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Vinson Kurian

The morbidity rate in the State is twice the all-India average in the rural areas and over 50 per cent higher than the national average in the urban areas.

Thiruvananthapuram, July 11

ENCOMIUMS poured on the Kerala health model by the UNDP-commissioned Human Development Report (HDR) 2003 have failed to set off wild celebrations in the State which, coincidentally enough, is emerging out of an epidemic scare created by dengue fever, among other seasonal afflictions, long thought to have been wiped out.The HDR 2003 extols the achievements by the "State of Kerala, which boasts health indicators similar to those of the United States - despite a per capita income 99 per cent lower and annual spending on health of just $28 a person."

A UNDP spokesman was quoted in New Delhi as saying: "India comes in for particular mention for its solid performance on decentralisation in many parts of the country including parts of States of Kerala, Madhya Pradesh and West Bengal."

The report goes on to add: "The public health facilities in the four southern States of Andhra Pradesh, Karnataka, Kerala and Tamil Nadu function better because drugs are distributed through primary healthcare network giving patients a reason to visit the facilities." But, there are people who beg todiffer. For instance, Dr D. Narayana, a Fellow of the Centre for Development Studies (CDS), Thiruvananthapuram.

In a recent paper on `A Health Policy for Kerala', he sought to give credit where it is due by acknowledging the State's reputation the world over for achieving high levels of life expectancy and low mortality, in particular infant mortality, at fairly low levels of income. There are few regions in the world with such achievements, he adds.

However, along with such achievements, the State reports one of the highest levels of morbidity. The morbidity rate is twice the all-India average in the rural areas and over 50 per cent higher than the national average in the urban areas. Further, the rural morbidity rate is over 40 per cent higher than the urban morbidity rate; such a differential is not to be found in any of the major Indian States.

A look at morbidity by age and residence suggests that in Kerala, rural morbidity - both acute and chronic - is higher than urban morbidity for all age groups. Acute morbidity is significantly higher in Kerala among the young (0-14 years) and productive age groups (15-59 years); but among the elderly (60+ years), acute morbidity is lower than the all-India average. Unlike acute morbidity, chronic morbidity increases with age and is higher in both rural and urban Kerala compared to the other States. However, urban morbidity by age groups in Kerala is comparable to that in Punjab, but as regards rural morbidity, the figures for Kerala are higher.

A fairly high proportion of the ailments, in rural and urban Kerala, receive medical treatment. There is hardly any variation across the fractile groups in the proportion of ailing receiving treatment, except that in the rural areas, among the lower 60 per cent of the population, the proportion receiving treatment is slightly lower. This would imply that irrespective of the level of household income, individuals go to seek treatment.

The number of persons hospitalised (per 1,000 persons) in Kerala is also one of the highest among the Indian States. In rural areas, the rate of hospitalisation is over five times the Indian average. The closest next is Haryana, reporting a rate of hospitalisation - one-third the Kerala average. In urban Kerala, the rate of hospitalisation is over three times the Indian average; the closest next is Maharashtra, which reports 40 points less. In both rural and urban areas of Kerala, hospitalisation does not vary with income unlike the other States of India. Thus, with regard to both outpatient and inpatient treatment, the variation across income classes is very less.

As regards the source of outpatient treatment, about one-third of those seeking treatment get treated in Government facilities, and less than 10 per cent get free treatment. There is not much difference between the rural and urban areas in this regard. One of the striking aspects with regard to the proportion paying for treatment in the Government facilities is that it is one of the highest among the Indian States.

The proportion of persons seeking inpatient treatment at Government facilities is about 40 per cent of the total in both the rural and urban areas of the State. Of those seeking treatment in Government facilities, almost 90 per cent in the rural areas and 80 per cent in the urban areas receive free treatment. The proportion of poor (population below the poverty line) in 1993-94 in Kerala is estimated to be around 30 per cent in the rural areas and about 20 per cent in the urban areas. It may then be presumed that it is mostly the poor who avail of the free treatment in the Government facilities.

The average medical expenditure per episode of illness in rural Kerala is close to the all-India average. But the expenditure for lower income classes is significantly lower than that for the upper income classes. In urban Kerala, the average expenditure is about 60 per cent of the all-India average, and is the lowest among the Indian States. Further, the expenditure is lower for the lower income classes.

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