A few months ago, a young road accident victim admitted to the ICU at the Government Medical College Hospital (MCH), Thiruvananthapuram, required an emergency interventional radiology (IR) procedure to control life-threatening bleeding.
The hospital has a full-fledged IR cath lab since 2019. But it did not work 24 hours. With no permanent IR faculty or support team to operate it 24×7, doctors were forced to transfer the patient to the Sree Chitra Tirunal Institute for Medical Sciences and Technology on the same campus for the procedure. The patient died on the way.
“It is unforgivable that the state’s oldest medical college does not have a 24-hour IR lab,” says a senior doctor. “The cath lab now works only three days a week with contract radiologists. Two trained interventional radiologists left two years ago, mainly due to poor entry-level salaries, an anomaly only partially rectified after the doctors’ strike.”
The public health system now has an abundance of cath labs across the state. However, doctors say many are not active round the clock to provide life-saving care to patients, who are often rushed in the middle of the night.
some bright spots
At the same time, K. of Vembayam in Thiruvananthapuram. The incidents are narrated by people like Anilkumar thanking the state-run Sree Evitham Thirunal (SAT) Hospital on social media. Their daughter, who has twins, was admitted to a private hospital for a C-section three weeks before the expected delivery date. But he took her to SAT, where she had a normal delivery.
In his post, Anilkumar said that in any private hospital, the family would have had to pay lakhs to pay the cost of neonatal ICU alone. These contradictory accounts reflect the contradictions of Kerala’s broader public health system.
There has been a stir in the health department for the last few weeks. Allegations of negligence and lapses in treatment have triggered public outrage and political attacks. The opposition claims the health system is “on ventilators”. Doctors argue that they are being made scapegoats while systemic shortcomings are ignored.
There are many incidents of negligence
Recent incidents of alleged medical negligence have intensified public scrutiny. A pair of artery forceps were recovered from a woman five years after her hysterectomy was performed at Alappuzha Medical College Hospital. A similar case had earlier come to light in Kozhikode MCH. A nine-year-old boy, who was undergoing treatment for a fracture at Palakkad District Hospital, later had to have his leg amputated following an infection.
According to the Economic Survey, 2025, between 2016 and 2025, Kerala invested ₹2,583 crore on 102 major medical infrastructure projects through the Kerala Infrastructure Investment Fund Board (KIIFB).
The expansion of infrastructure in the form of new hospital blocks, intensive care units, cath labs and diagnostic facilities has also led to a rapid increase in outpatient numbers in public sector hospitals. According to government data, currently more than 45% of the state’s population is using OP facilities of public sector units, while the figure was 30% in 2014.
Yet, when it comes to hospitalisation, people continue to prefer the private sector. About 72% of deliveries in the state now take place in private hospitals. Despite the increase in health expenditure and insurance coverage under Karuna Arogya Suraksha Patna (KASP), out-of-pocket expenditure (OOPE) remains the highest in the country.
Many dangers of staff shortage
“Huge buildings and equipment do not make the public health system efficient. People do. Constructing big buildings or purchasing high-tech equipment without making provision for human resources (HR) to operate these additional facilities puts pressure on the system. Naturally, the quality of care suffers and human errors increase,” says B., a public health worker. Ekbal explains.
Shortage of human resources remains a central issue, concerns the Comptroller and Auditor General’s performance audit of the health sector of Kerala (2016-2022). While patient load has increased significantly, HR expansion has not kept pace proportionately. “It is impossible to limit the OP numbers, which range from 200 to 400 per day. We cannot even give 10 minutes to a patient,” says PK Sunil, president of the Kerala Government Medical Officers Association.
“HR shortages, irregular supplies and cumbersome processes affect the quality of care. Also, some institutions with adequate staff are underutilized,” he says.
Dr Sunil explains, “There is a need for rationalization and redistribution of human resources across institutions; standardization of hospitals at different levels; and realigning of duties and responsibilities of different categories of health workers. The general hospital in Palakkad is quite different from the hospital in Ernakulam, which does organ transplants.”
Doctors at medical colleges say the shortage of nursing staff often forces them to make slight changes to essential surgical safety protocols. He points out that the shortage of anesthesia faculty is another serious concern.
lack of anesthesia support
A faculty member from MCH, Thiruvananthapuram believes, “Procedures like endoscopy and reduction of fractures in casualties are now done without the support of anesthesia, causing a lot of pain and discomfort to the patients. As a teaching hospital, we cannot even teach standard protocols to the students.”
