research topics in kerala

Emerging challenges in the health systems of Kerala, India: qualitative analysis of literature reviews

Journal of Health Research

ISSN : 2586-940X

Article publication date: 12 February 2021

Issue publication date: 11 February 2022

The substantial increase in non-communicable diseases (NCDs) is considered a major threat to developing countries. According to various international organizations and researchers, Kerala is reputed to have the best health system in India. However, many economists and health-care experts have discussed the risks embedded in the asymmetrical developmental pattern of the state, considering its high health-care and human development index and low economic growth. This study, a scoping review, aims to explore four major health economic issues related to the Kerala health system.

Design/methodology/approach

A systematic review of the literature was performed using PRISMA to facilitate selection, sampling and analysis. Qualitative data were collected for thematic content analysis.

Chronic diseases in a significant proportion of the population, low compliance with emergency medical systems, high health-care costs and poor health insurance coverage were observed in the Kerala community.

Research limitations/implications

The present study was undertaken to determine the scope for future research on Kerala's health system. Based on the study findings, a structured health economic survey is being conducted and is scheduled to be completed by 2021. In addition, the scope for future research on Kerala's health system includes: (1) research on pathways to address root causes of NCDs in the state, (2) determine socio-economic and health system factors that shape health-seeking behavior of the Kerala community, (3) evaluation of regional differences in health system performance within the state, (4) causes of high out-of-pocket expenditure within the state.

Originality/value

Given the internationally recognized standard of Kerala's vital statistics and health system, this review paper highlights some of the challenges encountered to elicit future research that contributes to the continuous development of health systems in Kerala.

• Kerala health system
• Kerala health insurance
• Kerala public health
• Heart disease
• Health economics
• Emergency healthcare

Muraleedharan, M. and Chandak, A.O. (2022), "Emerging challenges in the health systems of Kerala, India: qualitative analysis of literature reviews", Journal of Health Research , Vol. 36 No. 2, pp. 242-254. https://doi.org/10.1108/JHR-04-2020-0091

Emerald Publishing Limited

Copyright © 2021, Manesh Muraleedharan and Alaka Omprakash Chandak

Published in Journal of Health Research . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

In India, health care follows a decentralized approach in which implementing and executing health facilities is the responsibility of each state, with considerable overlook from the central government. Health-care financing and policymaking are the responsibilities of the central government, whereas implementing the policy is the responsibility of the state government [ 1–3 ]. The national health policy established in 1983 was the first initiative toward implementing a structured health-care system and introducing various national health programs in the country. Records indicate that because of the decentralization and health care being a state's responsibility, a considerable disparity can be observed in the health-care delivery standards among different states; some states are still struggling, whereas others display enormous improvements [ 4 ].

Kerala has a gross domestic product (GDP) per capita of US$3,200 and is classified as a lower-middle-income state. Kerala is well known for maintaining one of the best health-care systems in the country for decades [ 5 ]. The “Kerala model of development” became a widely used term after the survey conducted by the Center for Developmental Studies on poverty and unemployment in 1975. According to experts, irrespective of its low per capita income, Kerala's health system has excelled and continuously garnered national and international attention. As stated by various health surveys, including the central government's analysis reports, Kerala leads many other states in having high health-care standards and life expectancy rates, low maternal mortality rate and the lowest infant mortality rate in the country ( Table 1 ). High literacy rates and women empowerment have contributed significantly toward this achievement. However, numerous past experiences and studies indicate that Kerala is in the era of an emerging puzzle because of its high morbidity rate with low mortality rate, besides having a significant increase in non-communicable diseases (NCDs) [ 3, 6–11 ].

This unique community has taken enormous steps to reduce mortality by implementing robust primary care facilities, resulting in a significant increase in chronic degenerative diseases among the middle-aged and adult population [ 12, 13 ]. A significant proportion of adults in Kerala are living with chronic morbidities, especially illnesses such as hypertension, diabetes and atherosclerosis, which are known to develop chronic complications such as heart failure and kidney diseases [ 9, 11, 14 ]. Moreover, previous studies state that the approach of the Kerala population toward seeking timely emergency medical attention was questionable [ 8, 9, 15 ]. Golden hour treatment is the most effective option during the acute phase of a stroke or coronary event and is possible only during the early hours of these illnesses. Golden hour treatment protocols are advised by medical authorities such as the American Heart Association and American Stroke Association. The golden hour is 4 h 30 min for an acute stroke and 6 h for an acute coronary event [ 16 ]. Delayed treatment or consultation for acute coronary syndrome or a stroke may lead to mortality or a high incidence of disability [ 8, 9, 15 ]. Delayed treatment can also lead to ineligibility to access the golden hour treatment, which may result in severe heart failure or stroke, often requiring long-term care, medication and rehabilitation [ 17, 18 ]. High morbidity status with low coverage of health insurance or other reimbursement facilities can prove lethal to the long-term financial sustainability of a community. Therefore, it is essential to analyze previous studies and reports to explore the loopholes in Kerala's health system.

Methodology

This study adopted a systematic review design with the purpose of exploring and describing the literature related to the health systems of Kerala and to identify emerging challenges and prospective research areas.

Data sources

Journal publications and gray literature such as relevant websites of the Government of India and state government reports available in the public domain.

Searching strategy

Data search and identification were done mainly using PubMed, Scopus and Google Scholar to retrieve journal publications. A Boolean search was employed using keywords and operators. The literature search was conducted between October and November 2019. The process of literature identification and refinement are summarized in Figure 1 .

