with Rajan and during the conversation, he said that in 2020 Kerala has nearly 16 per cent people aged 60 years and above. (Interview with S Irudaya Rajan by one of the Authors of this research paper on August 13, 2020.)

39 Three factors may help to explain this scale of out-migration: (i) the lack of employment opportunities in Kerala, (ii) the opening of new opportunities in the Gulf countries, and perhaps most importantly from the perspective of the Kerala model, (iii) the rapid spread of basic and even higher education in Kerala enabling its young people to compete successfully in the job market in these countries. The downside (if it may be called thus considering the environmental risks of such a state to sustain conventional types of polluting industries) of the Kerala model of development has been its failure to create industries and employment. The more recent economic and income growth (with at least the second highest per capita income and consumption among Indian states) has been triggered by the tertiary sector, also backed by the substantial remittances from the non-resident Keralites.

40 The first cases reported were of three medical students who had returned from Wuhan. All three recovered quickly. Then came report of a Covid-infected person with no history of traveling abroad from a primary health center in Pathanamthitta district. The concerned authorities lost no time in tracing this puzzling case to a family of three who had returned from Italy on February 25, 2020. It turned out that these three had evaded the required protocols and had been freely visiting relatives and friends and. --in fact infecting a number of them.

41 The Kerala government’s successful response to the Nipah virus outbreak-- quickly diagnosing the virus in a district hospital in Kozhikode (but with the help of research facilities in other parts of India and imported drugs from Australia) had already greatly increased the reputation of the Kerala government and its heath care facilities. There is a 2019 popular Malayalam film named, “Virus”, mostly based on actual events, that depicts the struggles of the patients in diagnosing, and identifying the virus and in taking effective steps in controlling the outbreak. Also see Wikipedia (2019) , Virus (2019).

42 Including civil society and volunteer organizations.

43 There is a controversy surrounding the exact number of deaths resulting from Covid 19 as government has reportedly excluded deaths of Covid 19 patients with co – morbidities from Covid 19 death toll. The above-mentioned figure is provided by officials of health department.

44 The authors of this paper interacted with frontline Covid 19 warriors. Based on the interaction, we realised that these frontline warriors were plagued by stress and tension. The incidents of health workers contracting the virus and the stigma and ostracization they had to face in the wake of pandemic have left them exhausted and drained out. It is also to be noted that despite all the odds and challenges, the healthcare workers are still offering their selfless service in the fight against Covid 19. (Interviews with 12 frontline Covid warriors on 24 July 2020.)

45 According to department of health and family welfare, nearly 14 per cent of health workers have complained that absence of adequate PPE kits and reuse of the kits as one of the major reasons for the spread of Covid 19 infections among health workers. Around 8 per cent of healthcare workers said that having food together in groups without wearing PPE kits as a reason for contracting the virus. A few others highlighted improper handling of throat swabs and fomites as a reason for infection among health workers. According to the department of health and family welfare, more than 70 per cent of the health workers who tested positive for Covid 19 had an identifiable person infected with Covid 19 as a contact.

46 First-Line Covid Treatment Centres (FLCTCs) are public health centres to treat Covid 19. Local Self Governments (LSGs) in the state have identified hotels, wedding halls, stadiums and colleges for setting up of FLCTCs. These FLCTS functions under the respective LSGs. At present Kerala has set up 178 FLCTCs.

47 See Varma Vishnu (2020) in The Indian Express and Unnithan Gopikrishnan (2020) in India Today. Also, one of the authors of this paper talked to the residents in the coastal villages of Poonthura and Manikkavilakam on July 13. They admitted that they hurled abuses at the health officials and scoffed at them, but residents added that they were forced into doing such activities based on misleading information given to them by external forces. They also said that they have apologized to the health officials in this regard. (Interviews with 12 residents on 13 July 2020). Experts have pointed out that coastal hamlets in the state served as a vulnerable cluster of Covid 19, which government failed to acknowledge initially. (Interviews with two experts and five health workers on July 13&14, 2020.)

48 See Chandna (2020) in The Print. Kerala has now included ayurveda practitioners in its early detection system. A State Ayurveda Covid 19 Response Cell has been set in the state specifically to work on ayurvedic formulations and drugs for developing immunity against diseases.

49 Geofence refers to setting up of a virtual fence around a geographical location or person. Using geofencing, police can track a person’s location using their mobile number, global positioning system (GPS), Wi Fi, radio frequency identification (RFID) tags and the cell tower of the respective mobile network. The geofencing software of the cyber cell department will trigger emails and SMS alerts to police or authorised government agency if a person moves 50 m away from his house or quarantine centre.

50 A technological research and development arm of Kerala Police.

51 One of the authors of this paper interacted with a few senior police officials in the state regarding geofencing. (Interviews with three police officials on March 26, 2020). They said it was first launched in Kottayam district and the officials were able to catch those violating quarantine instantly. Following the success in Kottayam, districts like Wayanad and Kasaragod also made use of geofencing technology.

52 On April 4, 2020, nearly 41 people, who ventured out for an early morning walk in Panampilly Nagar, Ernakulam District were caught on night vision cameras of a drone deployed by the city police to enforce physical distancing to prevent spread of the Covid 19.

53 A total of 215 police personnel has tested positive for Covid 19 since March 2020. In the wake of rise in contact cases, the spread of infection among the police force, who are in the frontline to fight the pandemic is not able to exercise their duties properly and diligently.

54 Authors of this research paper talked to three social observers and three political scientists on August 7, 2020. A few of them compared the surveillance on the lines of Covid 19 to George Orwell’s fictional state depicted in the book “1984”. See, Orwell George (1949) .

55 The government made the submission on the petition filed by the leader of opposition challenging the circular by the State Police Chief on the collection of call data records (CDR) of Covid-19 patients.

56 Customs officials seized a consignment of gold worth Rs 15 crores (US $2.05 Million) at the Trivandrum International Airport on July 5. The consignment that came via diplomatic channel was addressed to the UAE consulate in Thiruvanthapuram. The two main accused were former employees of the UAE consulate and one of them was also a marketing officer for one of the firms linked to the Kerala government's information technology department. This accused allegedly was close to a senior bureaucrat in the CMO. The National Investigation Agency (NIA), a Counter Terrorism Law Enforcement Agency in India is currently investigating the gold smuggling scam. Also see, Phillip (2020) in The Indian Express.

57 A housing project of the state government to build houses for families without land or housing. Emphasis is given on financial empowerment and providing means of livelihood. Also see Malayala Manorama (2020, August 22) .

58 For instance, the number of people watching his live broadcasts on major social media platforms like Facebook and Twitter has gone down drastically since the beginning of third wave of Covid 19 infections in Kerala. The average number of likes and views for the live videos on CM’s Facebook page on April 17, had 29k likes and more than 565.64k views but it has fallen to 9.4k likes and 339.41k views as per the latest figures. But the government claims people continue to watch the press briefings of the CM. However, the public opinion is that they only watch it for the sake of knowing the number of Covid 19 cases and not because they are admirers of the CM. Also see, Vidyanadan (2020) , in The New Indian Express.

59 A division bench, comprising Chief Justice, directed the government to take preventive measures to ensure that no political party or association violates the directives issued by the government and judgements of the Supreme Court. It also stated that the organisations should abide by both the Centre’s and state’s COVID-19 regulations while carrying out protests. The Court also ruled that there should not be any protests or demonstrations in the state till July 31, 2020 and it was further extended to August 31, 2020.

60 Kerala government has imposed a fine of Rs. 10,000 (US $ 137) or a two – year jail term for those not wearing mask. Even though a large section of people wears masks but not many wears them properly. Some of them wear mask under their nose and chin. While talking some people lowers masks till their neck.

61 See, Sanjay Satviki in Vice News. (2020) . For instance, in Kerala, an electronic goods shop published a bizarre advertisement promising customers cashback offer of Rs. 50,000 (US $ 684) if they tested Covid 19 positive within 24 h of shopping.

62 See, Kallungal (2020) in The New Indian Express.

63 On March 25, India went into a complete nationwide lockdown and only essential services were given the permission to operate. Due to the pandemic induced lockdown, many people especially daily wage labourers and migrant labourers lost their jobs and thus were left with no money. Since the lockdown was imposed after a 4 – hour prior notice, migrant labourers working in various parts of the country got stranded as public transport including buses and railways were suspended. Kerala has a large chunk of migrant workers (Kerala calls them as ‘guest workers’). There are nearly 25 lakh guest labourers in Kerala ( Narayana et al., 2013 ) and out of it a considerable number left the state prior to nationwide lockdown and some 4.10 lakh were not able to go back to their native states due to lockdown. Without a job and not able to go back to homes, the guest labourers were forced to depend on someone for food and their necessities. The destitute, homeless and those belonging to economically weaker sections of the society were also in the same situation. The authors of this research paper interacted with 18‘guest workers. (Interview on April 3 & 4, 2020).

64 In the wake of nationwide lockdown, 144,145 guest laborers were housed in 4608 shelters in the state. With the easing of the lockdown, many of these the guest labourers are returning to their homes each day. The community kitchens served the guest laborers, the elderly, the homeless, the destitute, and the sick.

65 A poverty eradication and women empowerment programme of Government of Kerala

66 Kudumbashree (2020) . On August 2, authors of this research paper interacted with 8 women who provided support to community kitchens (Interview on August 2, 2020).

67 A model that contains multiple centers of sourcing and delivering food, but with a “hub” that coordinates the activities and provides a central point of contact to all the clients.

68 At present there are a total of 253 Janakeeya hotels are functioning in Kerala. These days demand for Janakeeya hotels are also rising. As per records, 38,27,255 meals have been provided through these hotels. On July 25, authors of this research paper interacted with 12 women who manage Janakeeya hotels and some of them expressed their doubt towards the sustainability of the hotels. (Interview on July 25, 2020).

69 A good example of this is sourcing community-based disaster management plans (CBDMs) already prepared by a large number of Gram Panchayats (village level governments) in the aftermath of the two earlier floods. These plans are based on extensive ward-based data on shelter management, hospital infrastructure, technical resource persons, and trained health workers. This valuable resource is now being used for the fact-based management of the new crisis.

70 Both World Health Organisation (WHO) and Indian Council of Medical Research (ICMR) mention that deaths should be included in the Covid 19 tally, irrespective of whether the novel virus was the first or second leading cause of the death.

71 On July 25, authors of this research paper interacted with three members in the government constituted expert committee on Covid 19. Panel members said that changing the criteria for inclusion of Covid 19 deaths, without proper clarification when the pandemic is claiming the lives of an increasing number of people would raise suspicion in the minds of public and would deeply affect the credibility of medical fraternity and the government. (Interview on July 25, 2020). Also see Maya (2020) in The Hindu.

72 However, there are exceptions too. Government Medical College in Kottayam was lauded for curing an elderly couple (aged 93 and 88 with high levels of co-morbidity. They got infected from their son who returned from Italy bringing the second wave of Covid 19 infections to Kerala. On July 29, a 105-year-old woman and on August 19, a 103-year-old man were also cured of Covid 19. See in Hiran (2020) in The Hindu, Babu Ramesh (2020) in Hindustan Times and Times of India (2020) .

73 In addition to the larger proportion of elderly, Kerala also has the largest incidence of non – communicable diseases (NCDs) in India. According to Report on Medical Certification of Cause of Death (2015 ) released by the Office of the Registrar General, India, in 2015 nearly 9.60 per cent people in Kerala died due to diabetes in Kerala whereas in India it was just 3.40 per cent. This itself is evident of the extent of higher incidence of comorbidities in Kerala. Also See, Sarma, Sadanandan and Thulaseedharan (2019) .

74 The following data was provided by the State Medical Board constituted for Covid 19 management. One of the authors of the paper interacted with an official from this medical board for estimating the deaths resulting from Covid 19 due to comorbidities. (Interview on August 1, 2020).

75 Dreze and Sen deal with the concept of ‘public action’ in many of their writings. See, especially Dreze & Sen, 1989 , 1998; Sen, 1999 .

76 This statement may not be strictly correct; San Marino, a tiny state bordering Italy appears to have elected a communist party earlier, but in coalition with a socialist party.

77 This act of dismissing a democratically elected state government seems to have set a bad precedent in Centre-state relations in Indian democracy that has now come to roost under a Hindu-nationalist majoritarian central government with strong base in North India. Its unilateral revocation of Article 370 of the Constitution and converting the state of Jammu and Kashmir into a union territory controlled by the Centre is a case in point. This was a blatant violation of the provision that any change in the status of this state could be made only in consultation with the democratically elected and legitimate government of the state. In the event, the democratically elected representatives heading the government were put in prison.

78 M A Oommen , one of the influential development economists in Kerala made this point while presenting a paper titled ‘“Covid-19 context in India and Working towards Alternative Paradigms” in a four day international webinar (August 27 to August 30, 2020), organized by Mahatma Gandhi University, Kottayam, Kerala and Kerala Institute of Local Administration (KILA). The international webinar was on the theme “Cooperativism, Self-management and Decentralized Development”

79 It still retained some features of orthodox communist parties including adherence to the doctrines of “democratic centralism” and its self-definition as a “vanguard” party. While these have resulted in some democratic deficits with regard to inner party democracy, this has not affected the effective functioning of the multi-party system.

80 These landless laborers, at the bottom of the caste/class system, did succeed in organizing what must be considered the most vibrant agricultural labor union in all of India and playing an important role in the political mobilization of the lower castes/classes in Kerala.

81 Just two examples of such movements: the Kerala People’s Arts Club (KPAC), a very popular theatrical movement that organized plays and road shows, especially in the 1950s, and the Kerala Sasthra Sahitya Parishad (also known as KSSP) a Peoples’ Science Movement that began in the 1960s and continues to be active even today. Also see Kerala Sasthra Sahitya Parishad in Wikipedia (2016) .

82 Popularly known as Dr. Palpu.

83 Quoted in Ramachandran 1998, pp. 308 .

84 Take the example of the Bengal famine of 1943 which killed over 2 million people. Sen asks why these 2 million (mostly the rural poor) died while others were well fed, yet others hoarded food and/or exported food out of Bengal. The answer has to be sought in the system of food distribution and resource allocation, a complex social, cultural, political and especially legal system. Those who starved were the ones who were excluded from access to food in this system, at the center of which was a “war economy” that determined and controlled such access, i.e., “entitlements” to food.

85 Global Hunger Index (GHI, 2019), a multi-dimensional index that includes measures of child malnutrition including infant mortality rate and rates of child wasting and stunting.

86 The SCs are the ex-untouchables, now generally called Dalits and the SCs are the country’s aboriginal or indigenous people. Their official and legal appellation of ‘scheduled” stems from the fact that they are listed in the Indian Constitution as entitled to some special provisions of affirmative action, reservations in employment and educational institutions.

87 Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) is a social security measure launched by the Government of India in 2005. The scheme was introduced to enhance the livelihood security in rural areas by providing 100 days of wage employment in a financial year. See, Chathukulam and Thottunkel (2010) .

88 The government of India passed the National Food Security Act in 2013. It aimed at ensuring access to adequate food at affordable prices.

89 It is noteworthy that the best performing Indian states in enhancing human development and reducing poverty also include some in the North East such as Manipur and Nagaland. We would suggest that the critical factor behind the difference between these so-called “tribal” states and the politically powerful, but socially backward North Indian states (also the main base of the BJP and the Hindutva movement) is the relatively weak presence (if any) of caste in the former and its entrenched and all-encompassing nature in the latter. A second factor may be the early lead of these North East states in literacy and education, mostly due to missionary activities.

