Status of Health and Health Infrastructure in the States of Gujarat and Kerala: A Comparative Analysis
Dr Hastimal Sagara1 Abstract
This research paper conducts a comparative analysis of the public health sectors in Gujarat and Kerala, two diverse states in India with distinct socio- economic characteristics and healthcare models. The study aims to assess and contrast their healthcare infrastructure, policies, challenges, and achievements, shedding light on the differing approaches to public health management. Utilizing data from government reports, statistical databases, scholarly articles, and relevant literature, this research evaluates key indicators such as healthcare accessibility, quality of services, healthcare expenditure, disease prevalence, and government interventions in both Gujarat and Kerala. These states represent unique paradigms in healthcare.
Gujarat, with its rapid economic growth, has made strides in healthcare infrastructure development and increased healthcare expenditure. In contrast, Kerala, despite having a relatively lower per capita income, boasts remarkable achievements in healthcare. Despite their divergent approaches, both states face common challenges ensuring equitable healthcare access and optimizing healthcare quality. This study contributes to the discourse on diverse healthcare approaches in India and offers insights for policymakers, healthcare practitioners, and stakeholders to enhance public health systems.
Keywords: Health, Human Development, Health Infrastructure, Gujarat, Kerala Introduction
The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The National Health Policy of India (2017) aims to inform, clarify, strengthen, and give priority to the role of the government in forming health systems in all of their aspects, including investments in health, healthcare service organization, disease prevention and promotion through cross-sectoral actions, technology access, human resource development, medical pluralism encouragement, knowledge building, improved financial protection strategies, regulation, and health assurance. However, India is among the least developed nations in Asia due to the poor health of its citizens. For instance, public health expenditure was only 2.9 per cent of India’s GDP for 2021-22 (Economic Survey of India, 2022-23: 148) and with 0.647 on HDI, it ranked 129th globally (HDR, 2019). Despite all economic strides in recent years, the life expectancy at birth (67.2 years) for 2022, under 5 child malnutrition rate (37.9 per cent), multidimensional poverty headcount (27.9 per cent) and infants lacking immunization for DTP and measles (8-10 per cent) show a dismal picture of India (Venkateswaran, 2022). Nevertheless, a select few states including Gujarat and Kerala outshine on several key parameters. Gujarat, on one hand has achieved notable industrial headways whereas Kerala has outperformed others on human development fronts.
1 Assistant Professor, Faculty of Commerce, GLS University, Ahmedabad
With this context in the background, this paper attempts to examine the progress of these two states, namely, Gujarat and Kerala in the health sector in recent times excluding the Covid-19 period. The arguments and discussion are entirely based on secondary data from reliable sources.
Review of Literature
Omar (2020) showed a direct, reciprocal relationship between economic growth and the human development indicators index in most Arab countries, meaning that increasing the index of human development indicators leads to an increase in the real gross national product, and an increase in the real gross national product results in an increase in the human development indicators index. Ramirez et al. (1997) demonstrated the existence of an iterative process between the ultimate objective — improvements in HD — and economic growth as a necessary but not sufficient condition for achieving such improvements. As argued in the HDRs (1993 and 1996), the link between growth and human development is not automatic. It means in order to improve human development, there has to be pro-poor government policies and programs, decent jobs, judicial use of natural resources among others. Public investments in social and physical infrastructure have a definite positive correlation with HDI advancement (HDR 2013: 35).