Data selection (inclusion and exclusion)

Studies and reports between 2010 and 2019 related to health systems of Indian states were included. Within these studies and reports, the following data were selected: socio-economic indicators, health system indicators, emergency health management system data and health financing data. Abstracts only and conference proceedings were excluded.

Quality check process

A reviewer and an external expert independently screened the articles using a standard quality assessment scale. Disparities in the selection of the documents were resolved by manual agreement.

Data management

Mendeley was used for the management of references. The articles were initially stored, categorized and refined in Mendeley based on the date of publication, topic and authenticity. The selected articles were analyzed after converting them to Microsoft Word format. A coding analysis toolkit (CAT) was used for coding the document.

Data analysis

The World Health Organization reports on health system performance were reviewed and used to develop preliminary codes for data analysis. Quantitative data served a descriptive statistical analysis using frequencies and proportions, whereas qualitative data served a thematic content analysis. Dixon–Wood's critical interpretive synthesis was employed for qualitative data.

A reviewer and an external expert individually coded the articles based on the preliminary codes developed. Operational definitions of codes were adjusted to iron out disparities.

Theme 1: Increasing burden of NCDs and chronic morbidity

Theme 2: Low utilization of emergency health-care facilities

Theme 3: Inequalities in the performance of the health system

Theme 4: High out-of-pocket expenditure

Ethical issue: Review paper do not need approval code

Theme 1: increasing burden of non-communicable diseases and chronic morbidity

Various records and experts have discussed the issue of high morbidity and low mortality in Kerala state and the long-term effects and complications associated with this [ 5, 6, 11, 19, 20 ] The prevention of communicable diseases and NCDs was one of the major objectives of the 12th five-year plan developed by Kerala state, 2012–2017. The case fatality rate of acute heart failure, which was up to 25% in the 1980s, is as low as 4% at the moment [ 15, 21, 22 ]; the same trend was observed for several similar NCDs [ 23 ]. This prevented a significant proportion of mortality among the middle and old-age population, which resulted in a higher number of people suffering from chronic illnesses [ 24, 25 ]. Studies have shown that 74% of the morbid population suffers from chronic illnesses [ 7, 9–11 ]. The substantial rise of chronic illnesses such as hypertension and diabetes in the middle-aged population was reported as a significant concern, and many medical practitioners and researchers considered the state as the diabetes capital of India [ 9–11, 26, 27 ].

The prevalence of diabetes among people in Kerala was projected to be around 14%, while it was around 40% for hypertension [ 11 ]. A recent study [ 28 ] mapped the prevalence of major NCDs of various Indian states ( Figure 2 ). The map shows a high prevalence of cardiovascular diseases, ischemic heart diseases, stroke and rheumatic heart diseases in Kerala compared with other states in the country. However, it is important to consider that a high literacy rate and awareness can be directly related to a higher reporting of diseases [ 29 ]. However, none of the literature or official reports showed any decline in the NCD statistics for 25 years. An increase in chronic morbidity is a real burden to any community. Hence, it is important to study Kerala's population characteristics in-depth and to intervene early [ 3, 20 ].

Theme 2: low utilization of emergency health-care facilities

A recent survey by the directorate of economics and statistics of Kerala concluded that only around 11% of the total registered deaths were medically certified, indicating that most of the deaths occurred outside medical environments. The survey also indicated that more than 30% of the deaths found among the young and middle-aged population were aged below 64 years [ 28 ]. However, the study did not reveal the causes for deaths that occurred outside the medical environment. Further study is needed, especially because of the higher mortality found among young and middle-aged people. Another noticeable fact is the low utilization of the golden hour treatment for any vascular illness, especially for stroke and cardiovascular diseases [ 5, 8, 9, 22, 31 ]. Studies related to emergency cardiac or stroke treatment in the Kerala population are scarce [ 8, 9, 32 ]. One of the studies concluded that the pre-hospital delay in acute stroke patients is significantly high compared to other communities. A similar study done on an acute cardiac event group exhibited concurrent findings of low utilization of pre-hospital emergency services in Refs. [ 8, 33 ].

The higher pre-hospital delay was associated with multiple stops the victims took before reaching the specialty center [ 8 ]. However, the reasons behind this observation were not revealed by the previous studies. According to some studies, awareness of the population regarding recognizing symptoms of a cardiac or cerebrovascular illness was contentious [ 5, 8, 32 ]. Patients with more disturbing symptoms such as limb weakness or chest pain arrived at hospital facilities earlier compared with subtle or vague symptoms [ 5, 8, 32, 34 ]. Some studies reported the issue of under-reporting of less severe or benign illnesses, especially among the poor [ 14, 35 ]. Higher education and better socio-economic status were factors for recognizing symptoms of vascular illnesses [ 34, 36 ]. Most studies from India and other countries concluded that people with higher educational qualifications tended to visit the hospital early in the event of an acute cardiac attack or stroke [ 37–40 ]. Regarding the pre-hospital emergency services in the state, some were termed as “not satisfactory” by some studies [ 9, 21, 28, 41, 42 ]. Additionally, organization-level management nicks play a role in the failure of emergency management in case of vascular ailments [ 9, 32 ]. Kerala's health system has achieved tremendous success in its primary care strategies; however, their emergency care efficiency is contentious. Only a few studies and limited data are available in this aspect, and most of them are limited to a particular disease or region.

