Local Planning and Democratic Participation as Mechanisms for Improving Third World Health Conditions: Recent Experiments in Kerala, India

Kerala Page

Dr. B. Ekbal
Vice Chancellor
Kerala University
Thiruvananthapuram 695 034
Kerala, India
Dr. Joy Elamon
Executive Director
Kerala Health Studies and Research Centre
AN-318 Adarsh Nagar
Pattom, Thiruvananthapuram 695 004
Kerala, India
Richard W. Franke
Professor of Anthropology
Montclair State University
Upper Montclair New Jersey 07043 USA


A research project funded by the John D. and Catherine T. MacArthur Foundation, Collaborative Research Grants, in the Program on Global Security and Sustainability. The collaborating institutions are the Kerala Health Studies and Research Centre, an NGO; and Montclair State University.

MacArthur Grant Number: #99-61670-GSS

Project Status as of 24 June, 2001:

We appreciate all comments, criticisms, and suggestions. If you are doing a study of a similar nature, let us know if we can exchange reports. Contact any or all of us at the email addresses above. Contents of the Project Report, currently being drafted:

1. The Kerala Health Scene: From Model to Crisis
2. The People's Campaign for Democratic Decentralization
3. Methods of Research and Analysis
4. The Investment Patterns of the Local Governments: a Quantitative Analysis
5. Case Studies: Local Communities Developing Important Experiments
6. Conclusions and Recommendations
7. References Cited

1. The Kerala Health Scene: From Model to Crisis

    Kerala is well known in development circles for its high material quality of life indicators at low per capita incomes. On major health indicators such as infant mortality, life expectancy, and birth rates, Kerala's statistics rival those of first world countries. The Kerala Fact Sheet on this website provides the most recent figures. Historical studies show that Kerala's public health campaigns and the organized political struggles of its people have produced the education, immunization, and other inputs necessary to generate high quality health and health care at low cost. Equity has been a major concern of Kerala's political scene and this is reflected in the health sector where the poor have generally had access greater than in most 3rd world settings.

    Recently, however, the Kerala health situation faces many problems. The quality of government health services has declined. Rapid expansion of private sector health facilities has led to overmedicalization to produce profits. This is seen in the very high rate of caesarian births and increasing health expenditure. Despite many decades of successful immunization programs, Kerala has not achieved as much as it could in providing safe drinking water to much of the population. In general, infectious and parasitic diseases have not been fully conquered but the longevity is leading to the spread of chronic and old age diseases including diabetes, arthritis, various forms of cancer, hypertension, and the like. The Kerala People's Campaign for Democratic Decentralization, launched in 1996, created a setting in which health activists could attempt to respond to the Kerala health sector crisis. Our study attempts to evaluate their successes and failures.

2. The People's Campaign for Democratic Decentralization

    A brief overview of the historical background, political philosophy, major stages, and important events in the Kerala People's Campaign within which our health projects study takes its data. The State Planning Board earmarked 35-40% of the plan budget for the years 1997-2002 to the local governmental units. The Campaign began with local assemblies across Kerala. This was followed by several stages including the writing of local development reports in all 990 villages. The reports were discussed at development seminars where task forces were elected to draft actual project proposals. The elected village or urban councils decided on the priorities and implementation and monitoring committees were established. Within general guidelines, local councils had substantial autonomy in deciding on which projects to devote resources. Health projects ranged overall from 13% to 15% of expenditures. For details of the Campaign, the reader is referred to:

Thomas Isaac, T. M. (with Richard W. Franke). 2000. Local Democracy and Development: People's Campaign for Decentralized Planning in Kerala. Delhi: Leftword Books.

3. Methods of Research and Analysis

    Our study utilizes five major sources of information:

The data on the local investments and the case studies are used to evaluate the extent to which:

    1. Health planning has become functionally divided among the various levels of government so that each deals with the problems it has the most effective means of solving;
    2. Local communities became inspired to mobilize additional resources through donations of land, labor, or money, thereby making the spending devolved from higher levels more productive and effective;
    3. Health policies at each administrative level have become more consistent with the expressed needs of the people represented by that level;
    4. The public health system and the health care delivery system began functioning more effectively overall;
    5. New resources and new responsibilities at the lower levels have generated innovative experiments that would not be as likely in the previous more centralized system where more of the decision-making power and the resources were kept out of the hands of potential local innovators.

4. The Investment Patterns of the Local Governments: a Quantitative Analysis

The data files contain for

1997-98 10,472 health projects
1998-99 14,276 health projects
1999-00 22,584 health projects
2000-01 9,626 health projects (6 districts only; remaining districts in process of collection)

The projects are grouped into 14 categories

Primary Health Centre and Hospital Equipment and Construction Ayurveda and Homeopathic Medical Investment
Other Public Health Awareness and Immunization
Piped Drinking Water Non-Piped Drinking Water
Drainage and Waste (incl sewage) Disposal Latrine Construction
Mosquito and Rodent Eradication Rabies Control
Other Sanitation Nutrition
Public Burial Ground Slaughterhouse

in which to compare and contrast the investment patterns by three major criteria:

The local government level (village, municipality, block, district, urban corporation)
The plan type (general, SC, ST, women)
Interactions between the level and the type

Along with the general investment patterns, we are also examining the levels of voluntary resource mobilization, a variable contained in the files, and several more detailed features such as the particular projects to construct public toilet facilities for women or to set up cancer or other disease detection camps for particular diseases that have been a concern of particular localities. We shall consider the total health expenditure as a percent of the total devolved funds to investigate whether local governments in particular areas or with particular demographic features tended to spend more or less.

The investment pattern analysis will attempt to evaluate to the degree possible those issues in chapter 3 that can be answered in a quantitative way.

5. Case Studies: Local Communities Developing Important Experiments

    Narrative data with some statistical materials have been compiled for several local communities that developed important experiments.

  • Erattupettah Panchayat created a "total village health" campaign with several components including health education, upgrading of the local Primary Health Centre (PHC), and a public latrine complex for pilgrams who pass through on their way to the important Sabarimala temple. The Erattupettah case study is available as a pdf file at:


  • Thrikkakkara Panchayat near Ernakulam City developed a cooperative hospital with substantial facilities and low cost for patients. The hospital has special concessionary prices for the lowest income households and has attracted a cadre of devoted medical specialists who work there partly for the commitment to community medicine as well as for the lower salaries offered. An htm file with some photographs of the hospital can be accessed at:


  • Koyilandy Municipality experimented with a mosquito eradication program using biological controls rather than insecticides. The mosquito population has been significantly reduced without side effects. The Koyilandy case study is complete and is posted on-line at:


        with links to a few photographs showing the ovitraps and stagnant drains

Nedumangad Municipality made substantial improvements in the taluk (subdistrict) hospital as have several communities. Chempilode Panchayat created a women's health status study task force that produced unexpected and valuable results and generated interest across Kerala in producing similar reports using trained local women as researchers.

A few other communities will be added to the final set of case studies currently being written up.

6. Conclusions and Recommendations

These will emerge from the results of the analysis in chapters 4 and 5.

7. References Cited

An extensive bibliography is being compiled.     Kerala Page