State Initiatives in Gujarat and Kerala
Ayushman Bharat, a flagship scheme of Government of India was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC) (Chandrashekar, et al., 2021). This program has been structured to accomplish the Sustainable Development Goals and their core tenet,
"leave no one behind." The goal of Ayushman Bharat is to transition the delivery of health services from a sectoral and segmented model to a comprehensive, need-based approach. At the primary, secondary, and tertiary levels, Ayushman Bharat seeks to implement ground-breaking interventions that comprehensively address health (covering prevention, promotion, and ambulatory care). Ayushman Bharat uses a continuum of care strategy, with two interconnected components: the Pradhan Mantri Jan Arogya Yojana (PM-JAY) and Health and Wellness Centers (HWCs). The Indian government announced in February 2018 that it would be converting Sub Centers and PHCs into 1,50,000 Health and Wellness Centers (HWCs). With the provision of Comprehensive Primary Health Care (CPHC), which brings healthcare closer to patients' homes and addresses non-communicable diseases as well as mother and child health, these centers will also provide free basic medications and diagnostic services. PM-JAY, the second part of Ayushman Bharat, intends to cover secondary and tertiary care hospitalization costs for around 10.74 crore poor and vulnerable families (about 50 crore beneficiaries) with health insurance coverage of Rs. 5 lakhs per family annually. The program has no upper limit on the size of the family. Prior to being renamed PM-JAY, this program was known as the National Health Protection Scheme (NHPS).
The enormous costs associated with household health care spending force many people into poverty. The population classified as Below Poverty Line (BPL) is more susceptible to the grave health concerns. To address this key vulnerability faced by the BPL population in the Gujarat, the State Government has launched a medical care scheme called Mukhyamantri Amrutum (MA) Yojana (Bhatt & Rana (2019). Through
the use of an empanel network of healthcare providers, the program seeks to increase BPL families' access to high-quality medical and surgical care for the treatment of recognized ailments, which may involve hospitalization, surgeries, and therapies.
Through an integrated panel network of hospitals, Mukhyamantri Amrutum Yojana offers BPL families high-quality medical and surgical care for catastrophic illnesses that need hospitalization, surgeries, and therapies. The State is preparing to handle second generation health care concerns despite the progress made toward universal healthcare and the excellent Human Development Indicators that have been attained.
Government healthcare systems are under considerably more pressure than they can handle. Mission AARDRAM aims at creating "People Friendly" Health Delivery System in the state (Sreekumar & Sundari 2023). The approach will be need based and aims at treating every patient with ‘dignity'. As a first level health delivery point, it envisions converting all PHCs into Family Health Centers using cutting edge investigation and intervention techniques. Ensuring PHCs provide high-quality care is the mission's goal. Every hospital with a lot of foot traffic will change to an outpatient facility that welcomes patients. A web-based appointment scheduling system, virtual lines, patient reception at registration centers, wi-fi-equipped waiting areas, and other services are among the offerings.
Data interpretation and analyses
Public expenditure on health has increased by almost three times in India between 2009-10 and 2017-18 (Table 1). Even the per capita income also increased from Rs.
621 in 2009-10 to Rs. 1657 in 2017-18. Government expenditure on central government health schemes has slightly more than doubled in the country. However, public expenditure as a percentage of GDP has increased only marginally during the same period.
Table 1: Trends in Public Expenditure on Health in India Year Public
Expenditure on Health (Rs. Crore)
Per capita Public
Expenditure on Health (Rs.)