Anandan, S. (2020, July 26). Why have COVID-19 cases surged in Kerala? The Hindu. Retrieved from https://www.thehindu.com/news/national/kerala/the-hindu-explains-why-have-covid-19-cases-surged-in-kerala/article32192847.ece .
Babu, R. (2020, July 29). 105-year-old woman in Kerala beats Covid-19 in nine days. Hindustan Times. Retrieved from https://www.hindustantimes.com/india-news/105-year-old-woman-in-kerala-beats-covid-19-in-nine-days/story-9vkjWy86FxlyrYlvyi11GI.html .
Expats upset as Kerala insists Covid-free certificate for chartered flights; Hindustan Times: 2020. June 13 Retrieved from https://www.hindustantimes.com/kerala/expats-upset-as-kerala-insists-covid-free-certificate-for-chartered-flights/story-71fRWQ9. [ Google Scholar ]
Balu, G. Vs. State of Kerala and Ors, W.P. (C). Temp No. 84 of 2020 along with other petitions. April 24, 2020. Retrieved from https://globalfreedomofexpression.columbia.edu/wp-content/uploads/2020/05/Balu-gopalakrishnan-v-State-of-kerala.pdf .
Biswas, S. (2020, April 16). Coronavirus: How India's Kerala state flattened the curve. BBC News. Retrieved from https://www.bbc.com/news/world-asia-india-52283748 .
Biswas, Soutik. (2020, July 20). India Coronavirus: How Kerala's Covid success story came undone. BBC News. Retrieved from https://www.bbc.com/news/world-asia-india-53431672 .
Centre for Development Studies (CDS), Trivandrum . Orient Longman; New Delhi: 1975. Poverty, Unemployment and development policy: A case study of selected issues with reference to Kerala. [ Google Scholar ]
Chandna, H. (2020, June 15). This is Kerala’s Ayurveda prescription to fight coronavirus and keep infections down. The Print. Retrieved from https://theprint.in/health/this-is-keralas-ayurveda-prescription-to-fight-coronavirus-and-keep-infections .
Chandran, Cynthia. (2020, May 22). Congress wins first round over Sprinklr deal. The New Indian Express. Retrieved from https://www.newindianexpress.com/states/kerala/2020/may/22/congress-wins-first-round-over-sprinklr-deal-2146389.html .
Chathukulam J., John M.S. Five years of participatory planning in Kerala: Rhetoric and reality. Economic and Political Weekly. 2002; 37 (49):4917–4926. [ Google Scholar ]
Chathukulam J., Thottunkel A.K. The Sen in the Neo-liberal developmental programmes of Kerala. International Journal of Rural Management. 2010; 6 (2):161–192. [ Google Scholar ]
Desai M. Routledge; London: 2006. State formation and radical democracy in India. [ Google Scholar ]
Dreze J., Sen A. Oxford University Press; New Delhi: 2002. India: Development and participation. [ Google Scholar ]
Dreze J., Sen A. Penguin; London: 2013. An uncertain glory : India and its contradictions . [ Google Scholar ]
Devika J. The capabilities approach in the vernacular: The history of capability building in Kerala. Economic and Political Weekly. 2010; 45 (26):269–277. [ Google Scholar ]
Dreze J., Sen A. Clarendon Press Oxford; Oxford: 1989. Hunger and public action. [ Google Scholar ]
Dreze J., Sen A., editors. Indian development: Selected regional perspectives. Oxford India; Delhi: 1998. [ Google Scholar ]
Evans P.B. Princeton University Press; New Jersey: 1995. Embedded autonomy: States and industrial transformation. [ Google Scholar ]
Evans P.B., editor. State-society synergy: Government and social capital in development. University of California; Berkeley: 1997. [ Google Scholar ]
Evans P.B., Dietrich R., Theda S., editors. Bringing the state back in. Cambridge University Press; Cambridge: 1985. [ Google Scholar ]
Fisher, M., & Taub, A. (2020, May 22). On our minds: How a southern Indian state crushed its coronavirus outbreak. The New York Times. Retrieved from https://static.nytimes.com/email-content/INT_sample.htm .
Franke, R. W., & Chasin, B. H. (1994). Kerala: Development through Radical Reform. New Delhi: Promila & Co. in collaboration with the Institute for Food and Development Policy, San Francisco.
George, K. K. (1999). Limits to Kerala Model of development: An analysis of fiscal crisis and its implications. Thiruvananthapuram: Centre for Development Studies.
Government of India (GOI), Planning Commission. (2008). Kerala Development Report. New Delhi.
von Grebmer, K., Bernstein, J., Mukerji, R., Patterson, F., Wiemers, M., NíChéilleachair, R., Foley, C., Gitter, S., Ekstrom, K., & Fritschel, H. (2019). Global hunger index: The challenge of hunger and climate change. Welthungerhilfe; and Dublin. Retrieved from https://www.globalhungerindex.org/pdf/en/2019.pdf .
Gurukkal R., Varier R. Orient Black Swan; Hyderabad: 2018. History of Kerala: Prehistoric to the present. [ Google Scholar ]
Harris J. Do political regimes matter? Poverty reduction and regime differences across India. In: Houtzager P., Moore M., editors. Changing paths: International development and new politics of inclusion. University of Michigan Press; Ann Arbor: 2003. pp. 204–232. [ Google Scholar ]
Heller P. Social capital as product of class mobilization and state intervention: Industrial workers in Kerala, India. World Development. 1996; 24 (6):1055–1071. [ Google Scholar ]
Heller P. Cornell University Press; New York: 1999. The labor of development: Workers and the transformation of capitalism in Kerala, India. [ Google Scholar ]
Heller P. Degrees of democracy: Some comparative lessons from India. World Politics. 2000; 52 (4):484–519. [ Google Scholar ]
Heller, P. (2007). Kerala: Deepening a radical social democracy. In Sandbrook et al.
Heller, P. (2020, April 18). A virus, social democracy, and dividends for Kerala. The Hindu. Retrieved from https://www.thehindu.com/opinion/lead/a-virus-social-democracy-and-dividends-for-kerala/article31370554.ece .
Herring R.J. Yale University Press; New Haven: 1983. Land to the Tiller: The political economy of agrarian reform in South Asia. [ Google Scholar ]
Hiran, U. (2020, April 3). A 93 – year – old Kerala’s oldest patient to recover from Covid 19, returns home. The Hindu. Retrieved from https://www.thehindu.com/news/national/kerala/elderly-couple-win-the-battle-capture-the-optimistic-spirit-of-the-state/article31252383.ece .
Houtzager P.P., Moore M., editors. Changing paths: International development and the new politics of inclusion. University of Michigan Press; Ann Arbor: 2003. [ Google Scholar ]
Isaac T.T.M., Franke R.W. Left Word; Delhi: 2000. Local democracy and development: People’s campaign for decentralized planning in Kerala. [ Google Scholar ]
Jacob, J. (2020, May 21). Kerala backs out of Sprinklr deal, cancels controversial pact over privacy issues. India Today. Retrieved from https://www.indiatoday.in/india/story/kerala-sprinklr-deal-covid-19-pinarayi-vijayan-high-court-1680484-2020-05-21 .
Jeffrey R. Palgrave Macmillan; London: 1992. Politics, women and wellbeing: How Kerala became ‘a Model’ [ Google Scholar ]
Jeffrey R. Legacies of matriliny: The place of women and the “Kerala Model” Pacific Affairs. 2004; 77 (4):647–664. [ Google Scholar ]
John, N., &Toms, M. P. (2020, May 4). A viral debate: The Sprinklr row turns the spotlight on privacy in Kerala. The Economic Times. Retrieved from https://economictimes.indiatimes.com/prime/economy-and-policy/a-viral-debate-how-the-sprinklr-row-turned-the-spotlight-on-privacy-in-kerala/primearticleshow/75523954.cms .
Kallungal, D. (2020, April 16). Infiltration through porous borders worries officials. The New Indian Express. Retrieved from https://www.newindianexpress.com/cities/thiruvananthapuram/2020/apr/16/infiltration-through-porous-borders-worries-officials-2130 .
Kannan K.P. Public intervention and poverty alleviation: A study of the declining incidence of poverty in Kerala, India. Development and Change. 1995; 26 (4):701–721. [ Google Scholar ]
Kannan K.P. People’s planning: Kerala’s dilemma. Seminar. 2000; 485 (1):1–10. [ Google Scholar ]
Kant, I. (1784). An answer to the question: What is Enlightenment? Cambridge University Press (Translated & Edited by Mary J. Gregor, 1996. Transcribed by Andy Bullen).
Kerala Economic Review (2019). Kerala State Planning Board, Government of Kerala.
Kohli A. Oxford University Press; New Delhi: 2009. Democracy and development in India. [ Google Scholar ]
Kohli A. State and redistributive development in India. In: Nagaraj R., editor. Growth, inequality and social justice in India: Is inclusive growth possible? Palgrave Macmillan; London: 2010. pp. 194–226. [ Google Scholar ]
Kohli A. Cambridge University Press; Cambridge: 2012. Poverty amid plenty in the New India. [ Google Scholar ]
Kohli A. Cambridge University Press; Cambridge: 2004. State-directed development: Political power and industrialization in the global periphery. [ Google Scholar ]
Koshy, M. S. (2020, June 19). Row Over Senior Congress Leader's “Covid Rani” Remark on Kerala Health Minister. NDTV. Retrieved from https://www.ndtv.com/kerala-news/congress-leader-mullappally-ramachandran-calls-kerala-health-minister-kk-shailaja-covid-rani- criticised-2249040 .
Krishnan T.N. AKG Centre for Research and Studies; Thiruvananthapuram: 1994. Foreign remittance, consumption and income. [ Google Scholar ]
Kudumbashree. (2020).Community Kitchen Live Data. Retrieved from http://kudumbashree.org/pages/826 Accessed April 29, 2020.
Kumar, D. (2020, May 15). Half a million COVID-19 cases in India: How we got to where we are. The Wire. Retrieved from https://thewire.in/covid-19-india-timeline#:~:text=A%20nationwide%20lockdown%20was%20imposed .
Kurien J. The Kerala model: Its central tendency and the outliers. Social Scientist. 1994; 23 (1–3):70–90. [ Google Scholar ]
Kurien J. The socio-cultural aspects of fisheries: Implications for food and livelihood security: A case study of Kerala state, India. In: McGoodwin J.R., editor. Understanding the cultures of fishing communities: A key to fisheries management and food security. Food and Agriculture Organization; Rome: 2001. [ Google Scholar ]
Malayala Manorama (2020, August 22). Life Mission Housing Project: Documents reveal Kerala government was aware of financial misdeeds. Retrieved from https://www.onmanorama.com/news/kerala/2020/08/21/life-mission-project-kerala-financial-misdeeds-government.html .
Maya, C. (2020, August 30). COVID-19 death audit report of Kerala raises eyebrows. The Hindu. Retrieved from https://www.thehindu.com/news/national/kerala/covid-19-death-audit-report-of-kerala-raises-eyebrows/article32478959.ece .
Migdal J.S. Cambridge University Press; Cambridge: 2001. State-in-society: Studying how states and societies transform and constitute one another. [ Google Scholar ]
Migdal J.S., Kohli A., Shue V., editors. State power and social forces: Domination and transformation in the third world. Cambridge University Press; Cambridge: 1994. [ Google Scholar ]
Moolakkattu S.J., Chathukulam J. Between euphoria and scepticism: Ten years of Panchayati Raj in Kerala. In: Oommen M.A., editor. A decade of decentralisation in Kerala: Experience and lessons. Har-Anand; New Delhi: 2007. pp. 54–87. [ Google Scholar ]
Mukherjee-Reed A. Taking solidarity seriously: Analysing Kerala’s Kudumbashree as a women’s SSE experiment. In: Utting P., editor. Social and Solidarity economy: Beyond the fringe. Zed Books; London: 2015. pp. 300–312. [ Google Scholar ]
Narayana D., Venkiteswaran C.S., Joseph M.P. Gulati Institute of Finance and Taxation (GIFT) Publication; Thiruvananthapuram: 2013. A study on domestic migrant labour in Kerala. [ Google Scholar ]
NORKA Roots Covid Services-NORKA. 2020. https://norkaroots.org/covid-services Retrieved from.
Nowrojee, B. (2020, August 9). How a South Indian State Flattened Its Coronavirus Curve. The Diplomat. Retrieved from https://thediplomat.com/2020/05/how-a-south-indian-state-flattened-its-coronavirus-curve/ .
Oommen M.A. Government of Kerala; Thiruvananthapuram: 2009. Report of the committee for evaluation of decentralized planning and development. [ Google Scholar ]
Oommen M.A., editor. A decade of decentralisation in Kerala: Experience and lessons. Har-Anand; New Delhi: 2007. [ Google Scholar ]
Orwell G. Secker & Warburg; London: 1949. 1984. [ Google Scholar ]
Pandey, V. (2020, May 7). India coronavirus: Why celebrating Covid-19 'success models' is dangerous. BBC News. Retrieved from https://www.bbc.com/news/world-asia-india-52527534 .
Phillip, S. (2020, July 7). Kerala CM’s principal secretary removed for alleged connection to gold smuggling accused. The Indian Express. Retrieved from https://indianexpress.com/article/india/kerala-cmo-principal-secretary-gold-smuggling-racket-6493872/ .
Rajan S.I., Mishra U.S. Centre for Development Studies(CDS) Publication; Thiruvanthapuram: 2013. A survey on ageing scenario in Kerala. [ Google Scholar ]
Rajan S.I., Mishra U.S. Springer; New Delhi: 2020. Senior citizens of India: Emerging challenges and concerns. [ Google Scholar ]
Ramachandran V.K. On Kerala’s development achievements. In: Dreze J., Sen A., editors. Indian development: Selected regional perspective. Oxford University Press; Delhi: 1998. pp. 205–356. [ Google Scholar ]
Report on Medical Certification of Cause of Death. (2015). Office of the Registrar General. Ministry of Home Affairs (MHA). Government of India. Retrieved from https://www.censusindia.gov.in/2011-Documents/mccd_Report1/MCCD_Report-2015.pdf .
Sample Registration System Statistical Report (SRS). (2015). (2018). The Sample Registration System (SRS) Statistical Report in India is carried out by the Office of Registrar General & Census Commissioner, India.
Sanjay, S. (2020, August 19). A store promised buyers cashback of Rs 50,000 if they got coronavirus within 24 hours of purchase. Vice. Retrieved from https://www.vice.com/en_in/article/4aypwg/kerala-india-store-cashback-for-coronavirus-positive-customers .
Sarma P.S., Sadanandan R., Thulaseedharan J.V. Prevalence of risk factors of non-communicable diseases in Kerala, India: Results of a cross-sectional study. BMJ Open. 2019; 9 (11) doi: 10.1136/bmjopen-2018-027880. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
Sen A. Anchor Books; New York: 1999. Development as freedom. [ Google Scholar ]
Sen, A. (2006). Education in Kerala’s development: Towards a new agenda. In Tharamangalam (Ed.). Kerala: The paradoxes in public action and development (PP. 258–272). New Delhi: Orient Longman.
Sinha, S. (2020, March 5). Carry ‘coronavirus – free’ health certificate to enter India if flying in from Italy, South Korea. Times of India. Retrieved from https://timesofindia.indiatimes.com/business/india-business/carry-coronavirus-free-health-certificate-to-enter-india-if-flying-in-from-italy-south-korea/articleshow/74492110.cms .
Special Correspondent. (2020, May 22). CM ducks’ questions on Sprinklr deal. The Hindu. Retrieved from https://www.thehindu.com/news/national/kerala/cm-ducks-questions-on-sprinklr-deal/article31653297.ece .
Spinney, L. (2020, May 14). The coronavirus slayer! How Kerala’s rock star health minister helped save it from Covid-19. The Guardian. Retrieved from https://www.theguardian.com/world/2020/may/14/the-coronavirus-slayer-how-keralas-rock-star health-minister-helped-save-it-from-covid-19 .
Swamy, R. (2020, May 5). Kerala could lose Rs 13,000 cr. in remittances as over 4 lakhs register to return from abroad. The Print. Retrieved from https://theprint.in/economy/kerala-could-lose-rs-13000-crore-in-remittances-as-61000-register-to-return-from-abroad/414774/ .
Tharakan, M. P. K. (2004). Historical hurdles in the course of the people’s planning campaign in Kerala, India. In Harriss, J., Stokke, K., & Tornquist, O. (Eds.), Politicising Democracy: The new local politics of democratisation (PP. 107–121). New York: Palgrave Macmillan.
Tharamangalam J. University of British Columbia Press; Vancouver: 1981. Agrarian class conflict: The political mobilization of agricultural laborers in Kuttanad, South India. [ Google Scholar ]
Tharamangalam J. The perils of social development without economic growth: The development debacle of Kerala, India. Bulletin of Concerned Asian Scholars (now renamed Critical Asian Studies) 1998; 30 (1):23–34. [ Google Scholar ]
Tharamangalam J. Rejoinder” to respondents to the Symposium, “The Kerala Model of Development, A Debate. Bulletin of Concerned Asian Scholars (now renamed Critical Asian Studies) 1998; 30 (4):23–24. [ Google Scholar ]
Tharamangalam, J. (2006). Understanding Kerala’s paradoxes: The problematic of the Kerala model of development. In Tharamangalam, J. (Ed.). Kerala: The paradoxes in public action and development (PP. 1–37). New Delhi: Orient Longman.
Tharamangalam J., editor. Kerala: The paradoxes in public action and development. Orient Longman; New Delhi: 2006. [ Google Scholar ]
The Economist. (2020, May 29). Vietnam and the Indian state of Kerala curbed covid-19 on the cheap. Retrieved from https://www.economist.com/asia/2020/05/09/vietnam-and-the-indian-state-of-kerala-curbed-covid-19-on-the-cheap .
Thomas, V. (2006). Kerala: A paradox or incomplete agenda? In Tharamangalam. (Ed.), Kerala: The paradoxes in public action and development (PP. 69–93). New Delhi: Orient Longman.
Times of India. (2020, August 19). 103-year-old man recovers from COVID-19 in Kerala’s Ernakulam. Retrieved from https://timesofindia.indiatimes.com/videos/city/kochi/watch-103-year-old-man-recovers-from-covid-19-in-keralas-ernakulam .
Tornquist O. UNRISD & SUM; Geneva and Oslo: 2002. Popular development and democracy: Case studies with rural dimensions in the Philippines, Indonesia and Kerala. [ Google Scholar ]
Unnithan, G. P. S. (2020, July 10). Locals forced their head inside car and coughed: Health workers attacked in Kerala's super spreader village. India Today. Retrieved from https://www.indiatoday.in/india/story/kerala-poonthura-super-spreader-village-locals-protest-health-care-workers-attacked-1699290-2020-07-10 .
Varma, V. (2020, July 10). Medical team cornered by mob in Kerala Covid-19 hotspot, coughed at, abused. The Indian Express. Retrieved from https://indianexpress.com/article/india/medical-team-cornered-by-mob-in-kerala-covid-19-hotspot-coughed-at-abused-6499590/ .
Vidyanadan, M. S. (2020, July 30). Facebook, Twitter followers not impressed by Kerala CM Pinarayi Vijayan’s pressers of late. The New Indian Express. Retrieved from https://www.newindianexpress.com/states/kerala/2020/jul/30/facebook-twitter-followers-not-impressed-by-kerala-cm-pinarayi-vijayan .
Wikipedia, 2016. Kerala Sasthra Sahitya Parishad. Retrieved from https://en.wikipedia.org/wiki/Kerala_Sasthra_Sahithya_Parishad .
Wikipedia Virus (2019 film) 2019. https://en.wikipedia.org/wiki/Virus_(2019_film) Retrieved from.
Woodstock G. Faber & Faber; London: 1967. Kerala: A portrait of the Malabar Coast. [ Google Scholar ]

Utility Menu

10129971600aaad23e949a49999289d8

Ga4 tracking code, the global health delivery project.

at Harvard University

Positive Outlier: Health Outcomes in Kerala, India over Time

This case explores how Kerala, India developed a reputation for exemplary health outcomes despite low per capita income. After providing historical background, including the social, political, and health system factors that contributed to a culture of seeking health care, the case describes Kerala’s health system and outcomes. The case describes how the fiscal decline in the latter half of the 20th century led to decreased spending on public services, including health, creating an opening for private-sector providers to meet a growing share of the demand for health services and the impact on out-of-pocket health spending. Readers must think about how emerging health threats such as noncommunicable diseases should be addressed in the 21st century, including the health department’s response and a new initiative to increase capacity in the public health sector, including efforts to improve the quality and reliability of health data through an electronic medical record system. The case concludes with Additional Chief Secretary for Health and Family Welfare Rajeev Sadanandan wondering if the new strategy will succeed and if Kerala can maintain its status as a positive outlier in health for the decades to come.

Teaching Note available for registered faculty through Harvard Business Publishing and the Case Centre.

Learning Objectives: to appreciate the relationships between education, literacy, and health; what the components of a health system are; the limitations of health indicators as measures of a national health system’s effectiveness; and, the challenges of sustaining demand and maintaining the supply and quality of public health services over time.

Key words : health care policy, universal health care, demand generation, health care delivery, health system, health outcomes, social determinants of health

Search case collection

Filter case collection by, content type.

Teaching case (43) Apply Teaching case filter
Brief case (6) Apply Brief case filter
Background paper (10) Apply Background paper filter
Case set component (2) Apply Case set component filter
Case supplement (5) Apply Case supplement filter
Instructional material (3) Apply Instructional material filter
Global (3) Apply Global filter
Africa (24) Apply Africa filter
Asia and the Middle East (20) Apply Asia and the Middle East filter
Latin America and the Caribbean (7) Apply Latin America and the Caribbean filter
North America (1) Apply North America filter
Capacity and infrastructure (12) Apply Capacity and infrastructure filter
Data, information, and technology (19) Apply Data, information, and technology filter
Ethics (9) Apply Ethics filter
Financing and economics (21) Apply Financing and economics filter
Health care delivery (66) Apply Health care delivery filter
Human resources (17) Apply Human resources filter
Leadership and management (35) Apply Leadership and management filter
Operations and administration (18) Apply Operations and administration filter
Partnerships and collaboration (35) Apply Partnerships and collaboration filter
Policy (30) Apply Policy filter
Strategy and innovation (29) Apply Strategy and innovation filter
Supply chain management and procurement (11) Apply Supply chain management and procurement filter

Medical Condition

Hepatitis C (1) Apply Hepatitis C filter
HIV/AIDS (26) Apply HIV/AIDS filter
Malnutrition (3) Apply Malnutrition filter
Maternal and child health (7) Apply Maternal and child health filter
Mental health (1) Apply Mental health filter
Surgical care (7) Apply Surgical care filter
TB (8) Apply TB filter
Tobacco addiction (3) Apply Tobacco addiction filter
Vaccine preventable illnesses (4) Apply Vaccine preventable illnesses filter
Vector-borne diseases (9) Apply Vector-borne diseases filter
Multiple (8) Apply Multiple filter

Teaching Themes

Community-based delivery solutions (18) Apply Community-based delivery solutions filter
Global health policy (18) Apply Global health policy filter
Global health technologies and products (14) Apply Global health technologies and products filter
Global surgery (7) Apply Global surgery filter
Health systems strengthening (25) Apply Health systems strengthening filter
Hospital design (6) Apply Hospital design filter
Program expansion and scale-up (20) Apply Program expansion and scale-up filter
Understanding local context (21) Apply Understanding local context filter

Stakeholders

Academia (7) Apply Academia filter
Government (49) Apply Government filter
Multilaterals (23) Apply Multilaterals filter
NGOs and civil society (36) Apply NGOs and civil society filter
Private (21) Apply Private filter

View complete collection

Kerala’s Innovative Health Policy

Kerala’s Current Health Needs

One of Kerala’s most pressing healthcare challenges is caring for its rapidly aging population. Kerala’s population over the age of 60 is expected to double by 2050, and as a larger proportion of people are retired, the state needs a healthcare infrastructure designed to support the health needs of the elderly.

A trustee of an NGO focused on healthcare for the underprivileged in Kerala, who wished to remain anonymous, pointed out changing lifestyles as the cause of some of Kerala’s growing health issues. Non-communicable diseases are on the rise; cancer and diabetes have become the two largest causes of death in the state.

While infectious diseases remain under control compared to other parts of India, re-emergence of certain diseases have led to rather high morbidity in some areas. Additionally, despite significant efforts on the part of the state to place healthcare in the hands of local authorities, and what the NGO trustee says is the highest ratio of doctors to the public in rural areas of any state in India, rural parts of Kerala still do not receive the same quality of care as do urban areas. Likewise, although Kerala has the lowest infant mortality and maternal mortality rates of any Indian state, the government still aims to reduce these rates further.

Policy Solutions

Because healthcare in India is managed at the state level, Kerala’s state government is responsible for formulating its own comprehensive healthcare policy. The state has a history and culture of providing health services to the public; as early as 1879, vaccinations were made mandatory for specific subsets of the population. Since India’s independence in 1947, Kerala has worked to expand easy, community-based access to primary care, prevention services, and specialized treatments.

Kerala’s decentralized healthcare model is a key component of its success in providing affordable and accessible care. After a statewide movement towards expensive private healthcare in the 1980s due to a lack of resources in the public health sector, in 1996, Kerala’s state government decentralized public healthcare through the People’s Campaign for Decentralized Planning. Decentralization shifted approximately 40 percent of state healthcare funding to local governments, prioritizing creating community-based services that are accessible to all regardless of income or caste, as a private-dominated system was consistently barring the poor from accessing care across Kerala.

Looking to the Future

Another key element of Kerala’s healthcare successes has been its willingness to generate policies anticipating future healthcare needs. As the state’s population ages rapidly, policy is already being generated to combat this coming issue. Senior care facilities are already being constructed across the state, existing facilities are being made more equipped for geriatric care, and the Pain and Palliative Care Policy of 2008 has increased the amount of home-based care at the local level.

Likewise, to combat the re-emergence of infectious diseases like diarrhea, typhoid, and Dengue fever, Kerala has invested in information-gathering at the household level in order to observe the spread of such illnesses. As diabetes, cancer, and cardiovascular disease came to account for more than half of all deaths in Kerala, the National Programme for Prevention of CVD, Diabetes, Cancer and Stroke (NPCDCS) was introduced in Pathanamthitta district in 2010 and has since been expanded statewide.

This year, Kerala’s government passed a policy for comprehensive healthcare reform. This new policy seeks to reshape the state’s health services to better account for an aging population, re-emerging infectious diseases and non-communicable lifestyle diseases like diabetes and cardiovascular disease, and to expand mental healthcare. It will increase public spending on healthcare more than eightfold in order to further lower the price of public health services as well as providing treatment guidelines to ensure a more even quality of treatment across the state. This comes at the same time as the state is expanding its public health insurance coverage.

Impact on Poverty

Despite the government’s continued efforts to decrease the cost of healthcare and the fact that privatized healthcare services are still largely inaccessible to the poor, Kerala has accomplished several significant victories in providing affordable and accessible healthcare. According to the NGO trustee, no one needs to travel more than 10 kilometers to a primary health centre (PHC), and medicines are provided for free at PHCs across Kerala. Decentralization of healthcare has cut costs significantly, and the state’s new health policy seeks to encourage subsidized public healthcare even further while increasing insurance coverage.

Certainly, Kerala’s innovative health policy is a critical component of its low and steadily decreasing poverty rate. However, underprivileged individuals–including the poor, those in rural areas, women, and the elderly–continue to receive lower quality care and less of it. That is why NGOs and nonprofits like the trustee’s organization must continue to exist, and why the government continues its fight for constant improvement of Kerala’s health policy.

– Macklyn Hutchison Photo: Flickr

“The Borgen Project is an incredible nonprofit organization that is addressing poverty and hunger and working towards ending them.”

-The Huffington Post

Inside the borgen project.

Board of Directors

Get Smarter

Global Poverty 101
Global Poverty… The Good News
Global Poverty & U.S. Jobs
Global Poverty and National Security
Innovative Solutions to Poverty
Global Poverty & Aid FAQ’s

Ways to Help

Call Congress
Email Congress
30 Ways to Help
Volunteer Ops
Internships
Courses & Certificates
The Podcast

Search Menu
Advance Articles
Editor's Choice
Supplements
Open Access Articles
Research Collections
Review Collections
Author Guidelines
Submission Site
Open Access Options
Self-Archiving Policy
About Health Policy and Planning
About the London School of Hygiene and Tropical Medicine
HPP at a glance
Editorial Board
Advertising and Corporate Services
Journals Career Network
Journals on Oxford Academic
Books on Oxford Academic

Article Contents

< Previous

Historical analysis of the development of health care facilities in Kerala State, India

Article contents
Figures & tables
Supplementary Data

V Raman Kutty, Historical analysis of the development of health care facilities in Kerala State, India, Health Policy and Planning , Volume 15, Issue 1, March 2000, Pages 103–109, https://doi.org/10.1093/heapol/15.1.103

Permissions Icon Permissions

Kerala’s development experience has been distinguished by the primacy of the social sectors. Traditionally, education and health accounted for the greatest shares of the state government’s expenditure. Health sector spending continued to grow even after 1980 when generally the fiscal deficit in the state budget was growing and government was looking for ways to control expenditure. But growth in the number of beds and institutions in the public sector had slowed down by the mid-1980s. From 1986–1996, growth in the private sector surpassed that in the public sector by a wide margin.

Public sector spending reveals that in recent years, expansion has been limited to revenue expenditure rather than capital, and salaries at the cost of supplies. Many developments outside health, such as growing literacy, increasing household incomes and population ageing (leading to increased numbers of people with chronic afflictions), probably fuelled the demand for health care already created by the increased access to health facilities. Since the government institutions could not grow in number and quality at a rate that would have satisfied this demand, health sector development in Kerala after the mid–1980s has been dominated by the private sector.

Expansion in private facilities in health has been closely linked to developments in the government health sector. Public institutions play by far the dominant role in training personnel. They have also sensitized people to the need for timely health interventions and thus helped to create demand. At this point in time, the government must take the lead in quality maintenance and setting of standards. Current legislation, which has brought government health institutions under local government control, can perhaps facilitate this change by helping to improve standards in public institutions.

local government
private sector
public sector
salaries and fringe benefits
statutes and laws

Email alerts

Citing articles via.