Theme 3: inequalities in the performance of the health system

Kerala is a relatively small state compared with other territories in India [ 43, 44 ]. The living standards and socio-economic inequalities were found to be higher in the urban areas compared to rural areas [ 14, 20, 45, 46 ]. Sometimes, this variation was observed in the same rural or urban territory, and regions occupied by lower financial class people seemed to utilize medical facilities at a lower rate [ 27 ]. Another interesting observation in the literature was the disparity between the north and south regions of the state, which was more evident in the past and is gradually narrowing down [ 47 ]. The southern part of the state is considered better in many areas of development, including living status and health-care consumption [ 20, 47 ]. Some studies revealed that certain regions lagged in the process of health-care improvement. For example, the Malabar region was far behind in the mortality reduction programs in the early stage [ 12 ], whereas higher morbidity was observed in the developed regions [ 43, 48 ].

This disproportionality is vividly depicted in the comparison of health-care infrastructure distribution in various districts [ 47 ]. A large geographical area in northern Kerala is still dependent on a few tertiary care public medical centers for specialty treatment and has no active tertiary care institutions in two major districts, Kasargod and Wayanad. On the contrary, a small geographical area in southern Kerala possesses a relatively large number of medical institutions. Trivandrum is the southernmost district and is flooded with several national and state-level specialty centers. Table 2 illustrates the disparities in the distribution of health-care facilities in the state. The northernmost districts of Kasargod and Wayanad have no low density of specialty medical facilities, and the bed ratio was low at 6.3 and 8.69, respectively. On the other hand, Trivandrum had a bed ratio of 18.48, with multiple specialty centers. Apart from this, all major private health-care players were concentrated in cities with a high population density. Quality of care and ease of access made private health facilities a primary choice in Kerala [ 49 ]. Public health-care facilities in Kerala are still struggling with financial and infrastructure crises. Although this was a nationwide observation, Kerala has also not made any differences [ 50–55 ]. Some studies have evidenced the caste or community-based stratification with poor health security coverage and higher health risks over certain marginalized groups in Kerala [ 14, 45, 56 ]. In addition, some studies reported gender-based inequalities, which were more evident in marginalized social groups [ 43, 57 ].

Theme 4: high out-of-pocket expenditure

The health system of Kerala has proved to be the best in India and is considered a model health system to be followed to achieve a high human development index for a struggling economy. However, the literature reveals that health financing in the state has been criticized because of the high rate of catastrophic expenditure on health and poor insurance coverage. Some surveys reported the financial status as a reason for restricting people from seeking health care [ 14, 59 ]. Recent reports based on various surveys showed that only a small percentage (less than 40%) of India's population availed themselves of any kind of health insurance protection [ 60–62 ]; Kerala is also struggling to improve its health insurance coverage [ 59 ]. The private health-care sector plays a significant role in Kerala's health-care system and is considered to be the highest compared to other states [ 31 ]. Some reports claim that it was slightly above 90%. Moreover, it was revealed that the people in Kerala fell below the poverty line because of costly treatment-related expenses, which are the highest in the country [ 10, 31, 63 ]. Catastrophic health expenditure after an acute heart failure treatment was reported in around 80% of the families [ 10 ]. An increase in early-onset lifestyle and vascular illnesses have propelled a large number of families toward financial crisis [ 64 ].

The 12th five-year plan aimed to provide comprehensive financial risk protection to the public and emphasized various health insurance and reimbursement schemes under state and central governments. Nevertheless, many recent surveys reported that Kerala has not yet achieved significant improvement in this sector [ 10, 46, 65 ]. Most of the government initiatives failed to reach the poor and needy communities in the state [ 65 ]. The official report states that the outreach of ambitious public health insurance programs under the aegis of Comprehensive Health Insurance Agency, Kerala (CHIAK) is making substantial progress, with a total enrolment of around 4,100,000 families [ 66 ]. However, the scope of this scheme has limited penetration and restricted specialty treatment access and financial support [ 46, 65, 67–70 ].

Sometimes, the disease event itself was high in the population group, leading to un-availed health security [ 10 ]. Despite all the efforts made by the government and private insurance facilities, socio-economic status, employment and disease profile have an adverse impact on insurance coverage in the state [ 46, 48, 65, 68 ]. One of the futuristic approaches the state government recently implemented is offering emergency care to all without the immediate payment of hospital bills, even in the private sector, but some of the reported limitations of this program include confusion among the public and late catastrophic issues [ 53, 71 ]. Apart from its highest educational achievements and robust health system, Kerala is known for its low GDP; this can impact insurance coverage. In reality, experts state that the neediest marginal population is devoid of financial protection during an adverse disease event [ 14, 46, 48, 65, 72, 73 ].

Kerala's health system is unique, not only in India but also at a global level because it has accomplished more from less [ 74 ]. Its asymmetrical development has been one of the most discussed topics for decades, considering that it maintained high health-care standards while struggling with sluggish economic growth. However, experts reveal that some risks have emerged in this unique community, the most obvious being the increase in the number of morbid populations with a lower mortality rate. Various studies have mentioned the increasing burden of NCDs and the challenges in managing them.

From the data obtained, a model illustrating inter-related health system issues was synthesized ( Figure 3 ). These issues are discussed in detail under the results section. The authors believe that these represent a potential research agenda on the Kerala health system.

Several studies and reports stated the higher prevalence of NCDs in the state such as heart disease, stroke, hypertension and diabetes. Often, this observation is explained as the result of increased life expectancy as a higher number of aged individuals suffer from chronic illnesses. However, the life-course perspective is often overlooked. Future studies related to risk factors and an upstream determinant of NCDs is necessary for the community.

From the data obtained, it is clear that about 30% of the total mortality in Kerala involves people below 64 years of age. Unfortunately, medically certified deaths represent only 11% of all registered deaths. As a result, less is known about the cause of deaths that occurred outside medical environments. Improving mortality data is important not only to enrich data but also to shed light on reasons for not seeking medical care during terminal illnesses.

