A Sustainable Healthcare Architecture for Kerala

CII Virtual Kerala Health Tourism Summit 2020

As prepared for delivery

This once-in a generation crisis has brought opportunities and lessons across a wide array of topics. Right at the top of this list is healthcare.  

Government hospitals in both urban and rural areas, and primary health centres (PHCs) and community health centres (CHCs) in rural areas, are leading India’s efforts to manage the epidemic. But apart from improving individual healthcare outcomes, there is also a compelling need to construct community healthcare surveillance systems as well as digital tracking systems to keep people safe.

I will share with you some perspectives based on a global vantage point as well as a proud Keralite who believes in the potential of the state.

Healthcare landscape in Kerala

The healthcare landscape in Kerala is ahead in many parameters when compared to other states.  In fact, the ‘Kerala Model for Development’ is often referred to as an example for other countries to follow. The State has received global attention and admiration for its model of development with its prime focus on education, healthcare, environment and cleanliness. 

Much before Kerala became a separate state in 1956, the region had seen several pathbreaking public health interventions. In 1879, the erstwhile rulers of Travancore made vaccination compulsory for public servants, prisoners and students. In 1928, a parasite survey, done in association with the Rockefeller Foundation, led to the control of hookworm and filariasis. This community health legacy got a further boost as the state’s focus on literacy and women’s education helped it attain near 100% vaccination levels and develop a culture of personal hygiene.
Today, the State ranks first among all Indian States in the Sustainable Development Index constructed by NITI Aayog, and which aligns with the United Nation’s Sustainable Development Goals.

The health gains made in Kerala can be attributed to several factors, including strong emphasis from the state government on public health and primary health care (PHC), decentralized governance, financial planning, girls’ education, community participation and a willingness to improve systems in response to identified gaps

In addition to the social development efforts, this progress has been achieved because of a strong primary healthcare infrastructure. Though Kerala has only been investing close to 5% of its total state plan outlay on healthcare — which is also roughly the national average spending in the sector and less than several states — its focus on healthcare at the level of PHCs and Community Health Centres is noteworthy.

Kerala will soon house one of the first medical device parks in the country, focusing on the high-risk medical device sector to provide a full range of services for the medical devices industry — like R&D support, testing, and evaluation.

Kerala’s health policy design, in the last decade has been informed by lessons derived from critical research as well as expat movement. An excellent example is Mission Aardram, which was launched in 2017 with a view to lowering out-of-pocket expenditure on healthcare, that stemmed from an expanding private sector and a growing demand for higher quality care. Interventions under Mission Aardram have been designed to encourage the utilisation of public healthcare services by enhancing the care-seeking experience at these facilities. PHCs now upgraded to Family Health Centres boast of longer working hours, web-based appointment systems, virtual queues and are equipped with better staff and capabilities.

The proportion of the population made up of adults over the age of 60 is expected to double by 2050; Kerala is already developing geriatric care wards and geriatric friendly facilities in preparation.

The State has pioneered Universal Health Care Services in the country and its palliative care services has been largely applauded.  Observing its popularity and the growing need for palliative care, the state created a Palliative Care Policy in 2008 and, five years later, required all local governments to implement palliative care. In 2013, the national government used Kerala’s policy as the basis for its National Palliative Care Strategy.

Kerala thus presents a model of health governance that is at par with several developed countries.  

Challenges in Kerala’s Public Healthcare System

Despite these health improvements, owing to the slower than expected economic growth, the burden of an aging society and the expense of technology advancement, Kerala’s health care system is facing new challenges.

The epidemiological transition towards chronic diseases, erosion of public health funding, and the continued presence of private health care at much higher cost expose a few of the challenges faced by existing systems. Lack of regulations over the private sector does not guarantee the quality of care.

Although mortality is low, the morbidity levels in urban and rural Kerala is high in Kerala compared to other Indian States.  Thus, the paradox is that on the one side Kerala stands as the State with all indicators of better health care development, and on the other it exceeds all other Indian States in terms of morbidity especially chronic illness.

