Emphasis on health reform

India is a middle-income South Asian country with a population of over 1.2 billion.
India was formed in 1947, and was divided into states starting in 1956. At present, there are
29 states and 7 union territories. In India, healthcare is managed at the state-level. Over the
last six decades, the Indian states have had varying levels of success in health outcomes.
Notably, Kerala, a southwestern state of 33.3 million people has consistently been a
prominent outlier with better health outcomes in a number of areas compared to most states
in India.
In 2011, Kerala attained the highest Human Development Index of all Indian states based on
its performance in key measures: 

 Lower infant mortality rate of 12 per 1,000 live births in Kerala vs. 40 per 1,000 live
births in India),
 Lower maternal mortality ratio of 66 per 100,000 live births in Kerala vs. 178 per
100,000 live births in India,
 Higher literacy among both males at 96% in Kerala vs. 82% in India and females with
92% in Kerala vs. 65% in India.

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), health
infrastructure, decentralized governance, financial planning, girls’ education, community
participation and a willingness to improve systems in response to identified gaps.

When it established statehood, the area that made up Kerala already had a long history of
health-focused policies; for example, vaccinations were made mandatory for certain segments
of the community—including public workers and students—as early as 1879 [6, 12]."

Once it achieved statehood, Kerala invested in infrastructure to create a multilayered health

system designed to provide first-contact access for basic services at the community level and
expanded integrated primary health care coverage to achieve access to a range of preventive
and curative services [13].

Additionally, Kerala rapidly expanded the number of medical facilities, hospital beds, and
doctors. From 1960 to 2010, the number of doctors increased from 1200 to 36,000, and the
number of primary health care facilities from increased from 369 to 1356 between 1960 and
2004. This increase in the number of PHC centers and doctors allowed for the provision of
the right care in the right place, reduced the costs of patient care, and lowered the burden on
secondary and tertiary care facilities. Additional public health and social development
initiatives that began soon after Kerala was made a state—such as a push for safe drinking
water in the state’s capital, Trivandrum, and primary education for men and women—aided
in creating the environment for a strong and effective primary care system.

Health successes in Kerala

Kerala provides an example of an approach that can provide vastly improved health at a rapid
rate. Overall, Kerala has maintained low infant and maternal mortality rates, and higher
literacy rates, when compared to the national average. Kerala has also continued to innovate
to meet the needs of more vulnerable populations including establishing a Weekly Iron and
Folic acid Supplementation (WIFS) Program and Adolescent Friendly Health Clinics
(AFHCs) to benefit adolescent health.

Kerala is also forward thinking in its health policy planning. The proportion of the population
made up of adults over the age of 60 is expected to double by 2050, and Kerala is already
developing geriatric care wards and geriatric friendly facilities in preparation. The state is
also a leader in palliative care with its own Pain and Palliative Care policy (2008), which
focuses on community-based home care initiatives. Kerala’s palliative care network contains
over 60 units and serves more than 12 million individuals. In addition, Kerala is investing in
health information systems to compile household level data designed to help with population
health management and surveillance of communicable diseases.

Outbreak of Nipah virus encephalitis in the Kerala state of India

On 19 May 2018, a Nipah virus disease (NiV) outbreak was reported from Kozhikode district
of Kerala, India. This is the first NiV outbreak in South India. There have been 17 deaths and
18 confirmed cases as of 1 June 2018. The two affected districts are Kozhikode and
Mallapuram. A multi-disciplinary team led by the Indian Government’s National Centre for
Disease Control (NCDC) is in Kerala in response to the outbreak. WHO is providing
technical support to the Government of India as needed. WHO does not recommend the
application of any travel or trade restrictions or entry screening related to the NiV outbreak.

The Nipah outbreak reported in Kozhikode and Malappuram districts of Kerala in May 2018
was the third of Nipah Virus Outbreaks in India, the earlier being in 2001 and 2007, both in
West Bengal. A total of 23 cases were identified, including the index case with 18 laboratory-
confirmed cases. The outbreak was managed by the state government and central government
agencies and has been acknowledged as a success story.

Recognizing the importance of documenting and sharing the Kerala experience, the Kerala
government requested WHO to conduct an external review and documentation of the NVD
response. SEARO HIM team led a joint RO & WCO team to review the programmatic
response to the NVD outbreak and document successes and challenges faced during the
response to enable better understanding with respect to future readiness for high threat
pathogens

The public health response and its performance were reviewed along with three domains of
inquiry:

 Coordination structure and mechanisms that were in place and that was established
anew in response to the outbreak.
 Performance of surveillance and interventions including non-technical support
functions
 Assessment of reduction of transmission and impact of interventions.

 
Kerala is known for achieving impressive health outcomes at modest incomes compared to
the rest of the states in India. Accordingly, Kerala relied on the strengths of its health system
to contain the outbreak. The leadership and commitment of all levels of Indian health
authorities were seen (state authorities, MoHFW, NCDC, EMR, ICMR (NIE, NIV)) and
private sector (inside and outside Kerala).

However, the outbreak response was characterized by a large degree of improvisation at the
early stage of response. Technical shortfalls were compounded by a relatively inexperienced
cadre of surveillance personnel requiring further training in field epidemiology and data
analysis. Despite continuing and close collaboration between India and WHO, data sharing
on the extent of the outbreak response and its efficiencies was sparse. The opportunity was
also missed to prospectively and timely collect accurate data to further understand the
epidemiology, clinical and virologic characteristics of NVD and make a timely introduction
of emergency-driven clinical trials of various curative treatment options

The outbreak of Nipah demonstrated that Kerala and the rest of the country are exposed to the
high risk of another outbreak making preparedness vital. The Kerala NVD outbreak
underscored the need to encourage annual preparative work before the traditional Nipah
seasons.

On an urgent basis, awareness of signs and symptoms of Nipah must be raised among the
community and healthcare professionals.

Simultaneously, reminding of case definitions, strengthening infection control practices

including ensuring prepositioning of medical supplies and adequate stocks of personal
protection equipment would be important steps in managing any similar outbreak in the
future. 

Familiarising hospital staff with standard operating procedures and protocols for incident
management, through tabletop exercises will ensure readiness; and maintaining universal
precautions and hospital IPC practices regardless of the type of patient handled would be the
need of the hour.

In addition, moving towards electronic health reporting and health information management
systems would be critical for managing and responding to acute events such as these.