Public
Expenditure on Health as per cent of GDP (%)
Expenditure on Central
Government Health Schemes (Rs. Crore)
2009-10 72536 621 1.12 NA
2010-11 83101 701 1.07 1296
2011-12 96221 802 1.1 1562
2012-13 108236 890 1.09 1691
2013-14 112270 913 1.0 1839
2014-15 121600.23 973 0.98 1799
2015-16 140054.55 1112 1.02 1977
2016-17 178875.63 1397 1.17 2238
2017-18 213719.58 1657 1.28 2843
Source: National Health Profile 2019, 14th Issue, p196 and 210
Table 2: Scheme wise Actual Expenditure on NRHM/NHM for various Annual Plans (in Rs. Crores)
Name of Scheme 2019-20
(BE)
NRHM-RCH Flexible Pool 16885.73
National Urban Health Mission-Flexible Pool 950.00
Flexible Pool for Communicable Diseases 1928.00
Flexible Pool for Non-Communicable Diseases, injury & Trauma 717.00
Infrastructure Maintenance 6043.41
Strengthening of State Drug Regulatory System 206.00 Prime Minister's Development Plan for J & K 63.36 Strengthening of National Programme Management of the NHM 115.00
Forward Linkages to NRHM 0
Pilot Projects 25.00
Human Resources for Health 0
Human Resources for Health & Medical Education* 4250.00
Tertiary Care* 550.00
Rashtriya Swasthya Bima Yojana Ayushman Bharat - Pradhan Mantri
Jan Arogya Yojana 6556.00
Janssnkhya Sthirtha Kosh (JSK) 11.50
Grand Total 38301.00
Source: National Health Profile 2019, 14th Issue, p199
* Schemes transferred to NHM
Policies for universal public health and education can be developed and put into action without compromising quality in order to increase coverage (HDR 2013: 35). Kannan (2016) offers a list of health indicators in which Kerala had taken the lead several decades after its foundation in 1956, rather than before to independence. Higher government spending on related infrastructure against the compelling backdrop of welfare policies pursued since the middle of the 19th century, as well as the enormous remittances from non-resident Keralites from other parts of India and abroad, particularly from the Gulf countries since the mid-1970s, were the major drivers of Kerala's social development (HDR, Kerala: 2005:28). The Kerala model is nearly ideal due to the accessibility of basic healthcare facilities, the high level of awareness and acceptability among the populace, and their availability. Right now, the staff involved must maintain these with the active participation and cooperation of the populace.
Although this task presents a difficulty, it is achievable with the effective involvement of the business sector, which plays a large role in the health sector, and with the influence of voluntary organizations. Prioritizing human development can help underprivileged and marginalized populations receive high-quality services (HDR:
2016: 186). In the early years of its establishment, the state of Gujarat made significant strides, especially in the industrial sector (Bhatt and Chawds: 1965 & (Trivedi et al., 2021). The state saw the growth of significant sectors such as diamond, energy, chemicals, textile, natural gas and oil, as well as gems and jewellery (Menon, 2008).
Kerala state leads Gujarat on several important human development variables including literacy rate, sex ratio, life expectancy at birth and maternal mortality rate (Table 3). The extent of population living below poverty line in Kerala is less than half of the Western state. However, their per capita Net Domestic Product at current prices
(base year 2011-12) was observed almost the same for 2015-16. In addition to this, both Kerala and Gujarat stood better on several parameters compared to their all-India values.
Table 3: Status of Health in Kerala and Gujarat States
Particulars Gujarat Kerala All
India
Literacy Rate (2011) (%) 78 94 73
Sex Ratio (per 1000 population) 919 1084 943
Population Density 308 860 382
Decadal Growth of Population 19.3 4.9 17.7
Birth Rate (2017) 19.9 14.2 20.2
Death Rate (2016-20) 6.4 7.4 7.1
Life Expectancy at Birth (2017) 30 10 33
Maternal Mortality Rate (2014-16) 91 46 130
Total Fertility Rate (2016) 2.2 1.8 2.3
Population below Poverty Line (%) (Tendulkar
Methodology) (2011-12) 16.6 7.1 21.9
Per Capita Net Domestic Product at Current Prices (base year 2011-12), 2015-16 (Rs.)