Studies show that emergency health-care utilization of the public in the state is low. This will create socio-economic shifts like increased disability-adjusted life years and long-term care costs. Factors embedded in the population for this behavior are infrequently studied and mentioned. Some of the literature reported reduced awareness and socio-economic factors as the reasons; however, most of the data are limited due to a narrow target population or limited sample size.

One major study [ 8 ] suggested that patients took multiple stops before reaching the appropriate specialty center. However, it remained unclear whether delays were due to health system inefficiencies, or patient-related factors, or patient's family-related factors. Studies related to the efficiency of the health system, including the referral system, in managing emergency vascular diseases are important. Further, public awareness about and access to specialty centers needs to be studied to inform health system development efforts. We suggest future studies on emergency medical care in Kerala to focus on the socio-economic status, access and quality of care, as suggested by the widely used three delays concept. Based on the results presented, it is clear that delay in the golden hour treatment can result in disability or long-term medical care. One study showed that 80% of the families faced catastrophic health spending in the state after a cardiac failure. Further studies to compare the medical expenses in patients who availed themselves of golden treatment and those who did not receive it could enhance insight into the cost-benefit of golden treatment, including a comparison of mortality rates, length of hospital stay and quality of life after treatment.

Another interesting factor is the observable disparity in the socio-economic status and health-care delivery in various regions of the state, such as rural–urban and north–south regional disparities. Differences are observed even within certain rural or urban communities based on the financial strata. Based on the evidence, high out-of-pocket expenditure is considered one of the major issues, which is making health financing more complex in the state.

Although government-provided health insurance and reimbursement made significant progress in the state, out-of-pocket health-related expenses remain high. Studies related to the various health insurance schemes are needed. These should include coverage of diseases and a co-payment policy for health expenditures. Further, homogeneity of the health-care cost across the state within and between public and private health-care providers is another recommended research area.

Finally, the interactions of the various issues raised were not clearly discussed in the selected literature. Future studies could include a focus on the relationship between insurance coverage and health-care utilization, and insurance coverage versus subscriber and disease profile.

This scoping review revealed emerging challenges in Kerala's health system in relation to the rise of NCDs and identified various research needs that could contribute to further the development of Kerala's health system. Based on the study findings, a structured health economic survey study is already under process and has been planned to be completed by 2021. In addition, the scope for future research on Kerala's health system includes: (1) research on pathways to address root causes of NCDs in the state, (2) determine socio-economic and health system factors that shape health-seeking behaviors of the Kerala community, (3) evaluation of regional differences in health system performance within the state and (4) causes of high out-of-pocket expenditure within the state.

Conflict of Interest: None

PRISMA flow diagram

Crude prevalence of cardiovascular diseases and major component causes in the states of India (2016). The changing patterns of cardiovascular diseases and their risk factors in the states of India and the global burden of disease [ 30 ]

Synthesized health economic model

Comparison of various socio-economic and health-care indicators of Kerala state and India

Source(s) : Directorate of health sciences 2011, 2013 [ 58 ]

Abbreviations: MCH – Medical college hospital, GH – general hospital, DH – district hospital, TH – taluk hospital, * – not fully functional

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Acknowledgements

Sincere thanks to the Symbiosis Center for Research and Innovation for their continuous support. Heartfelt thanks to Mr. Deepanshu Lekhi for his guidance and support. Sincere thanks to Ms. Neha Saini for her expert editing.

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Original research

Strategies and challenges in kerala’s response to the initial phase of covid-19 pandemic: a qualitative descriptive study, kannamkottapilly chandrasekharan prajitha.

1 Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India

Sujatha Chintha

Gopakumar soumya, meenu maheswari suresh, anjana nalina kumari kesavan nair, mathew joseph valamparampil.

2 District Medical Office(Health), Department of Health Services, Kasargode, Kerala, India

Aravind Reghukumar

3 Infectious Disease, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India

Sriram Venkitaraman

4 Department of Health and Family Welfare, Government of Kerala, Thiruvananthapuram, Kerala, India

Thekkumkara Surendran Nair Anish

Associated data.

Data are available upon reasonable request. The data underlying this article cannot be shared publicly due to the privacy of the participants. Data will be shared at reasonable request to the corresponding author.

To understand the structures and strategies that helped Kerala in fighting the COVID-19 pandemic, the challenges faced by the state and how it was tackled.

Qualitative descriptive study using focus group discussions and in-depth interviews.

State of Kerala, India.

Participants

29 participants: four focus group discussions and eight in-depth interviews. Participants were chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities, from the department of health and family welfare, police, revenue, local self-government and community-based organisations. Districts, panchayats (local bodies) and primary health centres (PHCs) were selected based on epidemiological features of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area to capture the wide range of activities undertaken in the state.

The study identified five major themes that can inform best practices viz social capital, robust public health system, participation and volunteerism, health system preparedness, and challenges. This study was a real-time exploration of the intricacies of COVID-19 management in a low/middle-income country and the model can serve as an example for other states and nations to emulate or adjust accordingly.

The study shows the impact of synergy of these themes towards more effective solutions; however, further research is much needed in examining the relationship between these factors and their relevance in policy decisions.

Strengths and limitations of this study

• The study has examined the response of the state of Kerala towards the COVID-19 pandemic comprehensively by involving representatives not only from different levels of the healthcare system but also from various other sectors including police and local self-government department.
• The possibility of a positive bias in highlighting the efficiency of the system cannot be excluded as the majority of the respondents were within the government system.
• The COVID-19 pandemic and associated social distancing have forced remote data collection techniques using the online platform which might have affected the data quality.
• At the same time, the remote data collection has increased the participation, who might not have otherwise consented to the study.