Kerala’s tremendous efforts at initially controlling the upsurge of the COVID-19 virus, won wide appreciation across India and beyond, as the State successfully managed to delay the disease peak through its efficient containment measures.  But with overall activity and travel resuming, current levels of management of the crisis appear to be facing pressure.

The State must consistently work towards making its people centric health system accessible, affordable, and most of all, sustainable.

Recommendations to transform Kerala’s Healthcare Architecture

An inflection point for Kerala is potentially here, and the State has the opportunity to build on its existing foundation.  Let me discuss five key themes which should inform the direction of Kerala journey to make its healthcare system more robust and relevant.

First, urgent investment to set up a data-driven national health parameter and epidemic spread monitoring system which can be used for predictive analytics and preventive interventions.

Technological enablement, digitization, and automation are affecting industries today in profound ways and Public Healthcare delivery is no exception.

The pandemic has particularly positiioned telehealth services for mainstream adoption. A recent report  by healthtech startup Practo revealed a 500 percent growth in online healthcare consultations, and almost half of these users were non-metro residents.

Second, newer technologies such as artificial intelligence (AI), robotics, precision medicine, 3-D printing, augmented reality/virtual reality and genomics can now be integrated into health care delivery.  Helping hospitals move from reactive maintenance to preventive or condition-based maintenance with smart equipment can make the existing systems more cost-effective.

Third, building a future ready health care infrastructure with a focus on infrastructure design, including the use of sustainable technologies.  Since hospitals are energy-intensive buildings, optimizing energy usage and ensuring critical systems function at all times is important. Singapore is a notable example of how intelligent technology infrastructure is enabling health services to grow and meet patient demand with its adoption of a  Data Center Infrastructure Management solution.

The Rebuild Kerala Mission offers a great opportunity to leapfrog to next-generation public infrastructure, which is interactive, connected, yet affordable, including in healthcare.

Fourth, continued investment in human care skills, for which Kerala’s nurses and care givers have earned a legendary reputation and brand equity in this profession.  This is an opportunity for Kerala. Establishing world class training institutions with state-of-the-art facilities, organisational back-up and international accreditation are some important steps to focus on.  Healthcare is more than just technology, and Kerala is poised to build on this sentiment.

And last, combining legacy strengths with new tools, finding new markets – Kerala is probably the only state in India where Ayurveda is used as a mainstream medicine.  The State is home to many Ayurvedic medical colleges and hospitals.  However, the main challenges inhibiting growth are standardization, availability of raw materials and use of technology. Traditional players like Kottakkal and new age players like BIPHA have larger roles to play in this area.  Further, life science is an area for collaboration of Ayurveda with Allopathy.

Healthcare tourism is a key segment in the tourism sector in Kerala with visitors from other countries for healthcare treatments.  Several factors such the State’s location, lower cost of treatments, facilities at par with international standards and English-speaking medical staff have made Kerala one of the most popular medical tourism destinations in India.

To continue building on these natural advantages, a healthcare tourism promotion PPP initiative could be woven into Kerala’s tourism promotion efforts particularly since the state’s scenic locales are one the best in the world for practicing alternative therapies.

The relatively reduced environmental footprint of such treatments in comparison to allopathic treatments and also the positive socio-economic footprint of sourcing all things locally can positively impact the entire supply chain. 

Fortunately, Kerala’s traditional healthcare practices are now receiving a level of international acceptance with “age care” emerging as an area of concern and where the world is discovering the value of Ayurveda. What is required is a convergence of traditional strengths in nursing, Ayurveda and physiotherapy to evolve an entirely new and holistic approach to healthcare.

Sustainability in the healthcare system covers several dimensions, which apart from quality of services, affordability and impact on environment must also consider elements related to employees, fair wages and operating environment.

Focused investment, skilling and continued repatriations from Kerala’s expat diaspora can also lead to the creation of substantial employment opportunities. What information technology is to India as a whole, healthcare must be to Kerala. In fact, healthcare has now emerged as the largest industry in the world, pushing tourism to the second place.

The world also faces scarcity across a range of healthcare professionals.  With a focused set of policies backed by concerted action, Kerala can emerge as one of the world’s most prominent destinations of high-quality and sustainable healthcare delivery.

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