Does Kerala’s New Public Health Bill Address the State’s Challenges?

Kerala does not have the same level of challenge in the management of basic health indicators as other states of the Union of India have. It has instead, challenges that are further along the complexity continuum.

In 1920, C.E.A. Winslow, the founder of Yale School of Public Health, stated, “Public health is the science and art of preventing disease, prolonging life, and promoting health through the organised efforts and informed choices of society, organisations, public and private communities, and individuals.” The US National Academy of Medicine (formerly known as the Institute of Medicine) in 1998 defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” 

By all metrics, Kerala has done better than most jurisdictions globally in securing health outcomes for its population. This hasn’t been an overnight achievement but the result of popular engagement and responsive governance. Unlike most other states, health was politically prioritised, and the population gradually become universally literate and rights aware.

A key highlight of the Kerala Public Health Bill, 2023 that was passed by the state assembly earlier this week is gender sensitivity in the language – the inclusion of feminine pronouns everywhere in conjunction with the masculine. This is entirely consistent with the status of women and the sex ratio at birth that is favourable to the female gender. However, for a state that has been making major strides in affirming third and inter-sex identities, the absence of non-binary pronouns is a missed opportunity, given that there are public health concerns that directly relate to this constituency.

Health, not merely the absence of disease, but complete physical, mental and social well-being, is a complex outcome at the individual level. At the level of the community, its mechanisms of achievement and measurement are not easy. Delivering health, and the administration of its operations at the population level requires analysis, understanding and incorporation of multiple influences and mechanisms. A simplistic, illness-specific approach reduces public health administration to a set of programmatic boxes in which communicable and non-communicable diseases are placed and managed from, with a nod to a few influencing factors like sanitation, water supply, the management of gatherings of people, and life destabilising emergencies. Life, and public health, is much more complicated and intertwined, at least in the 21st-century context.

Kerala does not have the same level of challenge in the management of basic health indicators as other states of the Union of India have. It has instead, challenges that are further along the complexity continuum, and the advantage of underlying administrative, political, and social infrastructure to address them. The new public health Bill does not reflect this status fully. Nor does it take advantage of the opportunity to forge a path forward that will set standards for others, in India, and globally, to emulate.

A One Health approach, as the Bill now reads after its review from the select committee, requires a still larger framing than the “focus on improving the social determinants of health such as clean water and environment, sanitation and waste management”, to quote the Kerala health minister. We have a far better understanding today of how commercial and social status motivations can impact health. For example, a state like Kerala with its sizeable diabetes burden, its consumption of nutritionally poor foods and beverages would need to become a focus for public health action.

We also understand that the shifting patterns of personal mobility – from walking to use of buses and trains, to use of personal vehicles – impact time spent sitting and on the air quality. Reduced physical activity and poor air do not help diabetics at all. Industrial pollution of air and water, and poor management of garbage generated by humans add insult to injury. The silent but real epidemic of mental illnesses gets layered on top. The elderly, who form a sizeable proportion of the population, represent a special societal responsibility. The changing patterns of weather, vegetation and water bodies influence disease-bearing vectors, impacting the population variably, sometimes with no prior experience of the disease being transmitted.

A one health approach, a public health perspective, would take all of these, and much more into account, and create a dynamic, responsive, platform to address them. The three-tier administrative formulation proposed is fit for purpose for a far-constrained perspective. In multi-layered, complex contexts, the easy way is to be seen doing something that can be held to account and audit. That may be counterproductive from a health outcomes perspective – we may get more activity and reports, while public well-being deteriorates. In such settings, as in politics and many other contexts, less is more. That “less” would conform to an agreed set of norms but would differ in how it gets administered at the state, district or local levels, and would leverage the full strength and social reach of local self-governing bodies.

The Bill also marks a missed opportunity for the state to reimagine the administrative structure of the health ministry, and transform itself into a Ministry of Public Health, with reorganised departments that would be responsible for 1. Health Services Delivery, 2. Biomedical Research and Education, 3. Emergency Preparedness and Response and 4. Health Metrics and Evaluation. It would also make autonomous and directly responsible to the apex bureaucrat of the ministry a ring-fenced Food & Drug Authority & a Healthcare Worker registry.

Consolidating and codifying old laws – the Travancore Cochin Public Health Act of 1955 and the Madras Hospital Act of 1939 – into the present Bill is certainly a good move. However, given its already impressive health achievements, it isn’t the best that Kerala could have done.

Bobby John is managing director, Æquitas Consulting Pvt Ltd.