Recommend to Your Librarian

Affiliations

Online ISSN 1460-2237
Copyright © 2024 The London School of Hygiene and Tropical Medicine and Oxford University Press
About Oxford Academic
Publish journals with us
University press partners
What we publish
New features
Open access
Institutional account management
Rights and permissions
Get help with access
Accessibility
Advertising
Media enquiries
Oxford University Press
Oxford Languages
University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

Copyright © 2024 Oxford University Press
Cookie settings
Cookie policy
Privacy policy
Legal notice

This Feature Is Available To Subscribers Only

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Open access
Published: 07 May 2024

Understanding caregiver burden and quality of life in Kerala’s primary palliative care program: a mixed methods study from caregivers and providers’ perspectives

Arsha Kochuvilayil 1 &
Ravi Prasad Varma 1

International Journal for Equity in Health volume 23 , Article number: 92 ( 2024 ) Cite this article

330 Accesses

1 Altmetric

Metrics details

Family caregivers are vital for long-term care for persons with serious health-related suffering in Kerala. Long-term caregiving and ageing may become burdensome and detrimental to patients and caregivers. We compared the caregiver burden and quality-of-life of ageing caregivers with younger caregivers. We also explored the palliative care nurses’ perceptions of the family caregivers’ issues.

We did a mixed method study focusing on two groups: (i) three in-depth interviews and a cross-sectional survey among 221 caregivers of palliative care patients in five randomly selected panchayats (most peripheral tier of three-tier local self-government system in India concerned with governance of a village or small town) of Kollam district, Kerala, as part of development and validation of the Achutha Menon Centre Caregiver Burden Inventory; (ii) five in-depth interviews with purposively selected primary palliative care nurses as part of a study on local governments and palliative care. We used a structured interview schedule to collect cross-sectional data on sociodemographic and caregiving-related characteristics, caregiver burden, and health-related quality of life using the EuroQol EQ5D5L and interview guidelines on caregiver issues tailored based on participant type for qualitative interviews.

Older caregivers comprised 28.1% of the sample and had significantly poorer health and quality-of-life attributes. More senior caregivers experiencing caregiver burden had the lowest mean scores of 0.877 (Standard deviation (SD 0.066, 95% confidence intervals (CI) 0.854–0.899) followed by younger caregivers with high burden (0.926, SD 0.090, 95% CI 0.907–0.945), older caregivers with low burden (0.935, SD 0.058, 95% CI 0.912–0.958) and younger caregivers with low burden (0.980, SD 0.041, 95% CI 0.970–0.990). Caregivers faced physical, psychological, social, and financial issues, leading to a caregiver burden. The relationships between the palliative care nurses and family caregivers were complex, and nurses perceived caregiver burden, but there were no specific interventions to address this.

In our study from Kollam, Kerala, three out of ten caregivers of palliative care patients were 60 years of age or older. They had significantly lower health-related quality of life, particularly if they perceived caregiver burden. Despite being recognized by palliative care nurses, caregiver issues were not systematically addressed. Further research and suitable interventions must be developed to target such problems in the palliative care programme in Kerala.

Norman Daniels “We should not allow misfortune to beget injustice” [ 1 ].

In Low- or Middle-Income Countries (LMIC), when a person becomes bedridden or homebound due to chronic illness or injury, family members are likely to be tasked with caring for a dependent [ 2 ]. State involvement still needs to improve in such situations, but the local government (LG) driven primary palliative care programme in Kerala state, India, has been functioning for nearly 30 years as a well-acknowledged approach for community-based sustainable palliative care [ 3 , 4 , 5 ]. Governance in India comprises powers that are divided between a central government of the country, more regional state governments with separate legislatures, and local governments with locally elected representatives. Local governments oversee governance administration and developmental activities within specific jurisdictions like villages or towns, overseeing local infrastructure and services. Health is considered a subject of interest for the state governments. Kerala initiated decentralization reforms in several sectors including health care, where substantial funds and many functions were transferred to local governments [ 6 ]. The Kerala primary palliative care programme evolved with the support of local governments. Bedridden or homebound patients with serious health-related concerns requiring long-term symptom management are usually registered under this programme [ 5 ]. Pain and symptom management, psychological support for patient and family and provision of assistive aids and medicines are integral parts of the services rendered [ 3 , 4 ]. However, even in this setting palliative care patients are highly dependent on others, primarily family caregivers, for their daily activities [ 4 ]. Family caregivers also help with medical and nursing care requirements [ 7 ]. Consequently, palliative care nurses often train family caregivers on simple and practical strategies of caregiving [ 4 ]. Thus, family caregivers play an integral role in translating programme services into better outcomes for the patient.

At times, for some such caregivers, this caregiving can become a burden, a multidimensional form of distress affecting their physical, psychological, social and financial well-being [ 2 , 8 , 9 ]. Perceived caregiver burden is associated with increased mortality, [ 10 , 11 , 12 ] poor health outcomes, including anxiety and depression [ 13 , 14 ] and reduced quality-of-life among family caregivers [ 15 ]. Several studies have explored caregiver burden and associated factors [ 16 , 17 ], but few studies have looked at these issues from the providers’ perceptive in LMIC [ 18 ]. Palliative care nurses have a limited understanding of caregiver burden and related issues. Patients remain the focus of care, while caregivers and their issues may go largely unnoticed [ 19 ].

Caregivers themselves may be sufferers of chronic diseases. This may be particularly true of Kerala, where the population aged 60 and above comprised 16.5% of the people in 2021 anisre expected to reach 20.9% by 2031 in Kerala [ 20 ]. Ageing caregivers may experience an increased impact of the consequences of caregiving along with physiological ageing, isolation and comorbidities [ 21 ]. With advancing age, multimorbidity is common among the ageing population [ 22 ]. Changing family structures due to migration and the increased number of women entering the workforce lead to many households having only ageing persons. Caring for a bedridden or homebound person by an ageing spouse is likely to be high in the Kerala population. Most such caregivers see ‘caregiving’ as their responsibility and feel obligated to provide care for their dependent. Spouse caregivers frequently report being more stressed and burdened compared to adult-child caregivers [ 9 ]. Ageing spousal carers may be at risk of increased cognitive impairment, loneliness, sadness, and anxiety compared to demographically matched ageing non-caregivers [ 23 ]. Also, our earlier analysis of depression among women caregivers had shown increasing odds of depression for higher age groups. These initial results underscore the significance of considering age as a potential factor that may contribute to varying experiences of burden among caregivers [ 13 ]. Age is usually treated as a confounder in studies on caregiving and adjusted at the time of analysis, and age-specific findings are not often reported [ 24 ]. Recently, however, research attention to the importance of ageing on caregiving outcomes is increasing [ 25 ]. There is a clear need to explore differences in experiences and needs of different age groups within the caregiver population so that targeted interventions and support strategies may be developed.

The World Health Organization in 2002 had recommended that services for chronic care should foster continuity of care and personal connection between the caregiver and the care recipient [ 26 ]. This will require functional relationships between the palliative care nurses and family caregivers, necessitating effective communication and rapport building by the nurse [ 27 ]. How the programme and its frontline representative, the palliative care nurse, perceive family caregivers, the caregiving role and caregiver issues are not adequately explored. A 2019 palliative care policy document from Kerala mentions caregiver support but this is still in a very early stage in the programme [ 28 ]. In this context, we studied the caregiver burden and quality of life of caregivers aged 60 years or above compared to younger caregivers of palliative care patients in Kerala. We also explored the perspectives of palliative care nurses on family caregiver issues in home care settings and whether these perspectives are reflected in the services offered by the nurses and the programme.

The palliative care programme

All panchayats in Kerala have a home care team that is led by a trained palliative care nurse. The nurse conducts periodic home visits along with the field staff of the local primary health centre, elected LG members and community volunteers. Each palliative care nurse schedules the home visits, directs patient health assessment and management and maintains several registers, one of which is the nominal register with patient name, contact information, diagnosis, and remarks on main service provision (e.g., catheter change, wound dressing etc.). We used the patient register of selected panchayats to identify patients and contact their caregivers for enrolment in the study.

The details of the sampling strategy for the cross-sectional survey have been published earlier [ 8 ].. The basis for sample size was adequacy for factor analysis– a sample size of 200 was deemed adequate for factor analysis with 25 items, achieving an item-to-participant ratio of at least 1:8 [ 34 ]. As male caregivers were very few, all male caregivers as reported by palliative care nurses were approached. Women caregivers were selected purposively from the list of patients in each panchayat palliative care registry to represent both cancer and non-cancer conditions.

Regarding sample size for the in-depth interviews, the primary objective of the in-depth interviews with caregivers was scrutiny of the representation of caregiver burden domains identified from the literature, and no new domains emerged after three interviews. For palliative care nurses, perceptions of caregiver burden were first identified and coded from literature and a draft thematic framework was prepared a priori. The first nurse interviewed belonged to the panchayats selected for the quantitative survey. During that interview, the interviewer (AK) felt that the nurse was fully aware of the caregiver issues encountered during the cross-sectional survey by the investigator and was giving responses conforming to the interviewer’s expectations. Therefore, four remaining nurses were purposively selected from panchayats in the same district that were not part of the quantitative study. Interviews were conducted to explore new categories and themes and data collection was stopped when no new categories emerged for two interviews.

Design and data collection techniques

An integrative knowledge synthesis using mixed methods was carried out using analysis of a cross-sectional survey and qualitative exploration using in-depth interviews. This analysis used data from two study components done by the investigators, one on caregivers of palliative care patients and one on palliative care nurses. Table 1 summarizes the participant profile and data collection techniques for each study component.

Data collection from caregivers

The caregiver survey and interviews took place between January and February 2020. The investigators collected data for a study on developing and validating a Caregiver Burden Inventory in early 2020, published earlier [ 8 ]. The portion of that data used here comprised three in-depth interviews (IDI) with caregivers of palliative care patients and cross-sectional survey data of caregiver burden and related issues of 221 caregivers in five randomly selected panchayats in Kollam district, Kerala, India. This analysis focused on a comparison of findings of the cross-sectional survey on the caregivers aged above 60 years with younger or middle-aged caregivers aged between 18 and 59 years. All family caregivers of patients registered under the palliative care programme, aged 18 and above, who identified themselves as the primary caregivers and are providing care for not less than three months were included in the study. Those caregivers having a condition that limits their participation in the study and those caring for a critically ill care recipient during the study period are excluded from the study. An interview schedule was used to collect the sociodemographic information, care recipient and caregiver issues, and caregiver burden based on the Achutha Menon Centre Caregiver Burden Inventory, a nine-item inventory for assessing caregiver burden that had two domains– (i) physical, psychological, and spiritual aspects and (ii) financial aspects. Each item was scored on a 4-point Likert scale from zero to three. A caregiver could potentially score between zero (lowest possible burden level) and 27 (highest possible burden score). Quality of life also was assessed using the Malayalam version of the EuroQol EQ-5D 5-level version (EQ5D5L) [ 29 ]. We used the EQ-5D-5L Indian value set to convert responses to utility values [ 30 ]. The EQ-5D-5L is a widely accepted five-dimension HRQoL measure that covers mobility, self-care, usual activities, pain, anxiety/depression, and overall health state. It is easy to apply in younger and older populations and persons with less education [ 31 ]. It has good psychometric properties and the index values and dimensions have been found to strongly correlate with other measures of global health indicators, physical/functional health, pain, daily activities, and clinical/biological variables [ 32 ].

Data collection from palliative care nurses

The researchers were part of a team working on decentralization and health in Kerala, in which one of the researched themes was the primary palliative care programme [ 33 ]. One of the themes selected for enquiry was caregiver issues. Five primary palliative care nurses (Table 1 ) with at least one year experience were purposively selected and interviewed to get an insightful account of their experiences with caregiver issues. Interviews were conducted telephonically due to COVID-19-related restrictions in 2020 and early 2021.

Data analysis

To assess the validity of the EQ-5D-5L, we performed internal consistency checks and factor analysis of the five items of the EQ-5D-5L for the whole sample and the two age groups of interest separately (up to 59 years and 60 years and above). We extracted one factor from observed item values using principal axis factoring with direct oblimin rotation and correlated it with the utility scores obtained from the Indian value set of the EQ-5D-5L.

For the quantitative data, general characteristics and caregiver issues were summarised as frequencies and proportions or means and standard deviations, along with 95 per cent confidence intervals. Burden scores were converted to a categorical variable using tertiles, and labelled as low, moderate and high burden. Chi-square or Fisher exact tests were done to compare proportions. Analysis of variance (ANOVA) and posthoc Bonferroni tests were done to compare means. IBM SPSS version 25 was used for the quantitative analysis. Qualitative analysis was done manually.

All recordings of the IDIs were translated to English and initially coded by the same researcher (AK) who maintained an audit trail to map the interview transcripts and related codes to categories and themes. The approach to coding and categorising was inductive for the caregiver interviews and deductive for the palliative care nurse interviews. Information extracted from the literature review was used to generate a codebook for qualitative analysis to portray caregiver issues and perspectives of the nurse. The search was limited to articles in English, and title and abstract mention of caregiver issues along with provider perspective. Both investigators reviewed the shortlisted papers, and prepared codes, categories and themes through an iterative process. Existing codes were verified and additional codes, if any, were explored through triangulation with transcripts from caregiver issues mentioned by palliative care nurses in the main decentralization study. (See Additional file 1 ) After describing the findings based on this approach, we referred to Eva Kittay’s critique of Daniels and Nussbaum, based on the burden of caregiving and its effect on the caregiver’s opportunities while interpreting our findings from the study [ 35 ].

Subjectivities of the researchers

AK conducted all interviews and both investigators were involved in the analysis and interpretations. Both investigators hold basic biomedical degrees and subsequently public health qualifications. The research experience of both researchers has been predominantly post-positivist. We believe that our experiences around epidemiological surveys would have shaped the data collection and interpretations in a predominantly biomedical perspective with some consideration of social determinants shaped by our experience level. However, our ongoing engagement with palliative care and caregivers’ issues also brings in some relational approaches and interpretations characteristic of literature on caring.

Ethical aspects

All prospective study participants were assured of their autonomy, benefits and risks, privacy and confidentially and non-effect on care or benefits before obtaining informed consent. Informed consent, written or electronically documented, was obtained from all study participants. The Institutional Ethics Committee of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum cleared all tools of the scale development phase. (Letter number SCTIMST/IEC/1444/NOVEMBER-2019 dated 14 November 2019). The proposal and tools of the palliative care nurse interviews, part of the decentralization project, were reviewed and cleared by the institutional ethics committee of Health Action by People Thiruvananthapuram. (IEC EC2/P1/SEP/2020/HAP dated 10 December 2020). While these were originally independent studies, clearance was obtained from the Institutional Ethics Committee of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum (Letter number SCTIMST/IEC/2048/MAY-2023 dated 17 June 2023) for a synthesis exercise as part of formative research for a forthcoming study on caregiver burden assessment and intervention.

Validity of the EQ-5D-5L in our study sample

We report the Cronbach’s alpha for internal consistency, the eigen value for the extracted factor, the factor loadings of the extracted factor onto each item of the EQ-5D-5L and Pearson’s correlation coefficient between the extracted factor and utility scores in Table 2 . Internal consistency was moderate to good, eigenvalue was more than one and there was a high correlation between the factor derived from observed values and utility score values taken from the India value set. Factor loadings for pain/ discomfort and anxiety/ depression were relatively higher in the younger age group while for usual activities, factor loadings were higher in the older caregiver group.

Findings from cross-sectional survey among caregivers

Palliative care recipients had various diagnoses ranging from stroke (23.9%), to cancer (12.8%) followed by other conditions. The mean age of the caregivers was 51.2 years (Standard Deviation (SD 12.7). The mean age of the older group was 66.2 years (SD 7.1) and of younger or middle-aged caregivers was 45.3 (SD 9.0). Caregiver ages ranged from 25 to 88 years. Demographic characteristic of the caregivers according to their age category is given the Table 3 . Most caregivers were women, but in the older age group, the proportion of men was significantly higher. Older caregivers were significantly less educated and less likely to be married, but the social class was comparable.

Table 4 depicts the distribution of variables related to caregiving. Nearly all caregivers in both groups were the sole caregiver for their care recipient. A significantly higher proportion of older caregivers were giving care to their spouses. Care requirements were significantly higher for the care recipients of younger caregivers, but most other variables were comparable. A higher proportion of older caregivers reported being satisfied with their caregiving activities.

Older caregivers reported poorer states for all variables related to self-reported morbidity and quality of life attributes measured using the EQ5D5L, except for self-care. (Table 5 ) Nearly three-fourths of older caregivers reported mobility issues; over half had pain or felt anxious or depressed.

The mean EQ-5D-5L utility score for the caregivers was 0.936 (SD 0.078, 95% CI 0.926–0.947). On comparing the caregiver’s age and burden experienced with the utility score, we found that the burden level impacted the perceived quality of life, irrespective of the caregiver’s age. As shown in Fig. 1 , younger caregivers generally had a better quality of life than older caregivers, and those with low caregiver burden had better utility scores than those with moderate to high levels of caregiver burden. Younger caregivers who perceived a high burden level had lower mean utility scores (0.926, SD 0.090, 0.907–0.945) than younger caregivers who perceived a low burden (0.980, SD 0.041, 0.970–0.990). Likewise, older caregivers who perceived a higher burden level had a lower mean utility score (0.877, SD 0.066, 0.854–0.899) than their counterparts with a low burden (0.935, SD 0.058, 0.912–0.958). Except for the difference in means between older caregivers with low burden and younger caregivers with moderate to high burden, all mean differences were statistically significant. ( p < 0.001)

Means and 95% confidence intervals of EQ5D5L utility scores for caregivers grouped based on age category and burden level

Table 6 maps the support these dyads received regarding palliative care nurse visits, assistive devices, food kits or support from non-governmental charitable organisations. The frequency of nurse visits (monthly or above) was determined almost exclusively by patient need and was not associated with caregiver burden level. Among other forms of support, receiving food kits from the LG was found to be significantly higher when high levels of caregiving burden were present.

Themes from in depth interviews with caregivers

“i do everything for her/him”.

All caregivers mentioned doing “everything” for the care recipient, including all activities of daily living, medications, and procedures like skin care.

CG1: “I do everything for her…I bathe her… take her to the toilet…help her to change her dress…. Give her food. Everything…”. CG2: “I’ve cared for my husband for the last 10 years. he is entirely dependent on me… everything…I clean him…bathe him… give him food…everything”.

Caregiving became physically and psychologically demanding

Doing “everything” involved physically demanding activities that reportedly led to chronic body pain for the caregiver.

CG2: “…a constant pain on my legs… I always lift him alone, there will not be anybody home…”.

Other issues mentioned included sleep deprivation, financial and job-related issues, and limitations to social participation due to caregiving. Care recipients could also have a temperament that made caregiving challenging.

CG2: “He is always very angry. He always shouts at me and my son… I’m always worried… I do not know what to do…”.

Care team is only patient-focused, caregiver issues are not addressed

The palliative care team when they visit would do patient-centred procedures, dispense medicines, and provide advice for improving patient care.

CG3: “…people from health (services) come once a month and change the urine tube…. They give medicines also…”.

Some advice provided could not be implemented, often due to affordability issues.

CG2: “…they give instructions about how to do physiotherapy…but it is no use…once in a month we used to call a physiotherapist…but it is expensive…”.

Themes from palliative care nurse interviews

We shortlisted 17 articles for further analysis. Four were from Kerala and the rest were from outside India. Caregiver issues highlighted included burden, burnout, and health and wellbeing-related issues. Four themes on the care provider perspective were initially decided upon, namely: (i) exposition of caregiver burden by providers (ii) nature of family caregiver-health provider relationships (iii) factors that enable or hinder caregiver support from providers (iv) specific interventions that foster caregiver endurance.

Each provider interview took about 40 min, ranging from 35 to 50 min. Open codes from documents were binned into existing categories in the schema or new categories were added, if felt necessary. (See Additional file 1 ) No codes fell into the theme “specific interventions that foster caregiver endurance”. Brief descriptions of the findings were as follows:

Accurate exposition of the caregiver burden by palliative care nurses

All nurses highlighted the “burden” experienced by the family caregivers, mainly expressed as socioeconomic deprivation and challenges.

“Issues like no secure house, no food due to lack of income… patients who cannot buy expensive medication and continue their treatment… bystanders struggling for their children’s education…” (PN2– when reporting quotes abbreviation PN indicates participant attribute - palliative care nurse). “They talk about the difficulties of not being able to go to work leaving their Amma (mother)” (PN1).

Added to this were disruptions and conflicts that the caregivers must handle along with the caregiving role.

Caregivers cannot sleep, they cannot look after their home and other household works, they cannot do their own activities like taking care of children (PN1).

Nurses often found themselves encountering conflicts, either between the caregiver and the patient or among family members taking the main caregiver responsibility. Sometimes patient behaviours were distressing for caregivers.

Sometimes patients will be so “violent” because of their condition; sometimes the patient’s condition is so bad… This also reflects on the caregivers. This affects them and they may also become frustrated. (PN1)

The caregiver role often limited the caregivers to their homes and restricted their social life. Societal perceptions of caring often deepened this social restriction. Nurses clearly described difficulties associated with long-term caregiving including physical pain, psychological distress, individual life disruptions, economic, and social challenges. Some caregivers had become sick from the long haul of physical exhaustion.

I know caregivers like these…so desperate and hopeless… (PN5)

Nurses also felt that caregivers often neglect their well-being and prioritise their patient’s care.

Disparate relationships between caregivers and health providers and the system

Nurse representations of caregiver-provider relationships were complex, ranging from excellent cordiality to open conflicts. Nurses were at times “being like a family member” and at other times involved in verbal altercations and in extreme situations, involvement of law enforcement when neglect of the care recipient was perceived. A consistent part of the relationship, however, was the instrumental contribution expected from the caregiver in caring for the care recipient. Family caregivers were taken for granted as resource persons for caring for the patient and interactions mostly involved general instructions on caregiving or specific training for skin care, wound care, or catheter care. Some task-shifting often happened from the nurses to capable caregivers.

“We made them do these in front of us… The caregiver has taken care of the patient so well.” (PN1, mentioning an example of caregiver education for wound dressing).

Referral for palliative care itself might be perceived by family members as further care was largely up to themselves. It would often take multiple visits to discern all such concerns.

“…they also share their concerns… as palliative (is understood as) end-of-life care…so these makes them worried…” (PN5).

The first time they won’t say everything… after numerous visits, they tell us everything (PN3)

When disagreements were encountered, nurses tried to resolve them by working for a healthy relationship between the caregiver and the care recipient. A somewhat stereotypical portrayal of caregiving emerged in the discourse, where caregiving was a moral imperative of the family, often women. The “best” caregivers were those who fulfilled this expected role well.

“I strongly believe that we should take care of our own parents” (PN2).

“There are no issues or problems for caregivers who are not working” (PN2)

“She is a widow…has two kids…the patient is her late husband’s mother…she (caregiver) is working… she does everything for her patient; only after that she leaves for work… When we visit the patient…it’s so clean and we never feel it’s a room of a bedridden patient…there are caregivers like this” (PN3).

Some caregivers were hesitant to build relationships with palliative care nurses. Nurses too might choose against investing time and visits for getting better acquainted with the caregiver. Caregivers who were demanding and making decisions independent of the nurse were considered problematic.