Introduction

When COVID-19 grew into a pandemic of extraordinary magnitude, several countries started following different strategies to contain and mitigate the spread. The unprecedented nature of the virus has contracted the economy of the world and there is a divergence in opinion on strategies adopted by different nations in handling the pandemic. 1 Kerala, the southernmost state of India, reported its first confirmed case of COVID-19 on 30 January 2020. 2 Amid the persistent vulnerabilities of high population density (860/km 2 ), 3 the high proportion of old age populations (12.6% of the total population) 4 and a large number of expatriates, 5 the state showed slow progression of cases, reporting zero new cases by the beginning of May 2020. 6 While the case fatality rate reached around 7% globally and 4% nationally in the month of May, Kerala could maintain a low fatality of less than 1%. 7 8 The state’s efficient handling of the initial phase of the pandemic received global appreciation. 9 10

As the COVID-19 pandemic is raging across the world, the responses and collective actions galvanising solidarity across nations are making the pandemic a social phenomenon. Qualitative methods help in understanding the social responses and the gaps between the assumptions and realities as well as why certain interventions work and others fail. 11 It can play a pivotal role in understanding the socio-political and management approach to control epidemics like COVID-19, especially to narrate and put forward effective solutions and strategies that could be used by other communities. 12 This demands a study on the intricacies of COVID-19 control to fill the lacunae put forth by various literature. The study aimed to understand the structures and strategies that helped Kerala in fighting the COVID-19 19 pandemic. The study also explored the challenges faced by the state and how they were tackled.

Methodology

This qualitative research was undertaken in Kerala spanning from May to August 2020. To understand the way in which the state and district level decision makers zeroed down to several combinations of measures and how people could cope-up with the decisions of the government, the paradigm used for the study was advocacy and participatory. We used a descriptive approach for the study and conducted in-depth interviews and focus group discussions. Participants were chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities. For a comprehensive understanding of the phenomenon, the researchers attempted a triangulation of data sources and the participants were chosen from the department of health and family welfare, the police, revenue, local self-government (LSGD) and community-based organisations. Districts, panchayats (local bodies) and primary health centres (PHCs) were selected based on epidemiological characteristics of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area to capture the wide range of activities undertaken in the state. Four focus group discussions and eight in-depth interviews were conducted ( table 1 ).

List of focus group discussions and in-depth interviews

PEID, Prevention of Epidemic and Infectious Disease.

The investigators who were well trained in qualitative research contacted each participant over the phone and the study objective was informed and willingness enquired. The researchers had no personal relationship with the participants. The only presupposition in the study was the social capital and a good public health system would have helped the state in handling the initial phase of the COVID-19 pandemic. Once verbal consent was obtained, the date, time and place were fixed according to the convenience of the interviewee. In the case of interviews using online platforms, informed consent was emailed and interviews were conducted at a time convenient for the interviewee. Every participant was informed about the freedom to refuse the invitation or to withdraw from the study at any point of time. Among the focus group discussions conducted, one was conducted at a PHC maintaining social distancing and taking adequate precautions, the other three were conducted over an online platform. The time duration for focus group discussions was 1–1.5 hours. An in-depth interview with a member of the state medical board was conducted at the author’s institute, and IDI3 with health inspector-1 was conducted at the PHC. The remaining in-depth interviews were conducted via an online platform. IDIs lasted for 45 min to 1 hour. The interviews were done with a topic guide ( table 2 ) and were participant-led. Discussions and interviews were conducted maintaining confidentiality after obtaining informed consent and were audio-recorded. At the end of each interview, the researchers summarised the information to the participants, to determine the accuracy. The recordings were transcribed and translated to English. Thematic analysis using a hybrid coding process was the approach followed. Data were coded using Nvivo and were rigorously reviewed and categorised. The emerging patterns, themes and relationships were identified. Consensus on emerging themes was reached through regular discussion among the researchers. Direct quotes were used wherever possible. Findings were shared with all the participants through email, allowing them to critically analyse and review their comments. The study has been reported in accordance with the Standards for Reporting Qualitative Research guidelines. 13

Interview schedule

Patient and public involvement

As our study was an attempt to understand the socio-political and management approaches adopted by the state of Kerala during the COVID-19 pandemic, patients and the public were not involved in the design, conduct, and reporting of the study.

Data analysis led to the emergence of 50 codes and five themes ( table 3 ).

Emergent themes and categories

Social capital

Historical aspects and socio-political movements.

The unique public health history of Kerala was commented on by majority of the participants.

By the beginning of the nineteenth century the princely state of Kerala initiated vaccination and within 25 years community-based vaccination programs evolved. Kerala was ahead in education and health compared to other states of India, contributed by the missionaries and the socio-political movements even before independence. The investments in public health and social determinants of health continued during the post-independence era. (State-level public health expert, IDI7)

The state has a legacy of linking health to non-health sectors. The socialist movements and land reforms were instrumental in nourishing equity by mitigating the difference in economics, education and social advantage between different communities.

Social determinants of health and health indicators

Kerala model of health care focussed mainly on social welfare elements like education, agriculture, water, and sanitation, which could bring substantial improvements in the health status of the population. This prompts the state to act at the level of social determinants in every emerging health issue. (SEC1, FGD1)

In the context of COVID-19, the high literacy rate of Kerala has helped in better penetration of knowledge and awareness among people, thereby creating more alert and response in the civil society. This has attributed to the involvement of people especially youth in campaigns and community organisations.