141504 147190 94130 Source: National Health Profile 2019, 14th Issue
Table 4: Important Health Information about Gujarat and Kerala Name of
State No. of Medical Colleges
Hospital
Capacity No. of Beds in attached Hospitals
No. of Sub Centres
No. of
PHCs No. of CHCs
Gujarat 29 4300 19703 9153 1474 363
Kerala 34 3450 22307 5380 849 227
Source: Drawn on data obtained from National Health Profile 2019, 14th Issue, P289 Kerala's achievements in the health sector have been often cited as role models for the country. Some of its health indices match with that of the developed countries. The State has a better health standard with low birth and death rate, rapidly declining growth rate, high level of acceptance of family planning methods and increased life expectancy. At every stage of health, the government of Kerala offers high-quality services through its patient-friendly hospital mission, AARDRAM. In order to provide efficient family-centered health services, it is intended to gradually transform PHCs into family health centers. The number of medical colleges in Kerala and Gujarat stood at 34 and 29 respectively. However, the hospital capacity was more in Gujarat (4300) than in Kerala (3450) (Table 4). No. of beds in attached hospitals were 19703 in Gujarat and 22307 in Kerala. The number of sub-centres, PHCs and CHCs was higher in Gujarat compared to Kerala. In terms of public expenditure on medical & public health and family welfare, Gujarat spent more than Kerala, however, their total expenditure on health stood almost six per cent of their total state expenditure (Table 5). But per capita health expenditure was marginally more in Kerala. Interestingly, none of the states spent over one per cent of their state GDP for 2015-16. From the Table 6, it is evident that average medical expenses during stay at hospital and average of other medical expenses on account of hospitalization in rural areas was significantly
greater in Gujarat compared to Kerala. But, for the urban areas, the expenses were almost same in both the categories. In fact, Gujarat was spending more than even at the all India level.
It has been observed that the non-communicable diseases dominate over communicable in the total disease burden of the country. According to a recent report by the India Council of Medical Research (ICMR) titled "India: Health of the Nation's States: The India State-Level Disease Burden Initiative" (2017), between 1990 and 2016, the percentage of the population suffering from communicable, maternal, newborn, and nutritional diseases decreased from 61 to 33 percent using Disability- adjusted life years (DALYs). In the same period, disease burden from non- communicable diseases increased from 30 per cent to 55 per cent.
Table 5: Public Expenditure on Health by Gujarat and Kerala States, 2015-16 (Rs. Crore) Name
of State
Medica l &
Public Health
Family Welfar e
Other
s Tota
l Health Expenditur e as a % of Total State Expenditur e
Per Capita Health Expenditur e (Rs)
Health Expenditur e as a % of GSDP Gujara
t
6270 855 74 7199 5.86% 1189 0.72%
Kerala 4336 436 0 4772 5.85% 1463 0.93%
Source: National Health Profile 2019, 14th Issue, p200 & 201
Table 6: Average Medical Expenditure and Non-Medical Expenditure on account of hospitalization per hospitalization case in Gujarat and Kerala States and in India
Name of State
Average Medical Expenses during Stay at Hospital
Average of other Medical Expenses on Account of Hospitalization
Total Expenditure
Rural Urban Rural Urban Rural Urban
Gujarat 29954 23165 2550 3237 32503 26401
Kerala 14091 22190 2027 2012 16118 24202
India 14935 24436 2021 2019 16956 26455
Source: National Health Profile 2019, 14th Issue, P204 and 207
"The neonatal mortality rate for Kerala and Gujarat was recorded as 6 and 21 and the under-5 mortality rate was observed as 11 and 33 respectively for the year 2016," states the Health Index (2019:54 & 55). While the Western industrialized state managed to reach 92% immunization rates in 2017–18, the Southern state was able to reach the goal of 100% immunization of infants between the ages of 9 and 11 months. It is critical for pregnant mothers to deliver in health facilities. Hygienic circumstances and life- saving equipment lower the risk of complications and mortality for moms and their babies. Home delivery is a powerful predictor of baby and mother mortality in poor nations. The proportion of births that take place in either public or private healthcare facilities indicates how easily people can get essential medical care. In Gujarat and Kerala, respectively, there were 91.6% and 90.9% institutional deliveries, according to the Health Index (2019: 58). Compared to the All India level, which was recorded at 78.9%, it is significantly superior. From Table 7, it can be stated that households in
Kerala had greater access to safe drinking water facilities compared to Gujarat as well as all India level. Around 95.2 per cent of people had access to latrine facilities within their own premises compared to only 57.3 per cent in Gujarat and 46.9 per cent at all India level in 2015-16. Both states had greater number of institutional deliveries compared to the national average for the same year. In Gujarat, only 63.4 per cent of mothers received post-natal care from trained health personnel within 2-days of delivery but this number was 88.7 per cent in Kerala. The national average stood at 62.4 per cent for 2015-16. Only half of all children aged 12 to 23 months had received all recommended vaccinations, which included three doses of each of the BCG, measles, and DTP vaccines. In Kerala, however, this rate was 82.1%, significantly higher than the 62 percent national average. Even when it came to children between the ages of 12 and 23 months who had gotten three doses of the Hepatitis B vaccine, Kerala (82.4%) performed better than Gujarat (38.6%) and the national average (62.8%). Nonetheless, only one-third of the children who were between the ages of 9 and 59 months and who received a vitamin A dose within the previous six months were found to be in Gujarat and Kerala. According to reports, the percentage of Gujarat and Kerala with unmet family planning needs was 17% and 13.7%, respectively.