“They (caregivers) “torture” us by making calls to the panchayat member (the elected LG representatives who helm the programme)…” (PN4).

Families perceived as neglecting the care recipient were labelled as outright problematic. At times, nurses tend to establish an authoritarian role in such instances.

“I say to them if you did not take care of your parents, your seven generations will suffer…” (From additional codes as indicated in the additional file, said by a nurse based on the spiritual belief on results of bad deeds being passed on to future generations) (See Additional file 1 ). “I say, “If you didn’t take care of them, I will inform to (the elected LG representatives) and doctor…If… your mother is lying in (urine and faeces), then you will be taken by police” (From additional codes) (See Additional file 1 ).

But palliative care nurses were often the first in the health system to recognize patient negligence and abuse by the family.

Caregivers who followed their instructions well and include nurses in treatment-related decisions were considered dependable. Yet, once good communication and rapport were established, caregivers often began to consider the nurse “like family” and this was highly valued by nurses, who mentioned several “friendships” that continued long after the death of the patient.

“(When her) daughter (finished school) she (caregiver) asked me which (field of education) is good for her daughter… now, following my advice, the daughter is doing nursing in the district hospital.” (PN3).

Systemic factors often hinder caregiver support

By systemic factors, we mean programmatic focus on the patient, lack of training, lack of time and limited attention to support schemes involving caregiver issues and burden. As such, there were no caregiver-specific initiatives or systematic documentation of caregiver issues. Caregiver support when existed was reactive rather than proactive. Caregivers were mostly given instructional support and/ or instrumental assistance for aiding patient care like medicines, cotton pads, gauze, catheters, Ryle’s tubes, or mobility aids. Communication and consoling were perceived as the main form of intervention by palliative care nurses.

“Their (caregivers) blood pressure will increase because of this lack of sleep. So, during our home visit we will check their BP also…” (PN1).

However, nurses informed eligible caregivers and families about beneficial schemes (‘ Ashwasakiranam ’, a state government-initiated financial assistance scheme for primary caregivers of palliative patients with cancer) or helpful charity organizations, if any.

Lack of time was the main impediment in addressing caregiver issues. Additionally, inadequate training and resources for giving caregiver support were also mentioned. Nurses suggested some systemic failures in recognizing the medical and social issues of caregivers.

“Some of the caregivers, have issues like CKD (chronic kidney disease), cancers or heart problems, but we cannot register them with the palliative care programme.” (PN5).

The main LG support specifically mentioning caregivers was the annual Kudumbasangamom (family gathering) with some recreational programmes, that too in the pre-pandemic days. Some LGs had schemes for self-employment generation for patients or caregivers, to make some products that could be sold for money. LGs support for hosting such schemes was patchy.

“But there was no adequate support from our panchayat for selling their product or purchasing the raw materials…no support for promoting these initiatives.” (PN1).

In this mixed methods study, we attempted to compare caregiver issues between older and younger caregivers in the palliative care program in Kerala. We also tried to document provider-side perspectives on family caregiver issues as articulated by palliative care nurses. The family caregiver issues we identified included physical, psychological, social, and financial issues, much like those reported by Ferrell and Wittenberg in their review of family caregiver trials in cancer patients [ 36 ]. As expected, older caregivers were more susceptible to health-related problems at this age. Irrespective of age, those who experienced a higher burden level had poorer quality of life. When combined, with higher burden experience, older caregivers had the poorest quality of life. This might be brought on by the physical demands of providing care as well as the ageing process’s effects on health.

The absence of any specific service or programme that enables caregiver endurance or any mention of systematic documentation of caregiver issues is a programmatic shortcoming. Nurses gave more attention to patients with skilled care needs and the level of caregiver burden was probably not a factor in determining their visits. Nurses’ tendency for “non-inviting interactions” with family members of patients, by prioritising medical and technical tasks, has been reported earlier from institutional settings [ 37 ]. But nurses recognised most caregiver issues and mentioned insufficient time to address them. Healthcare providers in similar programmes may not even have time for meeting their personal needs due to work demands [ 19 ]. Nurse perceptions about caregiving-related challenges mentioned social determinants of health but also mirrored prevalent socio-cultural and patriarchal norms. Family caregiver-centric studies are rare from LMIC, but available studies reflected socioeconomic deprivation and intense gender-role-driven concentration of caregiving in women [ 38 ]. Nurses however actively tried to improve the family caregivers’ skills in caregiving. This is important to prevent and delay burnout [ 39 ]. Additionally, they provide psychological support, often bonding well with caregivers long after they are bereaved [ 40 ]. Receiving interventions like food kits was significantly higher when the perceived caregiver burden was high. Caregiver burden is multi-dimensional and includes financial difficulties [ 8 ]. LGs generally focus more on the poorest and this finding is expected. The interventions remain basic, but it is promising that LGs can prioritise families with high caregiver burdens for interventions.

Poor households might disproportionately access the LG-run palliative care service, as the services are free of cost. Such households may already have high burden due to pre-existing structural and social disadvantages. Yet, even if caregiving was not causal for the problems expressed, the perceived burden would still be detrimental to quality of life. The directive principles of state policy of the constitution of India clearly list the fundamental rights of citizens and the responsibility of the state to protect citizens unable to access the minimal provisions for social and economic well-being. These principles also mention the autonomy of LGs [ 41 ]. It is thus a moral requirement of the LG-run palliative care programme to focus on the needs of families in addition to the patients.

Our findings draw attention to an important element of long-term care that is somewhat neglected– caregiver impact. Caregiving is a moral responsibility between individuals and at the collective level, as all individuals need care and are dependent at some point in their lives. But caregiving is a mix of reward and burden. Caregivers remain seen as a means to an end when in reality the caregiver is also an end in herself or himself. Allocation of caregiving responsibility is heavily gendered, rendering it as a form of inequity. Potential disadvantages of women may get compounded when she gets restricted to the caregiver role– lesser education, or work opportunities, and often treated as if she is unemployed or not doing economically productive work– leading to depression and a low sense of worth. Another aspect of caregiving that has implications for equity is the way society often works, based on normative or normal people. This may become unfair to suffering people as well as their caregivers, and the burden may be considered inevitable. The family caregiver is not a biological extension of the care recipient’s situation, to be moulded to sustain the biological functions of the care recipient. Neither is caregiving by a family member a law of nature that cannot be changed. This is a situation shaped by relationships between people and societies and the values and practices thereof. Moral requirements of caregiving should also consider what is lost to a caregiver and provide respect for the caregiver. Solutions may be explored by forming partnerships between the caregiver and others and by tapping into existing community resources. This has to happen without diminishing the relationship between the caregiver and the care recipient [ 26 ].

Norman Daniels proposes a lifespan approach of justice that may be useful to consider in this setting [ 42 ]. As individuals get older, their needs changes. When the society itself in an ageing society, that too brings in a new set of needs. In such a situation, reasoning has to be applied on how competing needs are to be met. Competing needs would be between different age groups or between care recipients and those giving care. Some needs would inevitable not be met when social obligations are to be met, but there should be fairness in the terms involved, and adequate social support to prevent issues like burnouts. Identifying beneficial interventions will remain an ethical challenge due to three aspects: (i) the vulnerability of the care recipient should not be exploited (Daniels); (ii) the voice of the caregiver has to be used for meeting the needs of the care recipient, as the capabilities of the latter have diminished (Kittay); (iii) the caregiver too has interests that would often be diminished (Kittay). The caregiver burden is disproportionately a woman’s issue because most of the caregiving work is rendered by women, many of whom are older persons. Discussions of fairness and equity often focus on fair distribution of goods like education and health. As Kittay points out in response to Norman Daniels and Nussbaum, conventional approaches to justice focusing on fair sharing of goods and aiming for equality of opportunity or capability do not talk about fair sharing of burden. In ageing societies, considerations of the distribution of burden may be as important as the distribution of goods.

The CARE framework refers to caregivers as “hidden patients” and recommends a framework comprising Caregiver well-being, Advanced care planning, Respite, and Education for planning to address caregiver issues [ 43 ] The first attribute in addressing family caregiver-related issues is an assessment of need. Symptom severity of care recipients, marginalized families and caregivers with significant psychosocial issues have been suggested as potential indicators of high caregiver issues [ 44 , 45 ]. The deployment of tools like carer support needs assessment tool might help identify support needs and decrease caregiver strain [ 46 ]. Newer modalities like an app-based assessment are being tested in Sweden for family caregivers of patients with dementia [ 47 ]. Examples of successful caregiver interventions from LMIC countries are generally few. The trials covered in the review by Ferrell and Wittenberg were mostly from high-income countries [ 36 ]. In New Zealand three themes of advice for caregivers were considered most useful by providers– caring for oneself physically, emotionally, and spiritually; learning practical skills; and knowing what to expect and plan for as the family member’s health declines [ 48 ]. Researchers from the Netherlands recommended appreciation, information, practical support, and opportunities for time off (like respite care) as useful to lessen caregiver problems [ 49 ]. An intervention based on group sessions for caregivers in South Korea also showed promising physical and psychological outcomes [ 50 ].

Most of these examples are based on individual-level interventions. Krieger et al. reported the need for comprehensive caregiver support at two levels– the individual caregiver level, and the system level [ 51 ]. The United States of America (USA) has had several legislative and programmatic structures aimed at minimizing caregiver distress [ 52 ]. Caregivers of veterans in the USA have specific support like training, financial support, and assistance of a caregiver support coordinator, although Zebrak mentions about the lack of coordination between such policies [ 53 , 54 ]. The National Health Service in the United Kingdom has some specific measures to support caregivers [ 55 ]. The National Institute for Health and Care Excellence, UK has included an assessment of caregivers’ quality-of-life in economic evaluation in its health technology evaluation manual published in January 2022 [ 56 , 57 ].

The primary palliative care programme in Kerala is run by the LGs with support from the health department. Each LG unit sets aside resources from its annual fund allocation to support the wages of the palliative care nurse, travel costs, and costs of equipment, materials, and drugs for home-based care. Additional community-based resources are also mobilised by some LGs. In Kerala, the decentralized health system and the agency available with LGs for extending welfare measures to the needy using locally identified resources offers promise for good interventions [ 6 ]. Caregiver training and certification could be done, and a list of authorised paid caregiver schemes could be piloted, with efforts to include men in the initiative [ 58 ]. Facilities for respite care [ 59 ] may offer some personal space and time for caregivers, or additional appropriate practical help [ 60 ] could be offered. Building the competency of caregivers could extend to self-care in addition to patient care [ 39 ]. The formation of caregiver peer groups could be another intervention that facilitates information sharing, coping and increased social interactions [ 39 , 61 ]. A specialist support service like a caregiver support coordinator or group could be initiated by the district-level health structures of the National Health Mission or the LG or by NGOs. Despite limited evidence of the success of such interventions on a large scale, it is useful to remember the economic value of family caregivers to the health system and community [ 45 ].

Limitations

The quantitative data being cross-sectional, the temporality of the associations we saw cannot be ascertained. Poor health may cause poor quality of life and that may precipitate caregiver burden rather than burden resulting in poor quality of life. However, the implication for the health system remains somewhat the same– poor health, poor quality of life and high caregiver burden need attention whatever the order of their occurrence. Another limitation of the study is the lack of direct interaction with palliative nurses due to COVID-19-related restrictions. The interviews were possibly influenced by the previous experience of the researchers on caregiver issues. Physical visits to the settings and interactions with a wider group of stakeholders from the health department, the LG and other community representatives would have provided richer descriptions of caregiver issues and more quintessential details of caregiver-provider/ system interactions. At the analysis stage, we did not do a multivariable analysis to account for potential confounding or effect modification as data were not primarily collected to explore these aspects. The largely deductive qualitative analysis based on a priori themes is another limitation. As our focus was on validating our literature-generated construct of caregiver burden, we did not explore the experiences of elderly caregivers at that stage of the study and this is a drawback of this synthesis. Yet, we feel that our findings offer some insights that can be used to inform future research in this area.

Caregivers aged 60 years or above made up three out of ten caregivers, with over half caring for their spouse, in this study setting. This is one of the first studies using Indian values of EQ5D5L utility scores for studying the quality of life of caregivers. Older caregivers reported a poor health-related quality-of-life and were experiencing a dual burden of caregiving and poor health, also having chronic health issues needing to take care of others while having to take care of others. The complex dynamics of caregiving by elderly caregivers have not been explored much, suggesting opportunities for future studies to explore these issues and develop targeted interventions for their specific needs. Potential interventions could be Respite care and support services for older caregivers that could offer temporary relief and help caregivers take breaks from caregiving responsibilities. Peer support groups could be another approach that can help caregivers to cope better with the burden. Also, comprehensive geriatric health and wellness programmes encompassing preventive, promotive, curative, rehabilitative and palliative care that jointly cater to patients and caregivers together are needed in settings with high ageing and chronic health conditions.

Data availability

The corresponding author will provide the transcripts, data set and analysis of this current work on reasonable request.

Abbreviations

Analysis of variance

Five level EQ-5D version of EuroQol

In-depth interviews

Low- or Middle-Income Countries

Local Government

Palliative Nurse

Standard Deviation

United Kingdom

United States of America

Daniels N. Just health: Meeting health needs fairly. New York: Cambridge University Press; 2007. p.13.

Ugargol AP, Bailey A. Family caregiving for older adults: gendered roles and caregiver burden in emigrant households of Kerala, India. Asian Popul Stud. 2018;14:194–210.

Article Google Scholar

Abdul Azeez EP, Anbu Selvi G. What determines the sustainability of community-based palliative care operations? Perspectives of the social work professionals. Asian Soc Work Policy Rev. 2019;13:334–42.

Philip RR, Philip S, Tripathy JP, Manima A, Venables E. Twenty years of home-based palliative care in Malappuram, Kerala, India: a descriptive study of patients and their care-givers. BMC Palliat Care. 2018;17:26.

Article PubMed PubMed Central Google Scholar

Sallnow L, Kumar S, Numpeli M. Home-based palliative care in Kerala, India: the neighbourhood network in palliative care. Prog Palliat Care. 2010;18:14–7.

Anju R, Sadanandan R, Vijayakumar K, Raman Kutty V, Soman B, Ravindran RM, et al. Decentralisation, health and sustainable development goal 3. Public Health Action. 2023;13(Suppl 1):51–6.

Article CAS PubMed PubMed Central Google Scholar

Reinhard SC, Given B, Petlick NH, Bemis A. Supporting Family Caregivers in Providing Care. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. http://www.ncbi.nlm.nih.gov/books/NBK2665/ Accessed 15 Mar 2023.

Kochuvilayil A, Varma RP. Caregiver Burden among Informal caregivers in the Kerala Palliative Care Program: Development and Validation of the Achutha Menon Centre-Caregiver Burden Inventory. J Palliat Med. 2021;24:1197–205.

Article PubMed Google Scholar

Oldenkamp M, Hagedoorn M, Slaets J, Stolk R, Wittek R, Smidt N. Subjective burden among spousal and adult-child informal caregivers of older adults: results from a longitudinal cohort study. BMC Geriatr. 2016;16:208.

Roth DL, Haley WE, Hovater M, Perkins M, Wadley VG, Judd S. Family caregiving and all-cause mortality: findings from a population-based propensity-matched analysis. Am J Epidemiol. 2013;178:1571–8.

Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health effects Study. JAMA. 1999;282:2215–9.

Article CAS PubMed Google Scholar

Perkins M, Howard VJ, Wadley VG, Crowe M, Safford MM, Haley WE, et al. Caregiving strain and all-cause mortality: evidence from the REGARDS study. J Gerontol B Psychol Sci Soc Sci. 2013;68:504–12.

Kochuvilayil A, Varma RP. Factors Associated with Screening positive for Depression among women caregivers of primary Palliative Care patients in Kerala, India. J Palliat Care. 2022;37:510–17.

Govina O, Vlachou E, Kalemikerakis I, Papageorgiou D, Kavga A, Konstantinidis T. Factors Associated with anxiety and depression among family caregivers of patients undergoing Palliative Radiotherapy. Asia Pac J Oncol Nurs. 2019;6:283–91.

Srivastava G, Tripathi RK, Tiwari SC, Singh B, Tripathi SM. Caregiver Burden and Quality of Life of Key Caregivers of patients with dementia. Indian J Psychol Med. 2016;38:133–6.

Devassy SM, Green D, Cheguvera N, Yohannan SV, Grills N, Joubert L. The lived experience of carers who assist people with disability in Ernakulam, Kerala, India. Disabil Rehabil. 2022;44:6660–7.

Usha K. PA26 unmet needs and stress among caregivers of bedridden stroke patients in north Kerala - a community based study. BMJ Support Palliat Care. 2015;5(Suppl 1):A27.

Krutter S, Schaffler-Schaden D, Essl-Maurer R, Wurm L, Seymer A, Kriechmayr C, et al. Comparing perspectives of family caregivers and healthcare professionals regarding caregiver burden in dementia care: results of a mixed methods study in a rural setting. Age Ageing. 2020;49:199–207.

Useros MV, Espín AA, Parra EC, Martínez AB. Family caregivers: nurses’ perception and attitudes. Social Med. 2012;6:151–61.

Google Scholar

Kerala State Planning Board: Economic Review. 2021. 2022. https://spb.kerala.gov.in/sites/default/files/2022-03/ECNO_%20ENG_21_%20Vol_1.pdf . Accessed 15 Mar 2023.

Neri AL, Yassuda MS, Fortes-Burgos AC, Mantovani EP, Arbex FS, de Souza Torres SV, et al. Relationships between gender, age, family conditions, physical and mental health, and social isolation of elderly caregivers. Int Psychogeriatr. 2012;24:472–83.

Pati S, Agrawal S, Swain S, Lee JT, Vellakkal S, Hussain MA, et al. Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study. BMC Health Serv Res. 2014;14:451.

Lavela SL, Ather N. Psychological health in older adult spousal caregivers of older adults. Chronic Illn. 2010;6:67–80.

Tough H, Brinkhof MWG, Siegrist J, Fekete C, SwiSCI Study Group. Social inequalities in the burden of care: a dyadic analysis in the caregiving partners of persons with a physical disability. Int J Equity Health. 2019;19:3.

Melo LA, Jesus ITM, Orlandi FS, et al. Frailty, depression, and quality of life: a study with elderly caregivers. Rev Bras Enferm. 2020;73Suppl(3):e20180947.

World Health Organization: Ethical choices in long-term care: What does justice require? Pp 19. Geneva: World Health Organization. 2002. https://apps.who.int/iris/bitstream/handle/10665/42614/9291562285.pdf;sequence=1 Accessed 15 Mar 2023.

Jika BM, Khan HT, Lawal M. Exploring experiences of family caregivers for older adults with chronic illness: a scoping review. Geriatr Nurs. 2021;42:1525–32.

Government of Kerala: Kerala State Policy on Palliative Care. 2019. https://palliumindia.org/wp-content/uploads/2020/05/Kerala-State-Palliative-Care-Policy-2019.pdf Accessed 15 Mar 2023.

Herdman M, Fox-Rushby J, Rabin R, Badia X, Selai C. Producing other language versions of the EQ-5D. In: Brooks R, Rabin R, de Charro F, editors. The measurement and valuation of health status using EQ-5D: a European perspective. Dordrecht: Kluwer; 2003. pp. 183–90.

Chapter Google Scholar

Jyani G, Sharma A, Prinja S, Kar SS, Trivedi M, Patro BK, et al. Development of an EQ-5D value set for India using an Extended Design (DEVINE) study: the Indian 5-Level version EQ-5D Value Set. Value Health. 2022;25:1218–26.

Marten O, Brand L, Greiner W. Feasibility of the EQ-5D in the elderly population: a systematic review of the literature. Qual Life Res. 2022;31:1621–37.

Feng YS, Kohlmann T, Janssen MF, Buchholz I. Psychometric properties of the EQ-5D-5L: a systematic review of the literature. Qual Life Res. 2021;30:647–73.

Kochuvilayil A, Rajalakshmi S, Krishnan A, Vijayanand SM, Kutty VR, Iype T, et al. Palliative care management committees: a model of collaborative governance for primary health care. Public Health Action. 2023;13:12–8.

Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34–42.

Kittay EF. Can contractualism justify state-supported long-term care policies? Or, I’d rather be some mother’s child. A reply to Nussbaum and Daniels. Ethical choices in long-term care. What Does Justice Require. 2002:77–83.

Wittenberg E, Buller H, Ferrell B, Koczywas M, Borneman T. Understanding Family Caregiver Communication to provide family-centered Cancer Care. Semin Oncol Nurs. 2017;33:507–16.

Söderström IM, Benzein E, Saveman BI. Nurses’ experiences of interactions with family members in intensive care units. Scand J Caring Sci. 2003;17:185–92.

Kipp W, Chacko S, Laing L, Kabagambe G. Adolescent reproductive health in Uganda: issues related to access and quality of care. Int J Adolesc Med Health. 2007;19:383–93.

Solli H, Hvalvik S. Nurses striving to provide caregiver with excellent support and care at a distance: a qualitative study. BMC Health Serv Res. 2019;19:893.

Salin S, Kaunonen M, Astedt-Kurki P. Nurses’ perceptions of their relationships with informal carers in institutional respite care for older people. Nurs Res Pract. 2013;2013:967084.

PubMed PubMed Central Google Scholar

Choudhry S, Khosla M, Mehta PB. The Oxford Handbook of the Indian Constitution. 1st ed. Oxford: Oxford University Press; 2016.

Book Google Scholar

Daniels N. Just health: Meeting health needs fairly. New York: Cambridge University Press; 2007. p.162.

Holliday AM, Quinlan CM, Schwartz AW. The hidden patient: the CARE framework to care for caregivers. J Family Med Prim Care. 2022;11:5–9.

Valero-Cantero I, Wärnberg J, Carrión-Velasco Y, Martínez-Valero FJ, Casals C, Vázquez-Sánchez MÁ. Predictors of sleep disturbances in caregivers of patients with advanced cancer receiving home palliative care: a descriptive cross-sectional study. Eur J Oncol Nurs. 2021;51:101907.

Hudson PL, Thomas K, Trauer T, Remedios C, Clarke D. Psychological and social profile of family caregivers on commencement of palliative care. J Pain Symptom Manage. 2011;41:522–34.

Aoun SM, Grande G, Howting D, Deas K, Toye C, Troeung L, et al. The impact of the carer support needs assessment tool (CSNAT) in community palliative care using a stepped wedge cluster trial. PLoS ONE. 2015;10:e0123012.

Kabir ZN, Leung AYM, Grundberg Å, Boström AM, Lämås K, Kallström AP, et al. Care of family caregivers of persons with dementia (CaFCa) through a tailor-made mobile app: study protocol of a complex intervention study. BMC Geriatr. 2020;20:305.

Angelo JK, Egan R, Reid K. Essential knowledge for family caregivers: a qualitative study. Int J Palliat Nurs. 2013;19:383–8.

Bijnsdorp FM, Pasman HRW, Boot CRL, van Hooft SM, van Staa A, Francke AL. Profiles of family caregivers of patients at the end of life at home: a Q-methodological study into family caregiver’ support needs. BMC Palliat Care. 2020;19:51.