It was not necessary to inform people, they were aware of COVID 19 and the importance of hand hygiene and sanitation practices. Even many expatriates reported and quarantined themselves. Monitoring alone was needed in those places. (Health inspector 1, IDI3)

The level of literacy and healthcare-seeking behaviour enabled people to understand the mode of spread of infection and improved the willingness to follow the protocols and guidelines.

With the health system well in place, the delay in symptom onset to admission was around 2.5 days. (State medical board member, IDI1)

Robust public health system

Efficiency and distribution.

The most important strength of Kerala’s health system is the wide distribution of health facilities, most importantly the PHCs that facilitate the grassroot-level healthcare of the community. Every panchayat (LSGD for every 20 000–40 000 population) in Kerala has a PHC and an AYUSH (indigenous system of medicine) hospital and evenly distributed compared with other parts of the country. Every PHC has 5–6 peripheral outreach centres known as subcentres manned with a junior health inspector and a junior public health nurse (JPHN). Along with the government facilities, there is a wide network of private hospitals in Kerala that cater to a major proportion of the state’s healthcare needs.

The well-qualified and trained healthcare staff with good unity of command resulting from the experience in managing several communicable diseases over the years is the backbone of Kerala’s healthcare system. The efficiency was not confined to identification, reporting and clinical management of cases, but also to the strong mechanism of supervising, monitoring and grievance redressal.

… So, once we have any program or guidelines in place, there is a system to receive it … and that is very important. In the absence of an efficient system, preparing guidelines is a futile exercise. I repeatedly use the word system … because in such responses system does matter, at the micro and macro level. (State PEID cell coordinator, IDI8)

Disease surveillance system

Integrated Disease Surveillance Project initiated in 2005 with daily and weekly reporting of communicable diseases through paramedical field staffs, clinical surveillance throughout hospitals and laboratory surveillance represent a robust surveillance network at the grassroots level.

Even though the disease was new, COVID only needed to be included in the established surveillance mechanisms of the state. In the same way as identifying a diarrhoea cluster through syndromic surveillance, we needed to identify ILI clusters here. (JPHN2, FGD4)

The existing strong surveillance mechanism for infectious diseases incorporating private institutions through Integrated Disease Surveillance Programme, Prevention of Epidemic and Infectious Disease (PEID) cells for medical college institutions and Joint Effort for Elimination of Tuberculosis for surveillance of respiratory symptoms has helped in building up mechanisms for tackling any emerging outbreak.

Anganwadi workers (outreach workers of Integrated Child Development Service Scheme) and a well-motivated group of Accredited Social Health Activists recruited through National Health Mission forms a network to capture potential health issues that can emerge in the community. During the pandemic, COVID-19 control became a part of their routine activities.

Participation and volunteerism

Effective leadership made the system well accommodative and open for community participation.

… I would like to call it an enlightened leadership … accepting scientific advice and trying to understand things as much as possible, has played a big role. (SCE 1, FGD1)

The knee-jerk administrative response and the checks and balances were evident from the very beginning of the pandemic. The daily press conference by the chief minister of the state and open discussions with the media made the leadership more democratic. Each district was assigned to a state minister and review meetings were held as and when needed. The vertical and horizontal integration made the administrative system of the state more transparent and acceptable to the people. At the subdistrict level, a medical officer was posted as the nodal officer to coordinate the activities related to COVID-19 and to ensure proper communication.

Intersectoral coordination

It would be too reductive to even think that, it’s the health system which alone has done all these activities. It’s the combined effort of all sectors, along with people who can understand and comply with the instructions of the state, which made this fight more fruitful. (DPM1, FGD2)

The role of various departments notably, LSGDs, public distribution system, police, disaster management, education, information technology, media and fire force were evident from the beginning. They played a pivotal role in addressing the medical and non-medical needs of the people, and in control measures including ensuring quarantine and maintaining social distancing. LSGD integrated different departments at the field level and provided financial assistance for COVID-19 control activities. The proactive action of LSGD in social mobilisation along with non-government organisations and self-help groups like Kudumbashree (Kudumbashree is the neighbourhood group of women, part of the poverty eradication mission of the government of Kerala and is widely distributed across Kerala) was evident during the pandemic. They were instrumental in ensuring an uninterrupted supply of food to quarantined people, migrant labourers and the destitute by initiating a ‘community kitchen’ immediately following the lockdown along with public distribution system. Disaster management authority along with LSGD identified unoccupied buildings and converted it to quarantine and treatment facilities.

The fire force department helped in procuring and delivering drugs and other medical needs, using the district and gram panchayat funds. The police force played an important role in enforcing the preventive measures at the community level including the use of face masks and preventing social gatherings. They ensured food and shelter to the vulnerable including migrants and the destitute.

… I would like to describe our police department in two phases, one before COVID and the other after COVID. Even though police are more community-oriented in Kerala through ‘Janamaithri’ (people friendly) police stations and students’ police cadets, the police department was more focused on enforcing law and order … But now, social welfare is our additional focus … (PF1, FGD3)

To a greater extend various campaigns were effective because of widespread awareness generation by social media. Media scrutinised different administrative data, integrating and debating expert opinion, and acted as a corrective force to the government.

… We witnessed epidemiology, public health, mathematical models being discussed in and out of medical circles in all media platforms. Medical personnel acquired an epidemiological perspective, so did common people. (DO 2, FGD2)

The information technology department simplified the surveillance and data management by developing platforms for contact tracing and surveillance, mobile application (named GoK Direct) to ensure the real-time transfer of information related to COVID-19, providing trained human resources and integrating data from various departments.