Table 7: Basic Health and related Facilities in Kerala and Gujarat States (NFHS*
2015-16)
Particulars Gujarat Kerala All
India Distribution of Households having Safe Drinking Water
Facilities (2011 Census) (untreated water for drinking) (%)
29.2 6 11.6
Distribution of Households with Latrine Facility available within Premises (%)
57.3 95.2 46.9
Institutional Deliveries (%) 88.7 90.9 78.9
Mothers who received Post-natal Care from Trained
Health Personnel within 2-days of Delivery (%) 63.4 88.7 62.4 Children Age 12-23 months Fully Immunized (BCG,
Measles and 3 Doses each of Polio and DTP (%) 50.4 82.1 62.0 Children age 12-23 months who have received 3 Doses of
Hepatitis B Vaccine (%)
38.6 82.4 62.8 Children age 9-59 months who received a vitamin A dose
in last 6-months (%) 71.2 74.4 60.2
Unmet Needs for Family Planning (%) 17 13.7 12.9
Source: National Health Profile 2019, 14th Issue, p184
*National Family Health Survey
Lack of manpower in public health facilities is one of main reasons of healthcare underutilization. The vacancy status of health professionals in relation to sanctioned positions shows how states address supply-side resources in relation to need. In public health institutions, a shortage of personnel is one of the major "The vacancies for staff nurse at the CHCs as well as PHCs in Gujarat and Kerala were reported as 23.7 per cent and 3.7 per cent respectively for 2017-18," according to the Health Index (2019:67). In addition, it was disclosed that for the 2017–18 fiscal year, the proportion of available posts for Medical Officers at the PHCs in Kerala and Gujarat, respectively, was 2.4% and 30.2%. In district level hospitals, there were 21% and 13.5% of available
seats for specialist doctors in Gujarat and Kerala, respectively, in 2017–18. In 2017, the number of pharmacists and AYUSH doctors practicing Ayurveda in Gujarat and Kerala was nearly similar, but the number of nurses in Kerala was significantly higher than in Gujarat (Table 8). Furthermore, Kerala offered a wider range of medical specialties than Gujarat, including naturopathy and siddha. There was never enough medical personnel in government hospitals. However, as of March 31, 2018, Kerala had 1169 and 40 physicians, while the PHCs and CHCs had 1321 and 118 specialists, respectively (Table 9). It's interesting to note that Kerala had significantly more female health aides than Gujarat did, but both states had about equal numbers of healthcare personnel. Figure 1 shows that between 2010 and 2018, Gujarat had a higher documented number of qualified doctors than Kerala.