Han EJ, Park M, Park S, Giap TT, Han D. Randomized Controlled Trial of the Caregiver Orientation for Mobilizing Personal Assets and Strengths for Self-Care (COMPASS) for Caregiving Journey: A National Family Caregiver Support Program in a Long-Term Care Insurance System. J Am Med Dir Assoc. 2020;21:1906-13.e3.

Krieger T, Feron F, Dorant E. Two-level multi-methodological evaluation of a new complex primary support programme for stroke care-givers in Germany. Ageing Soc. 2022;42:1–31.

Rozario PA, Palley E. When the private sphere goes public: exploring the issues facing family caregiver organizations in the development of long-term care policies. Soc Work Public Health. 2008;23:49–68.

Smith VA, Lindquist J, Miller KEM, Shepherd-Banigan M, Olsen M, Campbell-Kotler M, et al. Comprehensive Family Caregiver Support and Caregiver Well-Being: preliminary evidence from a Pre-post-survey Study with a non-equivalent Control Group. Front Public Health. 2019;7:122.

Zebrak KA, Campione JR. The Effect of National Family Caregiver Support Program Services on Caregiver Burden. J Appl Gerontol. 2021;40:963–71.

National Health Service: Support and benefits for carers. (2018) https://www.nhs.uk/conditions/social-care-and-support-guide/support-and-benefits-for-carers/ Accessed 20 Mar 2023.

Pennington BM. Inclusion of Carer Health-Related Quality of Life in National Institute for Health and Care Excellence appraisals. Value Health. 2020;23:1349–57.

Dawoud D, Lamb A, Moore A, Bregman C, Rupniewska E, Paling T, et al. Capturing what matters: updating NICE methods guidance on measuring and valuing health. Qual Life Res. 2022;31:2167–73.

Cross ER, Emanuel L. Providing inbuilt economic resilience options: an obligation of comprehensive cancer care. Cancer 2008113(12 Suppl):3548–55. https://doi.org/10.1002/cncr.23943 .

Roberts E, Struckmeyer KM. The impact of Respite Programming on Caregiver Resilience in Dementia Care: a qualitative examination of Family Caregiver perspectives. Inquiry. 2018;55:46958017751507.

PubMed Google Scholar

Simon C, Kumar S, Kendrick T. Who cares for the carers? The district nurse perspective. Fam Pract. 2002;19:29–35. https://doi.org/10.1093/fampra/19.1.29 .

Greenwood N, Habibi R, Mackenzie A, Drennan V, Easton N. Peer support for carers: a qualitative investigation of the experiences of carers and peer volunteers. Am J Alzheimers Dis Other Demen. 2013;28:617–26.

Download references

Acknowledgements

The authors thank the Department of Health and Family Welfare, Government of Kerala, the Local Self Government Department of the Government of Kerala and the Panchayats for granting permission to undertake the study.

AK received partial financial support from the project Local Government and Health in Kerala, implemented by Health Action by People (HAP), Thiruvananthapuram, Kerala, for conducting the palliative care nurse interviews. The Local Government and Health project was supported by the Health Systems Transformation Platform, through a financial contribution from the Sir Ratan Tata Trust. The funders had no role in data collection and analysis or preparation of the manuscript.

Author information

Authors and affiliations.

Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Thiruvananthapuram, Kerala, India

Arsha Kochuvilayil & Ravi Prasad Varma

You can also search for this author in PubMed Google Scholar

Contributions

AK conducted the interviews, undertook the analysis and wrote the first draft of the manuscript. RPV supervised the work and contributed to the conceptualization, design, analysis and revision of the manuscript. Both authors have reviewed and approved the manuscript in its present form including the revisions.

Corresponding author

Correspondence to Ravi Prasad Varma .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Ethics approval and consent to participate

All study participants provided written or electronic documentation of their informed consent. The study draws on data from two previous studies conducted by the researchers. Both previous studies were cleared by the respective Institutional Ethics Committee (Letter dated November 14, 2019, with number SCTIMST/IEC/1444; and letter dated 10 December 2020, numbered IEC EC2/P1/SEP/2020/HAP). The synthesis is part of the formative work towards the doctoral dissertation of Dr Arsha Kochuvilayil and the protocol and tools were reviewed and cleared by the Institutional Ethics Committee of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. (Letter number SCTIMST/IEC/2048/MAY-2023 dated 17 June 2023).

Consent for publication

Not applicable.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Additional File 1. Coding Schema for Coding Palliative Care Nurse Interviews.

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kochuvilayil, A., Varma, R.P. Understanding caregiver burden and quality of life in Kerala’s primary palliative care program: a mixed methods study from caregivers and providers’ perspectives. Int J Equity Health 23 , 92 (2024). https://doi.org/10.1186/s12939-024-02155-x

Download citation

Received : 23 March 2023

Accepted : 18 March 2024

Published : 07 May 2024

DOI : https://doi.org/10.1186/s12939-024-02155-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Family caregivers
Caregiver burden
Quality of life
Utility scores
Palliative nurse
Palliative care

International Journal for Equity in Health

ISSN: 1475-9276

General enquiries: [email protected]

We have updated our terms and conditions and privacy policy Click "Continue" to accept and continue with ET HealthWorld

We use cookies to ensure best experience for you

We use cookies and other tracking technologies to improve your browsing experience on our site, show personalize content and targeted ads, analyze site traffic, and understand where our audience is coming from. You can also read our privacy policy , We use cookies to ensure the best experience for you on our website.

By choosing I accept, or by continuing being on the website, you consent to our use of Cookies and Terms & Conditions .

Leaders Speak
Brand Solutions
Kerala's success in healthcare is due to a successful primary healthcare infrastructure : Dr. M I Sahadulla

ETHealthWorld
Updated On Feb 22, 2017 at 08:38 AM IST

Published On Feb 22, 2017 at 08:38 AM IST

All Comments

By commenting, you agree to the Prohibited Content Policy

Find this Comment Offensive?

Foul Language
Inciting hatred against a certain community
Out of Context / Spam

Join the community of 2M+ industry professionals

Subscribe to our newsletter to get latest insights & analysis., download ethealthworld app.

Get Realtime updates
Save your favourite articles

kims healthcare group
healthcare landscape
Dr. M I Sahadulla
Ethical practises

Prevalence of multimorbidity and associated treatment burden in primary care settings in Kerala: a cross-sectional study in Malappuram District, Kerala, India

Affiliation.

1 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India.
PMID: 35592547
PMCID: PMC9086527
DOI: 10.12688/wellcomeopenres.17674.2

Background: Multimorbidity or co-existence of two or more chronic conditions is common and associated with reduced quality of life and increased risk of death. We aimed to estimate the prevalence and pattern of multimorbidity in primary care settings in Kerala and the associated treatment burden, and quality of life. Methods: A cross-sectional survey was conducted among 540 adult participants in Malappuram District, Kerala. A multi-stage cluster sampling method was employed. Hypertension, diabetes, chronic obstructive pulmonary disease, depression and anxiety screening were done by trained medical professionals. The remaining medical conditions were self-reported by the respondent and verified with patient held health records. The health-related quality of life [HRQoL] was measured using the EQ-5D-5L tool. The MTBQ tool was used for measuring the multimorbidity treatment burden. Logistic regression was used to identify variables associated with multi-morbidity. Results: Overall, the prevalence of multimorbidity was 39.8% (35.7 - 44.1). The prevalence of multimorbidity among men (42.6%) was relatively higher than that in women (38.1%). Lower educational attainment, higher age group, and overweight or obesity status were independently associated with higher prevalence of multimorbidity. The most common pairs of coexisting chronic conditions reported in the study were hypertension and diabetes in males (66.7%) and females (70.8%). All domains of quality of life were impaired in individuals with multimorbidity. Conclusion: Multimorbidity is a norm and affects two of five participants seeking care in primary care settings in Kerala. The social gradient in the prevalence of multimorbidity was evident with higher prevalence in individuals with low educational attainment. Multimorbidity seriously impairs quality of life and increases treatment burden. The focus of management should move beyond individual diseases, and pivot towards interventions targeting multi-morbidity management, with a specific focus for people living in lower socio-economic strata.

Keywords: India; Kerala; Multimorbidity; Primary Care.

Associated data

figshare/10.6084/m9.figshare.17277167.v1

Grants and funding

In Kerala, we find a steadily aging population which comprises of about 11.2% of people above the age of 60. The birthrate is also less which makes Kerala one of a few area that have undergone the “demographic transition” characteristic. According to 1991 statistics, the total fertility rate (TFR) i.e. children born per women is the lowest in India. The TFR of hindus is 1.66, christianshave TFR 1.78 and that of Muslims is 2.97. The female-to-male ratio is comparatively higher than the rest of India. In Kerala the morbidity rate is 118 per 1000 in rural areas and 88 per 100 in urban areas. It is high when compared to any other Indian state. In India this rate is 55 and 54 per 1000, respectively.

Communication
Information Technology
Agriculture
Electricity

Sign in to your account

Essay on Kerala

Students are often asked to write an essay on Kerala in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Kerala

Kerala: the introduction.

Kerala, a state in India, is known as ‘God’s Own Country’. It’s located in the southern part of the country and is famous for its natural beauty.

Geographical Features

Kerala is blessed with unique geographical features. It has high mountains, deep valleys, and long coastlines. The Western Ghats and Arabian Sea add to its charm.

Culture and Tradition

Kerala’s culture is rich and diverse. It’s famous for its classical dance forms like Kathakali and Mohiniyattam. The Malayalam language is widely spoken here.

Kerala’s economy thrives on agriculture, fisheries, and tourism. It’s known for its spices, coconuts, and tea plantations.

Kerala, with its diverse culture and stunning natural beauty, is a gem of India. It’s a perfect blend of tradition and modernity.

Also check:

10 Lines on Kerala
Paragraph on Kerala
Speech on Kerala

250 Words Essay on Kerala

Introduction.

Kerala, often referred to as “God’s Own Country”, is a state in the southern part of India. Renowned for its unique geographical features, Kerala boasts a blend of serene beaches, tranquil backwaters, lush hill stations, and exotic wildlife, which makes it a paradise for tourists.

Cultural Richness

Kerala’s culture is deeply rooted in a history of diverse influences, from Dravidian and Aryan cultures to Arab and European. The state is famous for its traditional dance forms like Kathakali and Mohiniyattam. The Malayalam literature, enriched by the works of writers like Thakazhi and M.T. Vasudevan Nair, is another cultural treasure of Kerala.

Economic Activities

The economy of Kerala is largely service-based, with services contributing to around 64% of the state’s GDP. It is also a major hub for spices, tea, and rubber production. The state’s literacy rate and Human Development Index are the highest in India, reflecting its emphasis on education and social welfare.

Environmental Conservation

Kerala’s environmental conservation efforts are commendable. The state is home to numerous national parks and wildlife sanctuaries. It also leads in sustainable practices, with projects like the Silent Valley National Park, which serves as a testament to its commitment to preserving biodiversity.

Kerala stands as a unique blend of natural beauty, rich culture, and social welfare. Its achievements in education, health, and environmental conservation set a benchmark for other states in India. Kerala truly embodies the essence of “God’s Own Country”.

500 Words Essay on Kerala

Kerala, also known as ‘God’s Own Country’, is a beautiful state located in the southern region of India. It is renowned worldwide for its mesmerizing natural beauty, rich cultural heritage, and diverse traditions. This essay aims to provide an in-depth understanding of Kerala, its unique attributes, and its significant contributions to India.

Geographical Splendor

Kerala is blessed with a unique geographical location, nestled between the Arabian Sea on the west and the Western Ghats on the east. The state’s topography is characterized by a network of 44 rivers, serene backwaters, lush hill stations, and stunning beaches. Kerala’s biodiversity is another remarkable feature, with two national parks, 12 wildlife sanctuaries, and several reserve forests, home to numerous endemic and endangered species.

Cultural Heritage

Kerala’s cultural heritage is as diverse and vibrant as its geography. The state is a fusion of Dravidian and Aryan cultures, which is evident in its music, dance, cuisine, and traditional art forms. Kathakali and Mohiniyattam are two of the most famous classical dance forms originating from Kerala. The state’s festivals, such as Onam and Vishu, are celebrated with great enthusiasm and reflect the rich cultural ethos of the region.

Economy and Development

Kerala’s economy is primarily service-oriented, with tertiary sector activities contributing to over 60% of the state’s gross domestic product. The state is a major exporter of spices, coir products, marine products, and handlooms. Kerala also has the highest Human Development Index (HDI) in India, indicating its superior living conditions and social development.

Education and Literacy

Education in Kerala is another area of commendable achievement. The state boasts a literacy rate of 96.2%, the highest in India, thanks to its effective literacy programmes. Kerala’s educational system emphasizes quality and inclusivity, with a focus on holistic development and critical thinking.

Healthcare and Social Welfare

In terms of healthcare, Kerala sets an example for the rest of the country. The state’s healthcare system is well-structured and accessible, ensuring a high standard of health and longevity for its residents. Kerala’s social welfare programs are equally impressive, ensuring the wellbeing of its most vulnerable citizens.

In conclusion, Kerala is a state that beautifully blends natural beauty, cultural richness, and progressive social policies. Its achievements in education, healthcare, and social welfare are a testament to the state’s commitment to sustainable and inclusive development. Kerala truly embodies the essence of ‘God’s Own Country’, offering a glimpse into a unique blend of nature, culture, and development.

That’s it! I hope the essay helped you.

If you’re looking for more, here are essays on other interesting topics:

Essay on Culture of Kerala
Essay on Cultural Programme
Essay on Heritage Handloom

Apart from these, you can look at all the essays by clicking here .

Happy studying!

Analysing the outbreaks of leptospirosis after floods in Kerala, India

Oluwafemi John Ifejube ORCID: orcid.org/0000-0003-3258-9561 1 ,
Sekhar L. Kuriakose 2 ,
T. S. Anish ORCID: orcid.org/0000-0002-6957-5895 3 ,
Cees van Westen ORCID: orcid.org/0000-0002-2992-902X 1 &
Justine I. Blanford ORCID: orcid.org/0000-0003-0844-9390 1

International Journal of Health Geographics volume 23 , Article number: 11 ( 2024 ) Cite this article

48 Accesses

Metrics details

A growing number of studies have linked the incidence of leptospirosis with the occurrence of flood events. Nevertheless, the interaction between flood and leptospirosis has not been extensively studied to understand the influence of flood attributes in inducing new cases. This study reviews leptospirosis cases in relation to multiple flood occurrences in Kerala, India. Leptospirosis data were obtained for three years: 2017 (non-flood year) and two years with flooding—2018 (heavy flooding) and 2019 (moderate flooding). We considered the severity of flood events using the discharge, duration and extent of each flooding event and compared them with the leptospirosis cases. The distribution of cases regarding flood discharge and duration was assessed through descriptive and spatiotemporal analyses, respectively. Furthermore, cluster analyses and spatial regression were completed to ascertain the relationship between flood extent and the postflood cases. This study found that postflood cases of leptospirosis can be associated with flood events in space and time. The total cases in both 2018 and 2019 increased in the post-flood phase, with the increase in 2018 being more evident. Unlike the 2019 flood, the flood of 2018 is a significant spatial indicator for postflood cases. Our study shows that flooding leads to an increase in leptospirosis cases, and there is stronger evidence for increased leptospirosis cases after a heavy flood event than after a moderate flooding event. Flood duration may be the most important factor in determining the increase in leptospirosis infections.

Introduction

More than 2 billion people have been affected by floods in the past two decades [ 1 ] and there is clear evidence that the number of flood incidences is increasing due to climate change [ 2 , 3 ]. The effects of flooding on health are varied and include a range of rodent-borne, water-borne, and vector-borne diseases [ 4 ]. One of these water-borne diseases associated with flooding is leptospirosis [ 4 , 5 , 6 ]. Severe flooding has led to a higher number of infections in areas endemic to leptospirosis [ 7 , 8 ].

The global burden of leptospirosis was estimated to be about 2.90 million Disability Adjusted Life Years (DALYs), with most coming from tropical LMICs [ 9 ]. Due to the close resemblance of symptoms with other acute febrile illnesses, clinical diagnosis is often missed or delayed leading to severe complications and increased mortality [ 10 ]. Despite the variability in the quality of disease incidence reporting, 59,000 persons are estimated to die every year from leptospirosis [ 9 ]. The case fatality of leptospirosis can be as low as 6% or as high as 50% depending on the availability of supportive care [ 11 ].

Human infections of leptospirosis are caused by either direct contact with the urine of an infected animal or more usually, indirect exposure from a contaminated environment such as water and soil (that have been contaminated by the urine of an infected host) [ 12 ]. The incubation period for leptospirosis can range from 2 to 20 days after initial exposure to the bacteria with infections lasting for weeks to months [ 13 ]. Symptoms include fever, headache, and myalgia [ 12 ].

Several risk factors have been identified and are associated with the occurrence of leptospirosis [ 14 , 15 ]. In LMICs, higher chances of direct and indirect human infections have been found to occur due to occupational affiliations (e.g., abattoirs, livestock, and agricultural farm workers) [ 12 ], as well as poor sanitation and hygiene practices, and rodent density in the environment [ 16 ]. The climatic environment also plays a complex role in the interactions between humans, zoonotic hosts, and pathogens in the environment [ 17 ]. Heavy rainfall and flooding have been shown to contribute to an increase in leptospirosis infections [ 18 ].

The use of spatial and temporal analytical methods has substantially improved our understanding of leptospirosis epidemiology [ 19 ]. Several studies have connected the incidence of leptospirosis with flooding by spatial and temporal analysis [ 7 , 8 , 20 , 21 ]. Nevertheless, limited studies have related and compared flood events and leptospirosis incidence across multiple years. Since not all flood events in endemic regions lead to an outbreak [ 21 ], there is a need to study the extent of the influence of flood characteristics in inducing leptospirosis infections by comparing multiple flood events. The impact of climatic changes on human health can be more accurately assessed using geospatial tools and techniques [ 22 ]. The analysis of the dynamics between flood exposure and leptospirosis infection can be used to further understand the transmission pattern of infection during floods.

The purpose of this study was to (i) explore the spatial distribution of leptospirosis cases in relation to flooding and (ii) examine the relationship between leptospirosis incidence and flood events in Kerala. To achieve this, we retrospectively examined the cases of leptospirosis across flood phases (before, during and after) and across three consecutive years that included a non-flood year, a severe flood year and a less severe flood year.

With a population of 33 million people, Kerala state is located on the southwestern coast of India. Nearly all districts in Kerala are vulnerable to multiple hazards, however, flooding stands out as the most common and may yet become an annual affair in Kerala [ 23 ]. In 2018, Kerala experienced a severe flood, largely due to an unexpected amount of rainfall in the monsoon season [ 24 ]. The 2018 flood was the most extreme in Kerala in almost a century, nevertheless, other flood events occurred in consecutive years [ 25 ].

Although the cases of leptospirosis in Kerala were first reported three decades ago, the floods of 2018 revitalized their presence [ 26 , 27 ]. Leptospirosis is endemic in Kerala with the highest mortality rates recorded in comparison to other infectious diseases [ 28 ]. In 2018, the highest number of cases were reported in the southern districts of Kerala [ 29 ]. For this reason, two of the most affected districts by leptospirosis (Alappuzha and Pathanamthitta) were selected to better understand the risk of leptospirosis incidences in relation to flooding events.

The districts—Alappuzha and Pathanamthitta consist of 135 local administrative units called panchayats (Fig. 1 ) home to a total population of 3.3 million people [ 30 ]. There are distinctions between the two districts geographically. Alappuzha is the smaller of the two districts with a size of 1414 sq. km. Pathanamthitta is almost double the size of Alappuzha covering 2653 sq. km. According to the District Planning Offices (DPO), Alappuzha has a higher population per sq. km (1079) than Pathanamthitta (453) [ 31 ].

Study area and the panchayats

Alappuzha is a low-lying area with some parts below sea level and is located between the Vembanad Lake and the Arabian Sea. Pathanamthitta is highly vegetated with forest reserves that account for 50% of the district area [ 31 ] and a varied topography with mountainous regions in the east. On average temperatures are 27 °C in Alappuzha and 25 °C in Pathanamthitta with the rainy season occurring during the annual southwest monsoon period (June–September).

We examined the relationship between flooding and leptospirosis in the study area for three years: 2017(a non-flood year), 2018 (a severe flood year) and 2019 (a less severe flood year). The flood events in 2018 and 2019 were assessed with respect to flood characteristics (e.g., discharge, duration and extent) and the impact this had in the study area. Furthermore, the distribution of cases regarding the flooding events was assessed spatially and temporally. Statistical comparisons were made between leptospirosis cases across each year and within each year to ascertain the relationship between flooding and leptospirosis.

Data was collected for the 3 years (2017 to 2019). For this study’s purpose, three phases of flooding were defined to examine how cases of Leptospirosis changed over time and space. The phases are the periods before the flood, during the flood, and after the flood. The associated dates for each phase are defined in Table 1 and coincide with the reports provided by the Government of Kerala. No reported flood events occurred in 2017. The 2018 floods occurred due to heavy rainfall within the monsoon period [ 32 ]. In this study, the 2018 flood period was defined based on the flood maps published by [ 32 ]. The 2019 flood period was in August 2019 [ 33 ].

For all three years, the pre-flood phase is defined as three months before the flood, and the post-flood phase as three months after the flood. Three months were chosen because it provides sufficient time for incubation and transmission between hosts [ 8 ].

All data used in this study are described next and summarised in Table 2 . The datasets used include the reported cases of leptospirosis, the variables relevant to the flood events, and the population residing in the study area. Data on Leptospirosis cases were obtained from KSDMA for three years (2017–2019). The daily reported cases were aggregated for each panchayat and each epidemiological week (epi week), where epi week 1 starts on the first Sunday of the new year and ends on the Saturday of the same week [ 34 ]. The administrative boundaries of each panchayat in the study area were obtained from KSDMA.

Precipitation data was obtained from local and global sources. Daily rainfall for 2018 was provided by KSDMA only for the rainfall station in Alappuzha. To capture rainfall for the study area, ERA5 daily precipitation data for 2018 were obtained. ERA5 is the fifth generation of global atmospheric reanalysis by the European Centre for Medium-Range Weather Forecasts (ECMWF) and has been used in other studies [ 36 , 37 , 38 ]. ERA5 data were validated by comparing the rainfall data obtained for the station in Alappuzha with the ERA5 data. A 0.67 correlation was found (Supplementary Information 1). Based on the classification of the correlation by [ 39 ] and validation of the aforementioned studies, we considered it acceptable to use ERA5 data to represent precipitation for the study area. The ERA5 daily precipitation was therefore used for all three years (2017–2019) in both districts.