People’s participation

Community participation saw many appreciable facets in Kerala from participating in government sensitisation campaigns to innovative community-level approaches and control measures. Through several groups like ‘Jagratha Samithi’ (means alertness committee and are ward level committees formed by volunteers), people came forward by themselves and took the responsibility. Social surveillance measures from the public acted as a third eye and helped the health workers in ensuring quarantine. The response from the community was quick and effective, and special strategies to ensure food delivery and medical provisions were possible largely due to the people’s participation.

We started a help desk for Non-Resident Indians to meet their medical needs, which later expanded to non-medical needs too, a project with zero budget and finally distributed around 48 lakh materials by volunteers … It’s like sleeping cells we just need to activate it … it’s not easy to find such systems in other parts of India. (SCE 3, FGD1)

Health system preparedness

Previous experiences.

… Both the Nipah outbreak and two flood experiences in successive years, 2018, 2019 and the successful prevention of outbreaks of infectious disease following the disasters, taught the health fraternity that more than the individual doctor/nurse skill, the system is more important and should be in place … (DPM 1, FGD2

By late January, even when the first case of COVID-19 was identified in the country from a Wuhan returnee under quarantine in Kerala, the state had established Corona Control Cell, and protocols were set in place. This pre-emptive response was possible from the previous experiences of managing an outbreak.

The experience with Nipah brought several guidelines in place for infection control including the establishment of an outbreak monitoring unit and regular training to all health workers through link nurses. It familiarised the health workers with triage, red channel, and personal protective equipment.

Evidence-based action

Even before the first case of COVID-19 was reported in the country, the health system of Kerala was preparing with abundant measures. Evidence-based guidelines and evolving protocols to accommodate the emerging evidence made the process more scientific.

Kerala was a step ahead in including people coming from Middle East countries in the surveillance network, even before WHO included those countries. We couldn’t allow even 1% error considering the high population density in the state. (SCE 5, FGD1)

Contact tracing of each positive patient with route maps and their risk stratification by the surveillance team at the district level helped in widening the surveillance network. Call centres were enabled to provide round-the-clock support. Guidelines for quarantine, testing and treatment were established. If the institutional medical board had difficulty in decision-making, they can refer to the district or state medical board. District Programme Management and Support Units acted as dedicated real-time management structures for coordinating admission, referrals and inpatient facilities across government and private sectors.

In our state, protocols are flexible, the institutional medical board is endowed with the power of decision making in COVID management. They should document it. There is currently no COVID 19 expert in the world. (State medical board member, IDI1)

The state announced several campaigns like ‘break the chain campaign’ and ‘SMS campaign-Soap-mask-social distancing’ for better penetration of preventive strategies to the grassroot level. Reverse quarantine was an important strategy post lockdown to protect the vulnerable from infection. Considering the evolution of disease spread along with the socio-cultural aspects, region-specific strategies for the containment zones were devised.

Upscaling of facilities and services

The rate-limiting element in terms of resources was the availability of personal protective equipment and prompt measures were undertaken to attain self-sufficiency. The increased demand for masks and sanitisers was well handled by initiating locally sustainable production, including N-95 masks.

Health system preparedness was ensured at all three levels of healthcare. At primary and secondary levels, protocols were set for respiratory triage, and all staff were provided training on infection prevention and control. A good example of institutional preparedness demonstrated by the state was the setting up of tiers of COVID-19 management centres including the COVID-19 hospitals, COVID-19 Second Line Treatment Centres, COVID-19 First-Line Treatment Centres (CFLTCs, dedicated centres to isolate and manage asymptomatic and mild cases) and COVID-19 care centres (centres for institutional quarantine). The disaster management authority with the help of LSGDs identified infrastructure in the form of buildings like schools, colleges, auditoriums and so on to establish these facilities. Increased demand for human resources was met by hastening the appointment of doctors through Kerala public service commission, appointing the freshly passed out batch of medical graduates in CFLTCs, and making a contract-based appointment through National Health Mission. Facilities for intensive care in the tertiary care centres were revamped. Daily district-wise forecasting of cases was done to plan for resource management. The private health institutions were well informed and their cooperation was ensured. Telemedicine facilities were established to reduce patient contact (for COVID-19 and non-COVID-19 services) with the hospitals. Walk-In Kiosk for sample collection and mobile testing units were established.

Victim of initial success

… It’s called prevention paradox when people start seeing a very low number of cases around, they might think all measures were unnecessary … (SCE 2, FGD1)

The low number of cases and deaths in the initial phase has given a false sense of security and complacency among people. People failed to recognise the seriousness of the situation when all services were provided free of cost.

… People started believing that they won’t get infected and when asymptomatic individuals became positive for the disease, they even denied their infections. … The involvement of religious leaders and peoples’ representatives have helped in tranquilizing people and obliteraterating their misconceptions … (PF5, FGD3) … At the end of it, how much ever we enforce and give Information Education Communication, it is people who need to self-restraint … so we need to shift the focus from enforcing for a short duration to a behavioural change ingrained in the society … (State police official, IDI2)

Limited resources

As the healthcare mechanisms focused on COVID-19, the non-COVID-19 care was affected and the restriction of movement and lack of conveyance reduced the access to even available facilities. This was tackled to a great extent by telemedicine facilities, home delivery of drugs for chronic ailments and designating COVID-19 hospitals enabling non-COVID-19 care to run smoothly in other hospitals.

The challenge of human resource scarcity cropped up when few of the existing workforce was diagnosed with the disease and many were quarantined.

… When one among us became COVID positive for the first time, around 19 officers were primary contacts and all had to go for quarantine, later we started following the duty shift practices as per the advice of public health experts, and when the second case was detected among officers, there were only 4 primary contacts … (PF2, FGD3)

There was discordance in communication at the state level and between the state and districts. With the evolving evidence, the guidelines were frequently modified without addressing the capacity and resources at lower levels. The lack of proactive actions and failure to understand the urgency of the situation by some sectors overburdened the existing system.