“The decade-old Government Medical College Hospital, Kollam, still does not have a 24×7 neurosurgeon. All trauma cases still come to us. The hospital also does not have 24-hour cardiology services, which is why Chavara’s auto driver Venu had to come here for “emergency care” after he suffered a heart attack and ultimately died here,” he says.
Doctors say every state budget adds more fancy infrastructure or projects to hospitals without making provision for posts to run them.
“Creating more idle infrastructure without posts becomes a burden on hospital administrators. Cath labs are in every district, but none of the secondary hospitals have enough doctors, ICU-trained nurses or even posts for dialysis and cath lab technicians,” says a senior health official.
1400 posts sought, 202 approved
Last year, the Directorate of Health Services had reportedly proposed 1,400 new posts, including specialist and super-specialist doctors. Dr. Sunil says, after long discussions with the Finance Department, only 202 posts of doctors were approved.
However, state planning board member and former Kerala health services director PK Jameela refutes the notion of neglect. Between 2016 and 2025, the number of general doctors is expected to increase from 4,613 to 6,171; Specialists from 2,317 to 3,185; nursing staff from 9,869 to 13,575; and other employees from 5,022 to 7,609, she argues citing the Economic Survey 2025.
“Additional human resources are also deployed through the National Health Mission, local self-governments and hospital development committees. The influx of patients into public hospitals shows confidence in the system,” she says. He further said that the story of the decline of the public health sector is politically motivated, with an eye on the upcoming assembly elections.
Why do they choose private hospitals?
However, V. Ramankutty, a renowned public health expert, believes that a serious lack of trust among the people in the public health system is evident. He says building huge infrastructure and facilities may not be the best way to win back that trust. “The key question is, how many of us in the “paying category”, including ministers and senior officials, would prefer to seek medical care in public health facilities than in a private hospital? The quality of care provided and the hospital experience is important to people, which is why they go to the private sector despite the higher cost of care. The government should choose institutions for growth and upgradation rather than draining resources, where people are provided with high quality care and hassle-free services,” said Dr. Ramankutty believes.
He says that decentralization was expected to bring many positive changes in the health sector, but sadly the benefits have not been uniform. Financial stress is increasing operational challenges. Since 2021-22, the Hospital Development Society (HDS) has been struggling due to delayed reimbursement of dues under KASP. Dr Sunil explains that without timely payment, HDS cannot make local purchases of medicines and consumables. Thus KASP beneficiaries have to pay out of their own pockets for equipment and services that are not available in hospitals.
Health Minister Veena George believes that a disinformation campaign is being run to defame the state’s public health system. They argue that in the last five years, the health department received around 600 complaints of alleged negligence/lapses in treatment in private sector hospitals, while only 57 complaints were received from public hospitals.
Need for regular medical audit
Doctors say the complaints should be investigated through a systematic clinical audit rather than a political reaction. A senior health official says, “Apart from maternal death audits, there is no regular medical audit in other specialties in the system. Unless we do this practice systematically, weaknesses will persist and accidents will continue. Instead, doctors are penalized and the rest are ignored.”
The second dimension is also the changing nature of medicine. Treatment today is more intensive and life-prolonging than it was a decade ago. ICU stays are longer and interventions are more complex. It is true, says Dr. Jamila, that HR provisions are not in line with these emerging realities.
“One solution would be to give functional autonomy to medical colleges, allowing moderate user charges from the paying category. The neonatal ICU in SAT is excellent. Instead of private sector rates of ₹40,000 per day, why not charge a reasonable ₹2,000 per day from those who can afford it?” The officer argues.
professional administrator
Dr. Ekbal believes that premier hospitals like medical colleges require professional hospital administrators who can streamline processes, establish protocols and checklists, conduct audits, and improve the patient experience. He argues that clear protocols as well as facilities for referral and back referral should be created – just issuing a GO will not cut it.
He says, “There is no ‘public’ in public health anymore. Hospitals have become high-tech, but the patient experience remains unchanged. People are still running from pillar to post to get work done in our hospitals.”
“People choose private hospitals because they get good service and convenience. Unless public facilities focus on service delivery and patient experience, Kerala’s OOPE will continue to rise,” says a senior health official.