River discharge data were obtained from daily river discharges to capture the flood occurrence in 2018 and 2019. Data were measured at two stations in the study area: Station Q_Erapphuza (located in the Alappuzha district), and Station Q_Kurudamannil (located in the Pathanamthitta district). A total number of 430 (out of 1460) days were missing (424 for Q_Erapphuza and 6 for Q_Kurudamannil) in the 2018 river discharge data. Missing values were infilled using temporal trend analysis [ 40 ] (the summary of the estimation is provided in Supplementary Information 2). This estimation uses the time-series values of consecutive days using the Interpolated Univariate Spline method in the SciPy Interpolation package [ 40 ]. To match the leptospirosis case data, river discharge data was averaged by epi week for each year.

Flood extents during 2018 and 2019 were captured by raster maps created by [ 35 ] from Sentinel-1 Radar imagery. The raster maps were obtained by determining the difference in the amount of water bodies in the flood phase as compared to the preflood phase. These maps were used to demarcate the extent of flooding in Kerala during the flood phases for both years.

The population density was obtained from Meta [ 41 ] using the most recently available data (2021) for the study area. Meta’s population maps have been used in a variety of studies (e.g., [ 42 , 43 , 44 ]) and are considered representative. Essentially, the population density maps were created by identifying human-made buildings from high-resolution satellite imagery and assigning population estimates using convolutional neural network (CNN) architectures integrated with census data [ 41 ]. The final population map provides the distributed population density raster at a 30m resolution, thereby enabling accurate population estimates to be determined in rural areas [ 41 ].

Characterization of flood events

Descriptive statistics were used to evaluate the amount of precipitation that occurred and how this coincided with the amount of river discharge for each year. The extents of the flood event were assessed for each year. The flood's impact was assessed for each flood year (2018 and 2019) by determining the percentage of panchayats and the population exposed during each flooding event. All spatial analyses were performed in ArcGIS Pro version 3.1.1.

Spatiotemporal distribution of leptospirosis across years

The total number of cases of leptospirosis and river discharges in each of the three years (2017–2019) were cross-examined through boxplots. An epidemiological curve was constructed to compare the trend of river discharge with the number of cases. The cases during the two flooded years were compared against 2017 (non-flood year) to understand their differences and similarities in order to understand the role flooding has on the occurrence of leptospirosis infections within the population.

Spatiotemporal distribution of leptospirosis across flood phases

The occurrence of leptospirosis cases was analyzed for each flood phase of the flooded years (2018 and 2019). Cluster and outlier analyses were conducted using the Anselin Local Moran's I statistic [ 45 ] to identify potential leptospirosis hotspots (high-high clusters: where panchayats with high leptospirosis incidence are near other panchayats with high leptospirosis incidence), cold spots (low-low clusters: panchayats with low leptospirosis incidence are near other panchayats with low leptospirosis incidence), and spatial outliers (high-low and low–high clusters: panchayats with high incidence surrounded by areas with low incidence and vice versa) among the panchayats. The flood-induced incidence rates were computed using the population exposed during floods and the post-flood cases. The incidence rates of leptospirosis were calculated by dividing the total number of post-flood cases by the total population affected and expressed as incidence per 100,000 people.

Comparison of the relationship between flood and leptospirosis

Spatial variation in leptospirosis cases and flooding was compared using a regression analysis. The regression between flood extent and cases in 2018 was compared against the flood extent and cases in 2019 to determine if there are differences between these two events. The spatially varying coefficient (SVC) regression model (in Eq. 1 ) was employed to compare the relationship between each pair (flood extent and the number of cases) for the flooded years (2018 & 2019). The R software was used to perform this regression analysis. Source code is provided in Supplementary Information 3.

where y is the total number of leptospirosis cases, s refers to the locations of each panchayat. ${\beta }_{0},{\beta }_{1}$ are the regression coefficients, ${x}_{1}$ refers to the flood extent.

Table 3 summarizes the precipitation for the two districts and the three time periods for 2017–2019. A higher amount of precipitation was recorded in Pathanamthitta (2788–3144 mm) than in Alappuzha (2602–2650 mm). In the three years, rainfall was highest in Pathanamthitta during 2018 (3144 mm), highest in Alappuzha during 2017 (2650 mm) and lowest in both districts during 2019 (2602 mm in Alappuzha and 2788 mm in Pathanamthitta) (Table 3 ). Unlike during 2017, increased and longer rainfall occurred majorly in the southwest monsoon period during 2018 and 2019 (Fig. 2 ).

Time series plot of precipitation and river discharge from 2017 to 2019 ( a ) precipitation ( b ) river discharge (where the light blue lines represent Alappuzha and the thick blue lines represent Pathanamthitta)

In all three years, the maximum river discharge was consistently higher in Pathanamthitta (ranging from 846.6 to 1360.3 m 3 /s) than in Alappuzha (ranging from 372.9 to 472.2 m 3 /s) (Table 3 ; Fig. 2 ). River discharge was highest in Alappuzha during 2018 (max river discharge 472.2 m 3 /s), highest in Pathanamthitta during 2019 (max river discharge 1360.3 m 3 /s), and lowest in both districts during 2017 (max river discharge: 372.9 m 3 /s in Alappuzha and 846.6 m 3 /s in Pathanamthitta) (Table 3 ).

The panchayats in the central areas of Alappuzha were the most affected by floods (Fig. 3 ). The Vembanad Lake is the largest water body close to flooded areas in Alappuzha. Despite high river discharges in Pathanamthitta, the flood extent was smaller than that of Alappuzha.

Flood extent maps in the study area ( a ) 2018 ( b ) 2019

Table 4 shows the total area affected by the flood during 2018 and 2019 was 278 km 2 and 220.0 km 2 , respectively. A total of 81 panchayats were exposed to flood in both years but the number of panchayats exposed to floods in Alappuzha was consistently higher than that of Pathanamthitta. An equal portion of panchayats (60%) were exposed to floods in 2018 and 2019; however, the population exposed in 2019 (1.0%) was lower than that of 2018 (1.9%). The population exposed to the flood was higher in Alappuzha than in Pathanamthitta.

In 2018, the peak in river discharge occurred on the 18th of August 2018 (949.9m 3 /s). At a similar time of the year in 2019, the river discharge peaked on the 8th of August 2019 (1360.3m 3 /s) (Fig. 2 ). Although the highest river discharge occurred in 2019, a longer period of discharge occurred in 2018 (Fig. 2 ).

The results of descriptive analyses of leptospirosis cases and river discharge are shown in Table 5 . Leptospirosis cases were reported for all three years with the highest number of cases occurring in 2018. Except for 2018, more cases were reported in Alappuzha than in Pathanamthitta. The highest reported cases per epiweek during 2018 in both districts were at least four times higher than during other years (Table 5 ; Fig. 4 ). Despite the high river discharges that occurred in 2018 and 2019, only the cases in 2018 showed a high increase (Fig. 5 ).

Total number of incidences of leptospirosis between 2017 and 2019 (A boxplot where green boxes = cases in 2017; red boxes = cases in 2018; yellow boxes = cases in 2019. A = Alappuzha, P = Pathanamthitta)

Amount of river discharge in study per epi week (where grey boxes = river discharge in 2017, dark blue boxes = river discharge in 2018 and light blue boxes = river discharge in 2019. A = Alappuzha, P = Pathanamthitta)

Leptospirosis cases were observed in multiple panchayats and the distribution of leptospirosis cases varied over the three years. The total number of panchayats reporting at least 1 case of Leptospirosis rose from 68 in 2017 to 105 in 2018 and reduced again to 89 in 2019. Figure 6 shows that higher cases occurred in Alappuzha communities during 2017 and 2019. During 2018, the central parts of both districts were affected.

Spatial distribution of the total number of cases by panchayats in ( a ) 2017 ( b ) 2018 ( c ) 2019

Significant clusters of leptospirosis cases were found for all three years (Supplementary Information 4). The cases in both flooded years (2018 and 2019) are therefore classified into the three different flood phases in further analyses.

Figure 7 displays the differences between the trend of leptospirosis cases during the three flood phases of flooded years (2018 and 2019) and the non-flooded year (2017) in the study area. A sharp increase in the number of cases can be seen after the flood phase in both districts in 2018. The highest number of cases was reported during week 36, precisely on the 4th of September 2018, which is 17 days after the flood peak (18th of August 2018). For 2019 no major peaks were observed in either district. Leptospirosis cases in 2019 were found to be similar to or less than those reported in the non-flooded year.

Time series plot of leptospirosis across flood phases in the study area. a Alappuzha in 2018. b Pathanamthitta in 2018. c Alappuzha in 2019. d Pathanamthitta in 2019

The highest number of cases in 2018 occurred during the post-flood phase in both districts, but this was not during 2019 (Table 6 a). The distribution of cases during the post-flood phase of 2018 is more evident than that of 2019 in both districts, even though the cases in all phases are distributed in similar locations (central parts of Alappuzha and Pathanamthitta) (Fig. 8 ). The number of cases during the flood phase was lower in comparison with other phases in both years.

Spatial distribution of leptospirosis cases among panchayats across flood phases, a before the 2018 flood, b during the 2018 flood, c after the 2018 flood, d before the 2019 flood, e during the 2019 flood, f after the 2019 flood

Table 6 shows the summary of river discharge and cases across the flood phases in the study area. The average amount of river discharge was highest during the flood phase in 2018 (277.9 m 3 /s in Alappuzha; 498.3 m 3 /s in Pathanamthitta) and 2019 (138.0 m 3 /s in Alappuzha; 341.7 in Pathanamthitta). The river discharges were consistently higher in 2018 than in 2019 in all phases, except during the postflood phase of 2019 (109.2 m 3 /s in Alappuzha; 150.2 m 3 /s in Pathanamthitta).

The clusters and outliers of leptospirosis cases across flood phases are presented in Supplementary Information 5. The result of overlaying the flood extent and the clusters of leptospirosis is shown in Fig. 9 . It can be seen that the flood events in 2018 and 2019 are related to the hotspots (high–high clusters) of the case during the postflood phase. Using the population exposed during floods and the post-flood cases, the flood-induced incidence rates are computed. Higher flood-induced incidence rates per 100,000 were observed in 2018, and in Pathanamthitta (Table 6 b).

Flood extent and the cluster of post-flood incidences in ( a ) 2018 and ( b ) 2019

The result of SVC regression analyses is presented in Table 7 . The flood extent of 2018 was found to be a significant explanatory variable for the 2018 post-flood leptospirosis cases at a 95% confidence level. Using the same confidence level, the flood extent of 2019 was not found to show statistical significance to post-flood leptospirosis cases in 2019.

Impact of flood events

The impact of the flooding events was analyzed based on the discharge, duration, and geographic extent of the flood. In all three attributes, the 2018 flooding event was more severe than that of 2019. As Pathanamthitta is located upstream of Alappuzha, it was the extreme rainfall in 2018 that caused the major flooding in both districts. This result is consistent with previous studies that have performed impact analyses for 2018 and 2019 flooding events [ 25 , 46 ] in this study area, especially in central Alappuzha. Even though Alappuzha would have been more flooded than Pathanamthitta, we didn’t have reliable flood discharge data to demonstrate this. The flooding appears to have been aggravated by the Vembanad lake and other main rivers in Alappuzha. Although the spatial extents of both floods were similar, many more people were exposed to the 2018 flooding event.

Interactions between flood and leptospirosis

The trend of leptospirosis during the flood periods offers invaluable insight into the dynamics between flood and leptospirosis in Kerala. The peak of leptospirosis cases occurred 17 days after the peak of the floods. This result is consistent with the findings by Sykes et al. that cases occur 2–20 days after initial exposure to the bacteria. It should be noted that the infections may have occurred on earlier dates because only the information on the reporting date at the facility was provided. The similarities in the trend of leptospirosis before the flood phase across the years suggest the presence of seasonal patterns of infection in the study area. The endemicity of leptospirosis around water bodies can also be linked to the occupations where people get exposed to contaminated environments [ 12 ].

The results indicate that flooded areas are more likely to experience cases of leptospirosis infection. Higher cases of leptospirosis were reported in Alappuzha (the most flooded district) during the post-flood phase. Additionally, other panchayats aside from the flooded panchayats also registered post-flood cases of leptospirosis. This shows that the spread of leptospirosis is not only limited to flooded areas. Other areas affected by leptospirosis could be previously endemic areas [ 47 ] or new settlements that evacuated people move into (such as relief camps) [ 48 ].

The cases in the three phases of floods were different regardless of the year involved. The lowest cases were observed during the flood phase. An evident reason for this is that the flood period was shorter in comparison with the preflood and post-flood phases. Therefore, given the incubation time of leptospirosis, infections during a flood may be reported during the post-flood phase. Additionally, the results consistently show that cases of leptospirosis are higher during the post-flood phase than in other phases [ 8 ].

Although a small part of the population was directly exposed to the flooding event, the possibility of secondary transmission cannot be ignored. Secondary transmission may be direct or indirect transmission based on the type of exposure to the pathogen. Indirect transmissions of leptospirosis are more common than direct transmission [ 12 ]. A further study is recommended to understand the influence of other risk factors of leptospirosis before and after flooding. For every 100,000 people exposed to floods, 641 were infected with the disease in the study area. This is notably higher than the global yearly rate of 14.77 cases per 100,000 estimated by the Leptospirosis Epidemiology Reference Group (LERG) [ 49 ].

This result suggests that the distribution and geographical spread of leptospirosis infections are dependent on the characteristics of floods. Nevertheless, there is a clear difference between cases in 2018 and 2019 despite floods occurring in both years in the study area: higher cases were consistently recorded after floods in Alappuzha, while only the 2018 flood led to an increase of cases in Pathanamthitta. This suggests that Alappuzha is more susceptible to flood-induced infections than Pathanamthitta. Nevertheless, a reason for the lesser number of cases in 2019 could be a result of improved awareness of leptospirosis infection which was beyond the scope of this study. Given the transmission pattern of leptospirosis, flood duration may be the most important flood severity indicator in estimating post-flood cases. Leptospira can survive longer in running water than in stagnant water [ 50 ]. Therefore, a longer flood event could increase the interaction between exposed people and the bacteria Leptospira .

The SVC regression similarly confirmed that the 2018 flood was more influential than the 2019 flood in inducing postflood cases given its statistical significance. Though previous studies have shown that leptospirosis outbreak is associated with flooding [ 6 , 7 , 8 ], this study further suggests that flood-induced cases are dependent on the severity of the flood event. Although floods can be a significant indicator for the prediction of future cases of leptospirosis, less severe floods may not cause a spike in the number of leptospirosis cases. Adequate forecasting and monitoring should be conducted before and during flood events to prepare for potential outbreaks in the study area. Future investigations should employ the multi-year spatiotemporal analyses used in this study to further examine the flood-leptospirosis interaction.

Limitations of the study

This study has potential limitations due to the availability of data. The datasets describing the case and flood events are limited by incomplete data or metadata. Nevertheless, the limitations are minor and do not deter the reliability of the study's results. The quality of the flood extent data derived from radar may have been affected because of the presence of vegetation which may not have been sufficiently distinguished. In addition to this, the flood extent over the flood phase appeared to be similar in 2018 and 2019, whereas more flood problems were reported in 2018. We could not obtain flood depth data which may have provided an additional component of analysis in this study to investigate its relationship with the number of cases that occurred. Potentially inundated areas could be mapped out using novel methods [ 51 , 52 , 53 ].

Although the incident case data provided enough possibilities for the analyses of this study to be completed, certain limitations were encountered. A higher level of precision would have improved the spatial granularity of this research, but due to ethical and privacy concerns, the cases had to be summarized at the panchayat’s level. There is no data on the demographics of people who got the disease, this may have helped to ascertain if people in flood-related workers were at more risk than others. Additional metadata such as the date of onset of disease, the date patients were seen at the facility, laboratory test results, and mortality would have provided a better context for the analyses. There is a high chance that the cases of leptospirosis have been underreported [ 54 ], and therefore, there is an amount of uncertainty in the completeness of the epidemic data provided.

The available information about flooding events is limited by unavailable or unreliable data. The record containing the river discharge (implied by the amount of river discharge) had many missing values. This was a result of damage to station gauges at certain times. Although an attempt was made to estimate the missing values through interpolation methods by comparing the trend in other stations, the data was insufficient for a more detailed temporal analysis. In addition, the data for the flood extent obtained from satellite observations have not been verified through ground truthing.

This study evaluated the incidence of leptospirosis cases in relation to flooding events by comparing the cases over flood phases and years. The total number of leptospirosis cases was higher in flooded years (2018 and 2019) than in the non-flooded year (2017). Despite the similarities between the flooding in 2018 and 2019, the 2018 flood event had a stronger impact in the study area than that of 2019. The Leptospirosis cases in both districts varied across the flood phases, but the cases were highest in the post-flood phase of both districts. The flood-induced cases of leptospirosis occurred after a time lag. While the cases in Alappuzha appeared to be similarly clustered spatially, the cases in Pathanamthitta varied significantly. Although leptospirosis is endemic in the study area, the central areas in Alappuzha were most impacted by the infectious disease due to the floods. Even though flooding led to an increase in leptospirosis cases in both years, there is stronger evidence for increased leptospirosis cases after the 2018 flood than after the 2019 flood. The significance of the 2018 flood in estimating post-flood infections could be due to the longer duration of the flood.

Availability of data and materials

All data used in this research are openly available and can be accessed freely except for the leptospirosis data due to its sensitive nature. Precipitation and flood information are not published but are available from the corresponding author upon reasonable request.

WHO. Floods [Internet]. 2020 [cited 2022 Nov 8]. Available from: https://www.who.int/health-topics/floods/#tab=tab_1

Tabari H. Climate change impact on flood and extreme precipitation increases with water availability. Sci Rep. 2022;10(1):1–10.

Google Scholar

López RE, Thomas V, Troncoso P. Climate change and natural disasters. Working Papers, University of Chile, Department of Economics; 2015. https://EconPapers.repec.org/RePEc:udc:wpaper:wp414 .

Brown L, Murray V. Examining the relationship between infectious diseases and flooding in Europe: a systematic literature review and summary of possible public health interventions. Disaster Health. 2013;1(2):117–27.

Article PubMed PubMed Central Google Scholar

Lau CL, Smythe LD, Craig SB, Weinstein P. Climate change, flooding, urbanisation and leptospirosis: fuelling the fire? Trans R Soc Trop Med Hyg. 2010;104(10):631–8. https://doi.org/10.1016/j.trstmh.2010.07.002 .

Article PubMed Google Scholar

Naing C, Reid SA, Aye SN, Htet NH, Ambu S. Risk factors for human leptospirosis following flooding: a meta-analysis of observational studies. PLoS ONE. 2019;14(5):e0217643. https://doi.org/10.1371/journal.pone.0217643 .

Article CAS PubMed PubMed Central Google Scholar

Chadsuthi S, Chalvet-Monfray K, Wiratsudakul A, Modchang C. The effects of flooding and weather conditions on leptospirosis transmission in Thailand. Sci Rep. 2021;11(1):1–12.

Article Google Scholar

Mohd Radi MF, Hashim JH, Jaafar MH, Hod R, Ahmad N, Nawi AM, et al. Leptospirosis outbreak after the 2014 major flooding event in Kelantan, Malaysia: a spatial-temporal analysis. Am J Trop Med Hyg. 2018;98(5):1281–95.

Torgerson PR, Hagan JE, Costa F, Calcagno J, Kane M, Martinez-Silveira MS, et al. Global burden of leptospirosis: estimated in terms of disability adjusted life years. PLoS Negl Trop Dis. 2015;9(10): e0004122. https://doi.org/10.1371/journal.pntd.0004122 .

Lau CL, Townell N, Stephenson E, van den Berg D, Craig SB. Leptospirosis: an important zoonosis acquired through work, play and travel. Aust J Gen Pract. 2018;47(3):105–10.

Smith S, Kennedy BJ, Dermedgoglou A, Poulgrain SS, Paavola MP, Minto TL, et al. A simple score to predict severe leptospirosis. PLoS Negl Trop Dis. 2019;13(2): e0007205. https://doi.org/10.1371/journal.pntd.0007205 .

Goarant C. Leptospirosis: risk factors and management challenges in developing countries. Res Rep Trop Med. 2016;7:49.

PubMed PubMed Central Google Scholar

Sykes JE, Reagan KL, Nally JE, Galloway RL, Haake DA. Role of diagnostics in epidemiology, management, surveillance, and control of leptospirosis. Pathogens. 2022;11(4):395.

Wasiński B, Dutkiewicz J. Leptospirosis-current risk factors connected with human activity and the environment. Ann Agric Environ Med. 2013;20(2):239–44.

PubMed Google Scholar

Cruz LS, Vargas R, Lopes AA. Leptospirosis: a worldwide resurgent zoonosis and important cause of acute renal failure and death in developing nations. Ethn Dis. 2009;19(1 Suppl 1):S1-37.

RSTMH. Leptospirosis in India: a forgotten tropical disease. 2021. Available from: https://rstmh.org/news-blog/blogs/leptospirosis-in-india-a-forgotten-tropical-disease .

Cucchi K, Liu R, Collender PA, Cheng Q, Li C, Hoover CM, et al. Hydroclimatic drivers of highly seasonal leptospirosis incidence suggest prominent soil reservoir of pathogenic Leptospira spp. in rural western China. PLoS Negl Trop Dis. 2019;13(12): e0007968. https://doi.org/10.1371/journal.pntd.0007968 .

Chadsuthi S, Chalvet-Monfray K, Geawduanglek S, Wongnak P, Cappelle J. Spatial–temporal patterns and risk factors for human leptospirosis in Thailand, 2012–2018. Sci Rep. 2022;12(1):1–11.

Dhewantara PW, Lau CL, Allan KJ, Hu W, Zhang W, Mamun AA, et al. Spatial epidemiological approaches to inform leptospirosis surveillance and control: a systematic review and critical appraisal of methods. Zoonoses Public Health. 2019;66(2):185–206.

Warnasekara J, Agampodi S, Rupika AR. Time series models for prediction of leptospirosis in different climate zones in Sri Lanka. PLoS ONE. 2021;16(5): e0248032. https://doi.org/10.1371/journal.pone.0248032 .

Suwanpakdee S, Kaewkungwal J, White LJ, Asensio N, Ratanakorn P, Singhasivanon P, et al. Spatio-temporal patterns of leptospirosis in Thailand: is flooding a risk factor? Epidemiol Infect. 2015;143(10):2106–15.

Kamel Boulos MN, Wilson JP. Geospatial techniques for monitoring and mitigating climate change and its effects on human health. Int J Health Geogr. 2023;22(1):1–7. https://doi.org/10.1186/s12942-023-00324-9 .

Shaji KA. thewire.in. 2019. Is Climate Change Making Floods an Annual Affair in Kerala? Available from: https://thewire.in/environment/floods-in-kerala-experts-point-to-climate-change .

Central Water Commission. Kerala floods of 2018. 2018.

Vijaykumar P, Abhilash S, Sreenath AV, Athira UN, Mohanakumar K, Mapes BE, et al. Kerala floods in consecutive years—its association with mesoscale cloudburst and structural changes in monsoon clouds over the west coast of India. Weather Clim Extrem. 2021;1(33): 100339.

