Kerala has achieved remarkable progress in human development, as reflected in the high levels of education and health of its population. The level of literacy among Keralites is far higher than the national average. Crude death rate, infant mortality rate, and life expectancy at birth in Kerala are comparable even to those in the developed countries. However, the question whether low mortality rates signal better health has generated heated debate in the light of the sequence of changes in the health profile, termed as "health transition, which the developed countries have experienced. Apparently, Kerala also has been passing through an advanced phase of health transition, despite remaining economically backward". In this paper, we shall attempt a survey of the sources and the stages of Kerala’s health transition and discuss its policy implications.

Health is a multi-dimensional and multi-causal variable. It is defined as a "state of complete physical, mental, and social well being" (World Health Organisation). Being a holistic concept, it is beyond measurability in terms of mortality and morbidity prevalence rates (Basch; 1978, pp. 204-206). The health status of a community depends on its socio-economic, environmental, biological, and political factors.

Health transition is a complex process comprising demographic (mortality), epidemiological, and health care transitions. It is manifested in rising life expectancy at birth due to changes in the fertility, mortality, and morbidity profile of a population. Demographic (mortality) transition brings down birth and death rates and changes the age structure; epidemiological transition reflects changes in the causes of death, from infectious (pandemic) diseases to non-communicable (degenerative, human-made) diseases (Caldwell: 1990; Mc Namera; 1982, p.147). However, the causal mechanisms of demographic changes are unclear and distinct variations in patterns, places, determinants, and consequence of population changes are observed in the case of epidemiological transition (Omran: 1982, p.172). Three fundamental changes in the configuration of a population’s health profile take place during epidemiological transition: (i) mortality decline due to infectious diseases, injuries, and mental illness; (ii) shift of the burden of death and diseases from the younger to the older groups; and (iii) change in health profile from one dominated by death to one dominated by morbidity. Epidemiological transition implies change in the morbidity profile from acute, infectious, and parasitic diseases (eg plague, smallpox, and cholera) to non-communicable, degenerative, and chronic diseases (eg cardiovascular diseases, cancer, diabetes, and neoplasms) (Mercer: 1990, p.262; Albala, 1995; Prata: 1992; Crews: 1987; Reis: 1978). A third component of health transition is health care transition brought about through changes in the patterns of the organised social response to health condition.

Kerala has apparently entered the third or final phase of the demographic transition characterised by low death rate and declining birth rate leading to a slow down in the growth rate of population. Thus, as of 1991, the birth rate in Kerala was estimated as a little over 18 (per 1000 population), as against 30 for all-India and an average of 28 for low-income and 24 for middle-income countries. The crude death rate of Kerala in 1991 was 6 (per 1000 population), compared to the national average of 11, and an average of 10 for low-income and 8 for middle-income countries. It is significant to note that the crude birth rates and death rates in a ‘low-income country’ like China and a ‘middle-income country’ like the Philippines exceeded the corresponding rates in the ‘least developed’ region of Kerala. Kerala’s demographic experience has attracted wide research attention (eg (i) Zachariah, 1983; (ii) Zachariah & Irudaya Rajan, 1994; (iii) Bhat and Irudaya Rajan, 1990; (iv) Ratcliffe, 1984; (v) Zachariah & Irudaya Rajan, 1997).

The period during 1971-’81 witnessed the most rapid growth of medical care institutions, especially government hospitals and dispensaries under the Allopathic system; the total number of public sector medical care institutions registered steady increase at the rate of 17.5 per cent during 1955-1960, 58.2 per cent during the 1960s, and 74.3 per cent during the 1970s. The number of medical care institutions and the populationtion coverage of health care facility in the major States is given in Table 4.10.

One important feature emerging from table Table 4.10 is that of the total number of hospitals in India, about two-thirds are in the private sector. The share of private hospitals in Kerala works out to be about 93 per cent. Of the total number of private hospitals among the States, one-fifth is located in Kerala.

The population coverage of health care facilities, ie the ratio of population to total number of medical care institutions, is far better for Kerala than in all the other States. That is, the number of persons per hospital works out to be 14,264 here as compared to the all-States average of 61,810. Except in Andhra Pradesh, Assam, Gujarat, and Punjab the ratio exceeded one lakh people per hospital. The high growth rate of medical care institutions in Kerala has naturally claimed an increasing share of the State Government’s budget. The total expenditure of this sector rose by around three-and half times between 1969 and 1971 and by over four times during the 1970s. The trends in the State government expenditure on medical and public health in Kerala in recent periods may be observed in Table 4.11

Health transition comprises three components, viz demographic transition, epidemiological transition, and health care transition. Kerala has apparently made significant advances in all the three components. Thus, the State has entered the final phase of demographic transition as exemplified by the low death and infant mortality rates, comparable to those of developed countries. The fall in death rates has resulted in a rise in expectation of life at birth, and increase in the proportion of the elderly-persons above 60 years - in the total population. These developments have major implications. Kerala has also been going through an epidemiological transition as reflected in its morbidity profile.

The picture emerging from a scrutiny of available data on morbidity pattern is a mixed one. On the one hand, the dominant disease group comprises acute infectious diseases including fever, diarrhoea, and worm infestation, resembling the morbidity profile of a typical underdeveloped country. On the other hand, the emergence of chronic diseases like diabetes mellitus, blood pressure, heart disease, and cancer as the major causes of death of the adult population, resembles the situation in developed countries which have gone through the epidemiological transition.

In brief, Kerala has made significant advances in health transition in terms of the rate of mortality and pattern of morbidity. True, high morbidity rates still persist. What are the causes of this apparently paradoxical phenomenon? Of the different factors governing the health status, spread of education, especially female education, and of medical care facilities have emerged as the most important. The role of the State government as the principal agent in the promotion of education, universal literacy, and expansion of medical care facilities aimed at ‘health for all’, has to be duly acknowledged. The high rate of prevalence of acute communicative diseases, despite these advances is a cause for concern. The causes for the persistence of infectious diseases - the diseases of poverty - are not far to seek. They are unfavourable environment, lack of access to safe drinking water, and sanitary facilities for the majority of the households in the State.