Table 8: AYUSH Doctors, Nurses and Pharmacists in Gujarat and Kerala (2017) State Ayurve
da Una
ni Sidd
ha Naturopa
thy Homeopa
thy Tota
l Nurses Pharmaci sts Gujar
at
26716 327 0 0 22930 499
73
1,60,19 2
66,237 Keral
a 25142 118 2275 224 13847 4160
6 3,00,9
88 64,223 Source: National Health Profile 2019, 14th Issue, P252, 230
Table 9: Health Human Resource (Government) in Rural Gujarat and Kerala as on 31.03.2018
Name of State
No. of Doctors at PHC*s
Total Specialists at CHC**s
Health Assistants Health Workers
Male Female Male Female
Gujarat 1321 118 826 851 7755 8340
Kerala 1169 40 2197 13 3401 7950
Source: National Health Profile 2019, 14th Issue, P255
*Primary Health Centre, ** Community Health Centre
Figure 1: Number of Qualified Doctors in Gujarat and Kerala
Source: Drawn on data obtained from National Health Profile 2019, 14th Issue
47231 49026 51223 53376 55564 57991 60446 63336 66944
40007 42015 45466 46948 49448 52800 56155 57850 59353
2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8
N u m b e r o f Q u l a f i e d D o c t o r s i n G u j a r a t & K e r a l a Gujarat Kerala
According to Health Index (2019), Kerala is the state with the best healthcare system in the nation, followed by Tamil Nadu, Punjab, and Gujarat. In order to stop the infection from spreading further, TB must be successfully treated. It serves as a crucial performance indicator for the National TB Program in India. The Indian government set a goal of treating tuberculosis patients with a success rate of over 85%. Kerala (83%), Gujarat (73%), and other states were unable to reach the target; nonetheless, Kerala missed by a little 2%, while Gujarat's deviation from the national target was 12%. Table 10 shows that Gujarat had much more cases of measles, swine flu, malaria, chikungunya, and acute diarrhoea than Kerala did. On the other hand, Kerala reported more instances of TB, pneumonia, and typhoid than Gujarat. When comparing Gujarat to Kerala, the percentage of anaemic women aged 15-49 years and children aged 6-59 months was found to be nearly twice as high.
Table 10: Prevalence of Select Diseases in Gujarat and Kerala (No. of Cases) (2018) Stat
e
M* C** D+ AD ++
T@ AR I
M
# H
##
P^ S
^
^ T B (
% )
Swi ne Flu
U
~ (
% )
A
~
~ (%
) A W
” (%
) Guj
arat 213 27 106
01 75
79 7291 32 563
90 65 6 8
6 9
73 25 51
59 14 4 7
3 216
4 17 62 .6 54
.9 Ker
ala 90
8 77 40
83 550
659 223
4 78
20 3 0 6
55 83 64
07 49 8 3 87
9 13
.7 35 .6 34
.2 Source: Drawn on data obtained from National Health Profile 2019, 14th Issue
*Malaria, ** Chikanguniya, +Dengue, ++Acute Diarrhoea, @ Typhoid, Acute Respiratory Infection, # Measles, ## Hepatitis, ^Pneumonia, ^^Syphilis, TB Treament Success, ~Unmet Family Planning Needs, ~~ Anaemic Children age 6-59 months, “Anaemic Women age 15-49 Years
With its exceptional performance in health and education indicators—which include the lowest rates of poverty, infant, maternal, and dropout rates, as well as the highest rates of literacy, life expectancy, sex ratio, and female enrolment in higher education and schooling years—Kerala happened to be the real "model" for all states and demonstrated its humanistic face of development (Salim, 2016).
Concluding Observations
Bhagwati and Panagariya contended that Gujarat has surpassed Kerala in terms of growth as well as the development of the social sector (Bhagwati and Panagariya, 2012:
85–98). Many, however, hold opposing opinions and dissent. Even with Gujarat's impressive economic development, more people in this state are susceptible to bacterial and viral diseases than in Kerala. Developing nations might take a cue from Kerala's model of high social development by implementing appropriate public policies (HDR, Kerala: 2005). The HDR (1995) made the compelling case that
development is threatened, if not outright engendered. Kerala's health metrics seem more inclusive than Gujarat's due to the latter's later investments in public health infrastructure, which ultimately made Kerala the best-performing state in India.
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