Kuriakose M, Eapen CK, Punnoose E, Koshi G. Leptospirosis—clinical spectrum and correlation with seven simple laboratory tests for early diagnosis in the Third World. Trans R Soc Trop Med Hyg. 1990;84(3):419–21. https://doi.org/10.1016/0035-9203(90)90343-D .

Article CAS PubMed Google Scholar

James S, Sathian B, van Teijlingen E, Asim M. Outbreak of Leptospirosis in Kerala, Nepal. J Epidemiol. 2018;8(4):745.

James S, Sathian B, Van Teijlingen E, Asim M. Outbreak of Leptospirosis in Kerala. 2018. Available from: https://idsp.nic.in/index.php

DHS. Data on Communicable Diseases. 2019. Available from: https://dhs.kerala.gov.in/data-on-communicable-diseases/

Government of India. Census of India 2011, National Population Register & Socio Economic and Caste Census. 2011. Available from: https://censusindia.gov.in/nada/index.php/catalog/42619#metadata-description

DPO. District Profile. Available from: https://web.archive.org/web/20160808051648/http://www.spb.kerala.gov.in/index.php/district-profile-pathanamthitta

Govt. of Kerala. Kerala Floods 2018. 1st August to 30th August 2018. Additional Memorandum. 2018.

Govt. of Kerala. Memorandum|Kerala. 2019.

PAHO. Norms and Standards in Epidemiology: Epidemiological Calendar 2000. 1999. https://www3.paho.org/english/sha/be993calend.htm

Glas V. Application of the fast flood simulation model for local risk-informed decision-making on flood risk reduction : a case study of Pamba Basin, Kerala India. 2023. Available from: http://essay.utwente.nl/97911/ .

Jiao D, Xu N, Yang F, Xu K. Evaluation of spatial-temporal variation performance of ERA5 precipitation data in China. Sci Rep. 2021;11(1):1–13.

Lavers DA, Simmons A, Vamborg F, Rodwell MJ. An evaluation of ERA5 precipitation for climate monitoring. Quart J R Meteorolog Soc. 2022;148(748):3152–65. https://doi.org/10.1002/qj.4351 .

Jiang Q, Li W, Fan Z, He X, Sun W, Chen S, et al. Evaluation of the ERA5 reanalysis precipitation dataset over Chinese Mainland. J Hydrol (Amst). 2021;1(595): 125660.

Schober P, Schwarte LA. Correlation coefficients: appropriate use and interpretation. Anesth Analog. 2018;126(5):1763–8.

ESRI. Fill Missing Values (Space Time Pattern Mining)—ArcGIS Pro|Documentation. Available from: https://pro.arcgis.com/en/pro-app/latest/tool-reference/space-time-pattern-mining/fillmissingvalues.htm .

Tiecke TG, Liu X, Zhang A, Gros A, Li N, Yetman G, et al. Mapping the world population one building at a time. Mapping the World Population One Building at a Time. 2017. Available from: https://arxiv.org/abs/1712.05839v1 .

Hierink F, Margutti J, van den Homberg M, Ray N. Constructing and validating a transferable epidemic risk index in data scarce environments using open data: a case study for dengue in the Philippines. PLoS Negl Trop Dis. 2022;16(2): e0009262. https://doi.org/10.1371/journal.pntd.0009262 .

Walter N, Stockman J, Odeph C, Butler B. Using meta’s relative wealth index and high resolution population density data to help expand electricity access in Uganda. 2023. Available from: https://www.wri.org/update/using-metas-relative-wealth-index-and-high-resolution-population-density-data-help-expand .

Lusseau D, Baillie R. Disparities in greenspace access during COVID-19 mobility restrictions. Environ Res. 2023;15(225): 115551.

Anselin L. Local indicators of spatial association—LISA. Geogr Anal. 1995;27(2):93–115. https://doi.org/10.1111/j.1538-4632.1995.tb00338.x .

Mehrishi P, Kundu A, Thakur IS. An appraisal of Kerala flood—2019. J Indian Soc Remote Sens. 2022;50(8):1563–7. https://doi.org/10.1007/s12524-022-01544-5 .

Sarkar J, Chopra A, Katageri B, Raj H, Goel A. Leptospirosis: a re-emerging infection. Asian Pac J Trop Med. 2012;5(6):500–2.

Mohd Hanapi IR, Sahimin N, Maackara MJB, Annisa AS, Abdul Mutalib RNS, Lewis JW, et al. Prevalence of anti-Leptospira antibodies and associated risk factors in the Malaysian refugee communities. BMC Infect Dis. 2021;21(1):1–11.

Costa F, Hagan JE, Calcagno J, Kane M, Torgerson P, Martinez-Silveira MS, et al. Global morbidity and mortality of leptospirosis: a systematic review. PLoS Negl Trop Dis. 2015;9(9): e0003898.

Wynwood SJ, Graham GC, Weier SL, Collet TA, McKay DB, Craig SB. Leptospirosis from water sources. Pathog Glob Health. 2014;108(7):334.

Van Den Bout B, Jetten VG, Van Westen CJ, Lombardo L. A breakthrough in fast flood simulation. Environ Model Softw. 2023;168: 105787.

Mangukiya NK, Sharma A. Flood risk mapping for the lower Narmada basin in India: a machine learning and IoT-based framework. Nat Hazards. 2022;113(2):1285–304. https://doi.org/10.1007/s11069-022-05347-2 .

Gangani P, Mangukiya NK, Mehta DJ, Muttil N, Rathnayake U. Evaluating the efficacy of different DEMs for application in flood frequency and risk mapping of the Indian Coastal River Basin. Climate. 2023;11:114.

Varughese A, Purushothaman C. Climate change and public health in India: the 2018 Kerala floods. World Med Health Policy. 2021;13(1):16–35.

Download references

Acknowledgements

The authors would like to acknowledge the contributions of Vera Glas whose study contributed to the flood maps used in this research. The authors also appreciate the support of KSDMA in facilitating the incidence data collection processes

No funding was received for this study.

Author information

Authors and affiliations.

Geo-Information Science and Earth Observation (ITC), University of Twente, Enschede, The Netherlands

Oluwafemi John Ifejube, Cees van Westen & Justine I. Blanford

Kerala State Disaster Management Authority (KSDMA), Thiruvananthapuram, Kerala, India

Sekhar L. Kuriakose

Government Medical College, Malappuram, Kerala, India

T. S. Anish

You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the article. All authors conceived and developed the scope of this research. O J Ifejube developed the ideas, performed all analyses, and took the lead in writing the manuscript. Cees van Westen and Justine I. Blanford helped supervise the research project. All authors contributed to the different versions of the manuscript by providing critical feedback.

Corresponding author

Correspondence to Oluwafemi John Ifejube .

Ethics declarations

Ethics approval and consent to participate.

This research was approved after a thorough ethical review by the GEO Ethics Committee, University of Twente (Request number 220098).

Consent for publication

Informed consent (either verbal or written) was obtained from KSDMA about the leptospirosis data used in this publication.

Competing interests

There are no conflicts of interest that may be declared regarding this study.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ifejube, O.J., Kuriakose, S.L., Anish, T.S. et al. Analysing the outbreaks of leptospirosis after floods in Kerala, India. Int J Health Geogr 23 , 11 (2024). https://doi.org/10.1186/s12942-024-00372-9

Download citation

Received : 27 November 2023

Accepted : 30 April 2024

Published : 13 May 2024

DOI : https://doi.org/10.1186/s12942-024-00372-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Epidemiology
Leptospirosis

International Journal of Health Geographics

ISSN: 1476-072X

Submission enquiries: [email protected]

Skip to main content
Keyboard shortcuts for audio player

Your Health
Treatments & Tests
Health Inc.
Public Health

Perspective

When pto stands for 'pretend time off': doctors struggle to take real breaks.

Mara Gordon

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off. Wolfgang Kaehler/LightRocket via Getty Images hide caption

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off.

A few weeks ago, I took a vacation with my family. We went hiking in the national parks of southern Utah, and I was blissfully disconnected from work.

I'm a family physician, so taking a break from my job meant not seeing patients. It also meant not responding to patients' messages or checking my work email. For a full week, I was free.

Taking a real break — with no sneaky computer time to bang out a few prescription refill requests — left me feeling reenergized and ready to take care of my patients when I returned.

But apparently, being a doctor who doesn't work on vacation puts me squarely in the minority of U.S. physicians.

Research published in JAMA Network Open this year set out to quantify exactly how doctors use their vacation time — and what the implications might be for a health care workforce plagued by burnout, dissatisfaction and doctors who are thinking about leaving medicine.

"There is a strong business case for supporting taking real vacation," says Dr. Christine Sinsky , the lead author of the paper. "Burnout is incredibly expensive for organizations."

Shots - Health News

Health workers know what good care is. pandemic burnout is getting in the way.

Researchers surveyed 3,024 doctors, part of an American Medical Association cohort designed to represent the American physician workforce. They found that 59.6% of American physicians took 15 days of vacation or less per year. That's a little more than the average American: Most workers who have been at a job for a year or more get between 10 and 14 days of paid vacation time , according to the U.S. Bureau of Labor Statistics.

However, most doctors don't take real vacation. Over 70% of doctors surveyed said they worked on a typical vacation day.

"I have heard physicians refer to PTO as 'pretend time off,'" Sinsky says, referring to the acronym for "paid time off."

Sinsky and co-authors found that physicians who took more than three weeks of vacation a year had lower rates of burnout than those who took less, since vacation time is linked to well-being and job satisfaction .

And all those doctors toiling away on vacation, sitting poolside with their laptops? Sinsky argues it has serious consequences for health care.

Physician burnout is linked to high job turnover and excess health care costs , among other problems.

Still, it can be hard to change the culture of workaholism in medicine. Even the study authors confessed that they, too, worked on vacation.

"I remember when one of our first well-being papers was published," says Dr. Colin West , a co-author of the new study and a health care workforce researcher at the Mayo Clinic. "I responded to the revisions up at the family cabin in northern Minnesota on vacation."

Sinsky agreed. "I do not take all my vacation, which I recognize as a delicious irony of the whole thing," she says.

She's the American Medical Association's vice president of professional satisfaction. If she can't take a real vacation, is there any hope for the rest of us?

I interviewed a half dozen fellow physicians and chatted off the record with many friends and colleagues to get a sense of why it feels so hard to give ourselves a break. Here, I offer a few theories about why doctors are so terrible at taking time off.

We don't want to make more work for our colleagues

The authors of the study in JAMA Network Open didn't explore exactly what type of work doctors did on vacation, but the physicians I spoke to had some ideas.

"If I am not doing anything, I will triage my email a little bit," says Jocelyn Fitzgerald , a urogynecologist at the University of Pittsburgh who was not involved in the study. "I also find that certain high-priority virtual meetings sometimes find their way into my vacations."

Even if doctors aren't scheduled to see patients, there's almost always plenty of work to be done: dealing with emergencies, medication refills, paperwork. For many of us, the electronic medical record (EMR) is an unrelenting taskmaster , delivering a near-constant flow of bureaucratic to-dos.

When I go on vacation, my fellow primary care doctors handle that work for me, and I do the same for them.

But it can sometimes feel like a lot to ask, especially when colleagues are doing that work on top of their normal workload.

"You end up putting people in kind of a sticky situation, asking for favors, and they [feel they] need to pay it back," says Jay-Sheree Allen , a family physician and fellow in preventive medicine at the Mayo Clinic.

She says her practice has a "doctor of the day" who covers all urgent calls and messages, which helps reduce some of the guilt she feels about taking time off.

Still, non-urgent tasks are left for her to complete when she gets back. She says she usually logs in to the EMR when she's on vacation so the tasks don't pile up upon her return. If she doesn't, Allen estimates there will be about eight hours of paperwork awaiting her after a week or so of vacation.

"My strategy, I absolutely do not recommend," Allen says. But "I would prefer that than coming back to the total storm."

We have too little flexibility about when we take vacation

Lawren Wooten , a resident physician in pediatrics at the University of California San Francisco, says she takes 100% of her vacation time. But there are a lot of stipulations about exactly how she uses it.

She has to take it in two-week blocks — "that's a long time at once," she says — and it's hard to change the schedule once her chief residents assign her dates.

"Sometimes I wish I had vacation in the middle of two really emotionally challenging rotations like an ICU rotation and an oncology rotation," she says, referring to the intensive care unit. "We don't really get to control our schedules at this point in our careers."

Once Wooten finishes residency and becomes an attending physician, it's likely she'll have more autonomy over her vacation time — but not necessarily all that much more.

"We generally have to know when our vacations are far in advance because patients schedule with us far in advance," says Fitzgerald, the gynecologist.

Taking vacation means giving up potential pay

Many physicians are paid based on the number of patients they see or procedures they complete. If they take time off work, they make less money.

"Vacation is money off your table," says West, the physician well-being researcher. "People have a hard time stepping off of the treadmill."

A 2022 research brief from the American Medical Association estimated that over 55% of U.S. physicians were paid at least in part based on "productivity," as opposed to earning a flat amount regardless of patient volume. That means the more patients doctors cram into their schedules, the more money they make. Going on vacation could decrease their take-home pay.

But West says it's important to weigh the financial benefits of skipping vacation against the risk of burnout from working too much.

Physician burnout is linked not only to excess health care costs but also to higher rates of medical errors. In one large survey of American surgeons , for example, surgeons experiencing burnout were more likely to report being involved in a major medical error. (It's unclear to what extent the burnout caused the errors or the errors caused the burnout, however.)

Doctors think they're the only one who can do their jobs

When I go on vacation, my colleagues see my patients for me. I work in a small office, so I know the other doctors well and I trust that my patients are in good hands when I'm away.

Doctors have their own diagnosis: 'Moral distress' from an inhumane health system

But ceding that control to colleagues might be difficult for some doctors, especially when it comes to challenging patients or big research projects.

"I think we need to learn to be better at trusting our colleagues," says Adi Shah , an infectious disease doctor at the Mayo Clinic. "You don't have to micromanage every slide on the PowerPoint — it's OK."

West, the well-being researcher, says health care is moving toward a team-based model and away from a culture where an individual doctor is responsible for everything. Still, he adds, it can be hard for some doctors to accept help.

"You can be a neurosurgeon, you're supposed to go on vacation tomorrow and you operate on a patient. And there are complications or risk of complications, and you're the one who has the relationship with that family," West says. "It is really, really hard for us to say ... 'You're in great hands with the rest of my team.'"

What doctors need, says West, is "a little bit less of the God complex."

We don't have any interests other than medicine

Shah, the infectious disease doctor, frequently posts tongue-in-cheek memes on X (formerly known as Twitter) about the culture of medicine. Unplugging during vacation is one of his favorite topics, despite his struggles to follow his own advice.

His recommendation to doctors is to get a hobby, so we can find something better to do than work all the time.

"Stop taking yourself too seriously," he says. Shah argues that medical training is so busy that many physicians neglect to develop any interests other than medicine. When fully trained doctors are finally finished with their education, he says, they're at a loss for what to do with their newfound freedom.

Since completing his training a few years ago, Shah has committed himself to new hobbies, such as salsa dancing. He has plans to go to a kite festival next year.

Shah has also prioritized making the long trip from Minnesota to see his family in India at least twice a year — a journey that requires significant time off work. He has a trip there planned this month.

"This is the first time in 11 years I'm making it to India in summer so that I can have a mango in May," the peak season for the fruit, Shah says.

Wooten, the pediatrician, agrees. She works hard to develop a full life outside her career.

"Throughout our secondary and medical education, I believe we've really been indoctrinated into putting institutions above ourselves," Wooten adds. "It takes work to overcome that."

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. She's on X as @MaraGordonMD .

American Medical Association

Share full article

Supported by

Guest Essay

Doctors Need a Better Way to Treat Patients Without Their Consent

By Sandeep Jauhar

Dr. Jauhar is a cardiologist in New York who writes frequently about medical care and public health.

Not long ago, I took care of a middle-aged man at my hospital who had severe heart failure requiring life support. When he was disconnected from machines after a few days of treatment, he began to display psychotic symptoms, including delusional thinking, tangential speech and paranoia. He had a long history of untreated schizophrenia, I learned, which had estranged him from family members and friends, with whom he had virtually no contact.

My patient demanded to leave the hospital. However, sending him home was going to be a problem. He could not take care of himself. There was little chance he would take his medications, including a blood thinner to dissolve a clot in his heart before it caused a stroke. He was even less likely to take psychiatric drugs that he did not believe he needed.

My colleagues and I didn’t know what to do, so we called the treating psychiatrist. The psychiatrist immediately declared that our patient lacked the capacity to discharge himself from the hospital. The patient could not grasp the implications of this choice, for instance, or properly weigh its risks and benefits. The psychiatrist said the patient should remain in the hospital to receive psychiatric treatment, even against his will.

The psychiatrist’s opinion made sense to me. Patients with untreated schizophrenia have a higher rate of death than those who undergo treatment. Hopefully treatment would restore my patient’s judgment to the point where he would take his medications when he went home — or even decide not to take them, but to make that risky decision in the full appreciation of the likely consequences. (If autonomy means anything, it means that patients have the right to make bad decisions, too.) Treating him, even over his objections, seemed to be in his best interests.

However, according to New York law — and the law of other states — such involuntary treatment would require a court order. As doctors, we would have to plead our case before a judge. But was a judge without medical or psychiatric expertise the best person to decide this man’s fate?

In this case and also more generally, I think the answer is no. The law ought to be changed to keep such decisions in hospitals — in the hands of doctors, medical ethicists and other relevant experts.

Doctors don’t always have to resort to the courts to treat patients without their consent. There are some notable exceptions, such as during a life-threatening emergency (if a competent patient has not previously refused such treatment) or when there is a pressing societal interest (such as requiring patients with communicable tuberculosis to take antibiotics).

But judicial review has been the cornerstone of “treatment over objection,” as it’s known, for the past four decades or so. Appellate courts in the 1980s ruled that judicial hearings in such cases are needed to safeguard patients’ rights. For example, in 1983, in Rogers v. Commissioner of Department of Mental Health, the Massachusetts Supreme Judicial Court declared that a judge could override medical judgments favoring involuntary psychiatric treatment.

The underlying motivation behind judicial review was and remains laudable: to avoid the sort of paternalistic abuses that have characterized too much of medical history. Doctors often used to withhold bad news from patients, to cite just a small example. Involuntary treatment, even with benevolent intentions, reeks of such paternalism.

But though medical practice is by no means perfect, times have changed. The sort of abuse dramatized in the 1975 movie “One Flew Over the Cuckoo’s Nest,” with its harrowing depiction of forced electroconvulsive therapy, is far less common. Doctors today are trained in shared decision-making. Safeguards are now in place to prevent such maltreatment, including multidisciplinary teams in which nurses, social workers and bioethicists have a voice.

In addition to being less necessary to prevent abuse than they once were, courts are by nature poorly suited for making decisions about treatment over objection. For one thing, they are slow: Having to go to court often results in delays, sometimes up to a week or more, which can harm patients who need care urgently.

Moreover, judges have neither the experience nor the expertise to properly evaluate psychological states, assess decision-making capacity or determine whether a proposed treatment’s benefits outweigh its risks. It is no surprise that by some estimates 95 percent or more of requests for treatment over objection are approved by judges, who invariably haven’t met the patient and must rely on information provided by the treating medical team.

A better system for determining whether a patient should be treated over his or her objection would be a hospital hearing in which a committee of doctors, ethicists and other relevant experts — all of whom would be independent of the hospital and not involved in the care of the patient — engaged in conversation with the medical team and the patient and patient’s family. Having hearings on site would expedite decisions and minimize treatment delays. The committee would make the final decision.

Of course, such a committee would have to be granted immunity from legal liability (as with judges in our current system), so that experts would be willing to serve and speak candidly. Patients’ interests could be safeguarded by requiring the committee to publish its reasoning. Periodic audits by a regulatory body could ensure that the committee’s deliberations were meeting medical and ethical standards.

In the event that the committee could not reach a consensus on the best course of action (or if there were allegations of wrongdoing), then the parties involved could appeal to a judge. But that would be the exception rather than the rule.

In the case of my patient with heart failure, the decision ultimately didn’t have to go before a judge. Multiple discussions involving the patient, the hospital ethics and palliative care teams, social workers, nurses, psychiatrists and other doctors — discussions that in many respects served the function of a formal committee of the sort I’m proposing — yielded an agreement with the patient that his interests would be best served by sending him home with hospice care.

Capacity must be judged relative to the decision being made, and it became clear over the course of hospitalization that our patient understood the terminal nature of his condition and had the capacity to choose hospice care. Forced treatment was unlikely to significantly improve his psychiatric symptoms before the natural progression of heart failure caused his death.

So he was discharged home. It was the best decision under the circumstances, one reached by expert deliberation, not legal procedure. He passed away a few weeks later without, fortunately, ever setting foot in court.

Sandeep Jauhar ( @sjauhar ) is a doctor at Northwell Health in New York and the author, most recently, of “ My Father’s Brain : Life in the Shadow of Alzheimer’s.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

Main Navigation

Contact NeurIPS
Code of Ethics
Code of Conduct
Create Profile
Journal To Conference Track
Diversity & Inclusion
Proceedings
Future Meetings
Exhibitor Information
Privacy Policy

NeurIPS 2024

Conference Dates: (In person) 9 December - 15 December, 2024

Homepage: https://neurips.cc/Conferences/2024/

Call For Papers

Author notification: Sep 25, 2024

Camera-ready, poster, and video submission: Oct 30, 2024 AOE

Submit at: https://openreview.net/group?id=NeurIPS.cc/2024/Conference

The site will start accepting submissions on Apr 22, 2024

Subscribe to these and other dates on the 2024 dates page .

The Thirty-Eighth Annual Conference on Neural Information Processing Systems (NeurIPS 2024) is an interdisciplinary conference that brings together researchers in machine learning, neuroscience, statistics, optimization, computer vision, natural language processing, life sciences, natural sciences, social sciences, and other adjacent fields. We invite submissions presenting new and original research on topics including but not limited to the following:

Applications (e.g., vision, language, speech and audio, Creative AI)
Deep learning (e.g., architectures, generative models, optimization for deep networks, foundation models, LLMs)
Evaluation (e.g., methodology, meta studies, replicability and validity, human-in-the-loop)
General machine learning (supervised, unsupervised, online, active, etc.)
Infrastructure (e.g., libraries, improved implementation and scalability, distributed solutions)
Machine learning for sciences (e.g. climate, health, life sciences, physics, social sciences)
Neuroscience and cognitive science (e.g., neural coding, brain-computer interfaces)
Optimization (e.g., convex and non-convex, stochastic, robust)
Probabilistic methods (e.g., variational inference, causal inference, Gaussian processes)
Reinforcement learning (e.g., decision and control, planning, hierarchical RL, robotics)
Social and economic aspects of machine learning (e.g., fairness, interpretability, human-AI interaction, privacy, safety, strategic behavior)
Theory (e.g., control theory, learning theory, algorithmic game theory)

Machine learning is a rapidly evolving field, and so we welcome interdisciplinary submissions that do not fit neatly into existing categories.

Authors are asked to confirm that their submissions accord with the NeurIPS code of conduct .

Formatting instructions: All submissions must be in PDF format, and in a single PDF file include, in this order:

The submitted paper
Technical appendices that support the paper with additional proofs, derivations, or results
The NeurIPS paper checklist

Other supplementary materials such as data and code can be uploaded as a ZIP file

The main text of a submitted paper is limited to nine content pages , including all figures and tables. Additional pages containing references don’t count as content pages. If your submission is accepted, you will be allowed an additional content page for the camera-ready version.

The main text and references may be followed by technical appendices, for which there is no page limit.

The maximum file size for a full submission, which includes technical appendices, is 50MB.

Authors are encouraged to submit a separate ZIP file that contains further supplementary material like data or source code, when applicable.

You must format your submission using the NeurIPS 2024 LaTeX style file which includes a “preprint” option for non-anonymous preprints posted online. Submissions that violate the NeurIPS style (e.g., by decreasing margins or font sizes) or page limits may be rejected without further review. Papers may be rejected without consideration of their merits if they fail to meet the submission requirements, as described in this document.

Paper checklist: In order to improve the rigor and transparency of research submitted to and published at NeurIPS, authors are required to complete a paper checklist . The paper checklist is intended to help authors reflect on a wide variety of issues relating to responsible machine learning research, including reproducibility, transparency, research ethics, and societal impact. The checklist forms part of the paper submission, but does not count towards the page limit.

Please join the NeurIPS 2024 Checklist Assistant Study that will provide you with free verification of your checklist performed by an LLM here . Please see details in our blog

Supplementary material: While all technical appendices should be included as part of the main paper submission PDF, authors may submit up to 100MB of supplementary material, such as data, or source code in a ZIP format. Supplementary material should be material created by the authors that directly supports the submission content. Like submissions, supplementary material must be anonymized. Looking at supplementary material is at the discretion of the reviewers.

We encourage authors to upload their code and data as part of their supplementary material in order to help reviewers assess the quality of the work. Check the policy as well as code submission guidelines and templates for further details.

Use of Large Language Models (LLMs): We welcome authors to use any tool that is suitable for preparing high-quality papers and research. However, we ask authors to keep in mind two important criteria. First, we expect papers to fully describe their methodology, and any tool that is important to that methodology, including the use of LLMs, should be described also. For example, authors should mention tools (including LLMs) that were used for data processing or filtering, visualization, facilitating or running experiments, and proving theorems. It may also be advisable to describe the use of LLMs in implementing the method (if this corresponds to an important, original, or non-standard component of the approach). Second, authors are responsible for the entire content of the paper, including all text and figures, so while authors are welcome to use any tool they wish for writing the paper, they must ensure that all text is correct and original.

Double-blind reviewing: All submissions must be anonymized and may not contain any identifying information that may violate the double-blind reviewing policy. This policy applies to any supplementary or linked material as well, including code. If you are including links to any external material, it is your responsibility to guarantee anonymous browsing. Please do not include acknowledgements at submission time. If you need to cite one of your own papers, you should do so with adequate anonymization to preserve double-blind reviewing. For instance, write “In the previous work of Smith et al. [1]…” rather than “In our previous work [1]...”). If you need to cite one of your own papers that is in submission to NeurIPS and not available as a non-anonymous preprint, then include a copy of the cited anonymized submission in the supplementary material and write “Anonymous et al. [1] concurrently show...”). Any papers found to be violating this policy will be rejected.

OpenReview: We are using OpenReview to manage submissions. The reviews and author responses will not be public initially (but may be made public later, see below). As in previous years, submissions under review will be visible only to their assigned program committee. We will not be soliciting comments from the general public during the reviewing process. Anyone who plans to submit a paper as an author or a co-author will need to create (or update) their OpenReview profile by the full paper submission deadline. Your OpenReview profile can be edited by logging in and clicking on your name in https://openreview.net/ . This takes you to a URL "https://openreview.net/profile?id=~[Firstname]_[Lastname][n]" where the last part is your profile name, e.g., ~Wei_Zhang1. The OpenReview profiles must be up to date, with all publications by the authors, and their current affiliations. The easiest way to import publications is through DBLP but it is not required, see FAQ . Submissions without updated OpenReview profiles will be desk rejected. The information entered in the profile is critical for ensuring that conflicts of interest and reviewer matching are handled properly. Because of the rapid growth of NeurIPS, we request that all authors help with reviewing papers, if asked to do so. We need everyone’s help in maintaining the high scientific quality of NeurIPS.

Please be aware that OpenReview has a moderation policy for newly created profiles: New profiles created without an institutional email will go through a moderation process that can take up to two weeks. New profiles created with an institutional email will be activated automatically.

Venue home page: https://openreview.net/group?id=NeurIPS.cc/2024/Conference

If you have any questions, please refer to the FAQ: https://openreview.net/faq

Ethics review: Reviewers and ACs may flag submissions for ethics review . Flagged submissions will be sent to an ethics review committee for comments. Comments from ethics reviewers will be considered by the primary reviewers and AC as part of their deliberation. They will also be visible to authors, who will have an opportunity to respond. Ethics reviewers do not have the authority to reject papers, but in extreme cases papers may be rejected by the program chairs on ethical grounds, regardless of scientific quality or contribution.

Preprints: The existence of non-anonymous preprints (on arXiv or other online repositories, personal websites, social media) will not result in rejection. If you choose to use the NeurIPS style for the preprint version, you must use the “preprint” option rather than the “final” option. Reviewers will be instructed not to actively look for such preprints, but encountering them will not constitute a conflict of interest. Authors may submit anonymized work to NeurIPS that is already available as a preprint (e.g., on arXiv) without citing it. Note that public versions of the submission should not say "Under review at NeurIPS" or similar.

Dual submissions: Submissions that are substantially similar to papers that the authors have previously published or submitted in parallel to other peer-reviewed venues with proceedings or journals may not be submitted to NeurIPS. Papers previously presented at workshops are permitted, so long as they did not appear in a conference proceedings (e.g., CVPRW proceedings), a journal or a book. NeurIPS coordinates with other conferences to identify dual submissions. The NeurIPS policy on dual submissions applies for the entire duration of the reviewing process. Slicing contributions too thinly is discouraged. The reviewing process will treat any other submission by an overlapping set of authors as prior work. If publishing one would render the other too incremental, both may be rejected.

Anti-collusion: NeurIPS does not tolerate any collusion whereby authors secretly cooperate with reviewers, ACs or SACs to obtain favorable reviews.

Author responses: Authors will have one week to view and respond to initial reviews. Author responses may not contain any identifying information that may violate the double-blind reviewing policy. Authors may not submit revisions of their paper or supplemental material, but may post their responses as a discussion in OpenReview. This is to reduce the burden on authors to have to revise their paper in a rush during the short rebuttal period.

After the initial response period, authors will be able to respond to any further reviewer/AC questions and comments by posting on the submission’s forum page. The program chairs reserve the right to solicit additional reviews after the initial author response period. These reviews will become visible to the authors as they are added to OpenReview, and authors will have a chance to respond to them.

After the notification deadline, accepted and opted-in rejected papers will be made public and open for non-anonymous public commenting. Their anonymous reviews, meta-reviews, author responses and reviewer responses will also be made public. Authors of rejected papers will have two weeks after the notification deadline to opt in to make their deanonymized rejected papers public in OpenReview. These papers are not counted as NeurIPS publications and will be shown as rejected in OpenReview.

Publication of accepted submissions: Reviews, meta-reviews, and any discussion with the authors will be made public for accepted papers (but reviewer, area chair, and senior area chair identities will remain anonymous). Camera-ready papers will be due in advance of the conference. All camera-ready papers must include a funding disclosure . We strongly encourage accompanying code and data to be submitted with accepted papers when appropriate, as per the code submission policy . Authors will be allowed to make minor changes for a short period of time after the conference.

Contemporaneous Work: For the purpose of the reviewing process, papers that appeared online within two months of a submission will generally be considered "contemporaneous" in the sense that the submission will not be rejected on the basis of the comparison to contemporaneous work. Authors are still expected to cite and discuss contemporaneous work and perform empirical comparisons to the degree feasible. Any paper that influenced the submission is considered prior work and must be cited and discussed as such. Submissions that are very similar to contemporaneous work will undergo additional scrutiny to prevent cases of plagiarism and missing credit to prior work.

Plagiarism is prohibited by the NeurIPS Code of Conduct .

Other Tracks: Similarly to earlier years, we will host multiple tracks, such as datasets, competitions, tutorials as well as workshops, in addition to the main track for which this call for papers is intended. See the conference homepage for updates and calls for participation in these tracks.

Experiments: As in past years, the program chairs will be measuring the quality and effectiveness of the review process via randomized controlled experiments. All experiments are independently reviewed and approved by an Institutional Review Board (IRB).

Financial Aid: Each paper may designate up to one (1) NeurIPS.cc account email address of a corresponding student author who confirms that they would need the support to attend the conference, and agrees to volunteer if they get selected. To be considered for Financial the student will also need to fill out the Financial Aid application when it becomes available.

Australian Government Department of Health and Aged Care

Budget 2024–25

Fact sheets and other health, aged care and sport information from the 2024–25 Budget.

Scroll down to access downloads and media.

Ministers' media releases

Budget 2024–⁠25: Cheaper medicines, new Medicare Urgent Care Clinics and more free mental health services in a stronger Medicare

Budget 2024–⁠25: Investing in quality aged care

Portfolio Budget Statements

Budget 2024–25: Health and Aged Care Portfolio Budget Statements

Stakeholder pack

Budget 2024–⁠25: Stakeholder pack

Budget 2024–25: Budget overview

Budget 2024–25: Ensuring all Australians get the health care they need

Fact sheets

Budget 2024–⁠25: Strengthening Medicare

Budget 2024–⁠25: Cheaper medicines

Budget 2024–⁠25: Quality aged care

Budget 2024–25: A fit and healthy Australia

We aim to provide documents in an accessible format. If you're having problems using a document with your accessibility tools, please contact us for help .

About the department

Is there anything wrong with this page?

Help us improve health.gov.au

If you would like a response please use the enquiries form instead.

Get a fresh perspective of people, events and trends that shape our world. A mix of news, features, interviews and music from around the world presents an engaging portrait of the global community.

Listen Live

Morning Edition

NPR's Morning Edition takes listeners around the country and the world with two hours of multi-faceted stories and commentaries that inform, challenge and occasionally amuse. Morning Edition is the most listened-to news radio program in the country.

Health Care

Citing ‘burnout,’ doctors with ChristianaCare file papers to form system’s first labor union

Two-thirds of the more than 400 doctors on staff at the health system’s major delaware operations, including christiana and wilmington hospitals, would be covered..

Cris Barrish

Doctors on staff at Christiana Hospital and other Christiana Care facilities in Delaware are seeking to unionize. (Cris Barrish/WHYY)

About Cris Barrish

Want a digest of WHYY’s programs, events & stories? Sign up for our weekly newsletter.

Together we can reach 100% of WHYY’s fiscal year goal

IMAGES

(PDF) Health care in Kerala
Kerala
Kerala role model for India's changing Health care system
Kerala health model
(PDF) Utilization of primary health care services: a case study in
The New Kerala Story: Kerala's Palliative Care Model

VIDEO

Kerala Model Health Care
Silver Jubilee: Celebrating 25 Years of Healthcare Excellence and Innovations in Kerala"
About Kerala in English paragraph on my Kerala essay in English 2022 essay on Kerala in English 2022
10 Lines on Kerala in English 💖
10 lines on Kerala in English
Best Paramedical Courses After 12th in Malayalam

COMMENTS

Emerging challenges in the health systems of Kerala, India: qualitative
Ethical issue: Review paper do not need approval code. Results Theme 1: increasing burden of non-communicable diseases and chronic morbidity. Various records and experts have discussed the issue of high morbidity and low mortality in Kerala state and the long-term effects and complications associated with this [5, 6, 11, 19, 20] The prevention of communicable diseases and NCDs was one of the ...
Reimagining health: A people's manifesto for Kerala
One of the significant consequences of the unregulated rapid privatization of health care in Kerala is over-medicalization and escalation of healthcare costs. Kerala has the country's highest caesarian rate of 30.5 per cent, which is three times higher than the national average. The World Health Organization's recommended rate is (15 %).
PDF THE ASCENT OF 'KERALA MODEL' OF PUBLIC HEALTH
THE ASCENT OF 'KERALA MODEL' OF PUBLIC HEALTH . CC. Kartha . Kerala Institute of Medical Sciences, Trivandrum, Kerala . [email protected] . Kerala, a state on the southwestern of India Coast is the best performer in the health sector in the country according to the health index NITI Aayog, a policy thinkof tank of the Government of - India.
Re-engineering primary healthcare in Kerala
INTRODUCTION: In the backdrop of the Sustainable Development Goals (SDGs), the state of Kerala, India, revamped its existing primary health centres (PHCs) into people-friendly family health centres (FHCs) in order to provide comprehensive primary care as part of a mission-based ('Aardram') initiative.It was envisioned that the mission's implementation and operation would make use of ...
PDF Public Health Care in Kerala: An Analysis of Public Opinion
opinion on change in health care system (Ch) in Kerala. Opinion on health care service (op), preference of healthcare (pc) system and frequency of visit to health care (v) facilities were tested to estimate the change in health care system. ln 𝐶ℎ=𝛽 0 +𝛽 + 𝛽 𝛽𝑣 + 𝜀 Paper ID: SR23109144625
The Kerala model in the time of COVID19: Rethinking state, society and
41 The Kerala government's successful response to the Nipah virus outbreak-- quickly diagnosing the virus in a district hospital in Kozhikode (but with the help of research facilities in other parts of India and imported drugs from Australia) had already greatly increased the reputation of the Kerala government and its heath care facilities ...
(PDF) Emerging challenges in the health systems of Kerala, India
The private health-care sector plays a significant role in Kerala ' s health-care system and is considered to be the highest compared to other states [ 31 ]. Some reports claim
The Health Care System in Kerala
Kerala launched a radical decentralization policy in 1996 by which the health care system would be responsive to the local people. Third Kerala must take a step to revamp the health care system in a way that the public and private sectors effectively cooperate and complement each other to meet the needs of the people.
Kerala's Early Experience: Moving towards Universal Health Coverage
On the basis of this, it was proposed that comprehensive care pathways be created—Kerala's version of an Essential Health Package, delivered through a re-engineered health system.
Emerging Challenges in the Health Systems of Kerala India
Keywords Kerala health system, Kerala health insurance, Kerala public health, Heart disease, Health economics, Emergency healthcare Paper type Review. JournalofHealthResearch Vol.36No.2,2022 pp.242-254 EmeraldPublishingLimited. e-ISSN:2586-940X. p-ISSN:0857-4421 DOI10.1108/JHR-04-2020-0091.
Positive Outlier: Health Outcomes in Kerala, India over Time
Abstract: This case explores how Kerala, India developed a reputation for exemplary health outcomes despite low per capita income. After providing historical background, including the social, political, and health system factors that contributed to a culture of seeking health care, the case describes Kerala's health system and outcomes.
PDF Health Care Challenges in Kerala
the 1980s, the private health care sector emerged as the major source of treatment in Kerala. The factors behind this growth were the decay of the public sector, rising disposable income and lack of barriers in opening a private hospital. The public health care facilities became under-utilized and people spend huge amounts for private health care.
Kerala's Innovative Health Policy
Certainly, Kerala's innovative health policy is a critical component of its low and steadily decreasing poverty rate. However, underprivileged individuals-including the poor, those in rural areas, women, and the elderly-continue to receive lower quality care and less of it. That is why NGOs and nonprofits like the trustee's organization ...
Historical analysis of the development of health care facilities in
V Raman Kutty, Historical analysis of the development of health care facilities in Kerala State, India, Health Policy and Planning, Volume 15, Issue 1, March 2000, ... probably fuelled the demand for health care already created by the increased access to health facilities. Since the government institutions could not grow in number and quality ...
PDF Review on Burden of Treatment- The Kerala Scenario
healthcare services in Kerala deserves importance. Studies on healthcare cost of treatment in Kerala Health systems provide a variety of services that can improve human health conditions; however, the use of these services may lead to catastrophic health expenditures or impoverishment for households (Xu et al., 2003).
Understanding caregiver burden and quality of life in Kerala's primary
The National Institute for Health and Care Excellence, UK has included an assessment of caregivers' quality-of-life in economic evaluation in its health technology evaluation manual published in January 2022 [56, 57]. The primary palliative care programme in Kerala is run by the LGs with support from the health department.
Revisiting the Kerala 'Model' of Development: A Sixty-year Assessment
This article seeks to revisit the much-acclaimed Kerala 'Model' of Development since the formation of the state of Kerala. ... All subjects Allied Health Cardiology & Cardiovascular Medicine Dentistry Emergency Medicine & Critical Care Endocrinology & Metabolism Environmental Science General Medicine ... Social intermediation and health ...
Kerala's success in healthcare is due to a successful primary
Kerala's success in healthcare is due to a successful primary healthcare infrastructure : Dr. M I Sahadulla. An organised approach in healthcare is very much the need of our country, only then the ...
PDF Functioning Mechanism of Primary Health Centres in Kerala
The Public health care system is considered as one of the factors for the attainment of affordable health care in the district. Since the formation of the district in 1982, health care incorporating western and traditional medicine received priorities in the district. The health care facilities in the district consist of Allopathy
Prevalence of multimorbidity and associated treatment burden ...
We aimed to estimate the prevalence and pattern of multimorbidity in primary care settings in Kerala and the associated treatment burden, and quality of life. Methods: A cross-sectional survey was conducted among 540 adult participants in Malappuram District, Kerala. A multi-stage cluster sampling method was employed.
Healthcare System in Kerala
Healthcare. The healthcare system of Kerala has achieved International acclaim. Kerala has been designated as the World's First "Baby Friendly State" by The United Nations Children's Fund (UNICEF) and the World Health Organization (WHO). In Kerala, almost 95% of births are taken place from the hospitals. There are different methods of ...
Understanding caregiver burden and quality of life in Kerala's primary
Three out of ten caregivers of palliative care patients were 60 years of age or older and had significantly lower health-related quality of life, particularly if they perceived caregiver burden, in this study from Kollam, Kerala. Background Family caregivers are vital for long-term care for persons with serious health-related suffering in Kerala. Long-term caregiving and ageing may become ...
PDF Tribals in Kerala a Situational Over View
TRIBALS IN KERALA - A SITUATIONAL ... Inaccessibility of the tribal settlements to the basic health care institutions is the major cause of severe health issues faced by the tribes. About 2139 settlements with Primary Health Centres, 3150 settlements with ... Primary Health Centre : 389 554 1531 1320 702 97 19 1 149 Community Health Centre ...
Essay on Kerala
Students are often asked to write an essay on Kerala in their schools and colleges. And if you're also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic. ... In terms of healthcare, Kerala sets an example for the rest of the country. The state's healthcare system is well-structured and accessible ...
Analysing the outbreaks of leptospirosis after floods in Kerala, India
The case fatality of leptospirosis can be as low as 6% or as high as 50% depending on the availability of supportive care ... Troncoso P. Climate change and natural disasters. Working Papers, University of Chile, Department of Economics; 2015. ... Purushothaman C. Climate change and public health in India: the 2018 Kerala floods. World Med ...
When doctors can't take real breaks from work, the health care system
"I remember when one of our first well-being papers was published," says Dr. Colin West, a co-author of the new study and a health care workforce researcher at the Mayo Clinic. "I responded to the ...
Opinion
Guest Essay. How to Treat a Patient Without His Consent. May 13, 2024. Video. ... Dr. Jauhar is a cardiologist in New York who writes frequently about medical care and public health.
NeurIPS 2024 Call for Papers
Call For Papers. Abstract submission deadline: May 15, 2024 01:00 PM PDT or. Full paper submission deadline, including technical appendices and supplemental material (all authors must have an OpenReview profile when submitting): May 22, 2024 01:00 PM PDT or. Author notification: Sep 25, 2024.
Budget 2024-25
Budget 2024-25: A fit and healthy Australia. 14 May 2024. Fact sheet. We aim to provide documents in an accessible format. If you're having problems using a document with your accessibility tools, please contact us for help. Publication date: 14 May 2024. Publication type: Collection.
ChristianaCare doctors petition for election to unionize
Let us know! Doctors employed by Delaware's dominant medical system, ChristianaCare, have petitioned the National Labor Relations Board to vote on forming a union, WHYY News has learned. Two-thirds of the more than 400 physicians who are on staff at the health care system's main Delaware operations — Christiana and Wilmington hospitals ...

Reimagining health: A people’s manifesto for Kerala

A vision for health in Kerala

Social determinants of health in Kerala

Lifestyle diseases major threat in Kerala

Global healthcare commitments

Need to curb road accidents

Privatisation of healthcare escalates costs

Share this:

The Kerala model in the time of COVID19: Rethinking state, society and democracy

Joseph Tharamangalam

1. Introduction

2. What did Kerala do with Covid 19?

3. Behind the success: The legacy of the Kerala model

3.1. A proactive and interventionist state

3.2. Social mobilization and public participation

3.3. State–society synergy

3.4. A ‘Navodhanam”: Kerala’s own century old renaissance

4. Concluding remarks

Declaration of Competing Interest

Acknowledgements

10129971600aaad23e949a49999289d8

Positive Outlier: Health Outcomes in Kerala, India over Time

Search case collection

Medical Condition

Teaching Themes

Stakeholders

View complete collection

Kerala’s Innovative Health Policy

Kerala’s Current Health Needs

Policy Solutions

Looking to the Future

Impact on Poverty

-The Huffington Post

Get Smarter

Ways to Help

Article Contents

Historical analysis of the development of health care facilities in Kerala State, India

Email alerts

Affiliations

This Feature Is Available To Subscribers Only

Understanding caregiver burden and quality of life in Kerala’s primary palliative care program: a mixed methods study from caregivers and providers’ perspectives

The palliative care programme

Design and data collection techniques

Data collection from caregivers

Data collection from palliative care nurses

Data analysis

Subjectivities of the researchers

Ethical aspects

Validity of the EQ-5D-5L in our study sample

Findings from cross-sectional survey among caregivers

Themes from in depth interviews with caregivers

Caregiving became physically and psychologically demanding

Care team is only patient-focused, caregiver issues are not addressed

Themes from palliative care nurse interviews

Accurate exposition of the caregiver burden by palliative care nurses

I know caregivers like these…so desperate and hopeless… (PN5)

Disparate relationships between caregivers and health providers and the system

The first time they won’t say everything… after numerous visits, they tell us everything (PN3)

Systemic factors often hinder caregiver support

Limitations

Data availability

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Ethics approval and consent to participate

Consent for publication

Additional information

Electronic Supplementary Material

Additional File 1. Coding Schema for Coding Palliative Care Nurse Interviews.

About this article

Share this article

International Journal for Equity in Health

We use cookies to ensure best experience for you

By choosing I accept, or by continuing being on the website, you consent to our use of Cookies and Terms & Conditions .

All Comments

Find this Comment Offensive?

Join the community of 2M+ industry professionals