Kerala’s experience with COVID-19 19 puts forth lessons to transcribe and assimilate, not only for the state and the nation but also on a global perspective. The trajectory of Kerala’s development is distinguished by the primacy of the social sector and the Kerala model of healthcare is often described as ‘good health based on social justice and equity’. 14 15 The state has held up this basic principle in every health scenario and the ‘humane’ nature of Kerala’s COVID-19 control has received wide global appreciation. 16

Kerala has marched far ahead of other states of India in health indicators decades back with its organised healthcare. 15 17 During this pandemic, with the effective containment strategies, Kerala had become the front runner in India’s initial fight against COVID-19. 18 19 The state has witnessed several viral outbreaks in the past, and the experiences thus gained paved the way to the expeditious response from the state in exercising strategies focusing on the prevention of the spread of infection rather than on curative care. When the impact of the pandemic especially the lockdown devastated the social sphere of already famished societies of other states, Kerala was well prepared to extend special care and uninterrupted food supply to all including migrant labourers and destitute. 14 20 21

In a pandemic situation, every government department and the non-government institute has a responsibility to the society and is pivotal for the well-balanced functioning of the system. 22 In a state where more than 60% of the population depends on the private healthcare system, an epidemic response from surveillance to management mandates private sector involvement. 23 The early initiative of the government to establish public–private partnerships ensured adequate manpower and material resources in the COVID-19 response. However, beyond the system, the backbone of Kerala’s COVID-19 control strategy was community participation and the social capital was well harnessed by the state at the time of crisis. In a state like Kerala with a high proportion of religious diversity, the religious/community leaders played an inevitable role in alleviating anxiety and ensuring safety measures. The use of local governance structures and community health networks in implementing dynamic policy made Kerala distinct from other states in the country, another example being Odisha. 24 25 The long experience with disaster in the state of Odisha had led to the repurposing of crisis prevention measures engaging a vast network of local institutions during the pandemic. 26 Unlike Odisha, Kerala is not historically known for frequent natural calamities; however, in the recent past, the state has been facing several disasters in quick succession. 27 The well-organised local self-governance of the state was further fine-tuned towards emergency preparedness and outbreak response and had facilitated a quick response during the pandemic. 28 29 The time and effort of the community became the major resource of the state, unlike other successful global models. While Germany had a well-prepared health infrastructure in advance which could cater the intensive care even during the peak of the outbreak, many other European counterparts had to adapt to other spaces in the hospital to accommodate the critically ill. As in Kerala, community care facilities were organised by repurposing large spaces like conference halls, schools and so on in countries like Hong Kong, Singapore, South Korea and the UK. 30

The state had its own challenges, foremost being the high number of expatriates and high population density. 31 32 The heavy burden of non-communicable diseases and the old age population in the state was a threat owing to the risk of severe illness and mortality. 21 33 34 This was tackled to a large extend by the coordinated activities of various departments by providing essential services via social welfare programmes, ensuring effective surveillance and stringent measures for reverse quarantine. This mechanism where each sector knows their capabilities and the ability to channelise those resources to function together helped in overcoming many challenges.

Officials working in the immigration department and the state coordinate national operations were not included in the study. Further, the possibility of a positive bias in highlighting the efficiency of the system cannot be excluded as the majority of the respondents were within the government system. Every possible effort was made to avoid this bias through probing questions ensuring documentation of all dimensions.

With the easing of restrictions and resuming of routine life, every nation is at a threat of rise in COVID-19 cases. It is of high priority to revisit the successful strategies from different nations to appraise the lessons learnt and to identify the challenges to help future planning. The present study is a much-needed treatise to provide a balanced perspective on the intricacies of epidemic management in a low/middle-income country. Kerala puts forth a model of evidence-based actions through a robust public health system with good community participation and intersectoral collaboration build on existing social capital. As the future of COVID-19 remains unknown, it is never late for any evidence-based innovative strategies and interventions to be cautiously implemented.

Supplementary Material

Acknowledgments.

We acknowledge all our participants for their cooperation amidst the pandemic situation. We thank Professor Indu P S, Head of Department of Community Medicine, Government Medical College, Thiruvananthapuram for the guidance.

Contributors: KCP, AR and TSNA had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. KCP, AR, TSNA and SC contributed to the plan and design of the study. KCP, AR, TSNA, SC, GS and MJV developed the interview guide. KCP, AR, MMS, ANKKN, SC, GS and MJV led the data collection and performed the data analyses. All authors participated in the interpretation of the results. KCP, AR, SC and TSNA drafted the manuscript. SC, GS, MJV, MMS, ANKKN, ARK, SV and TSNA contributed to the critical revision of the manuscript for important intellectual content and approved the final version of the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: Author TSNA is a member of the state expert committee group, a scientific group that helps the state to assimilate available scientific evidence on COVID -19 and provide evidence-based opinions on prevention and control of the COVID-19 pandemic. Author ARK is a member of the state expert committee group, state rapid response team with a role to assess and formulate responses to infectious diseases of public health importance, and state medical board providing evidence-based opinions on patient management to the institutional level medical boards during the pandemic. Author SV is joint secretary to the Government of Kerala in the department of Health and Family Welfare. TSNA was involved in the plan and design of this study, interpretation of the results, drafting, and critical revision of the manuscript. ARK and SV were involved in the interpretation of the results and critical revision of the manuscript.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

Ethics approval

Ethics clearance for the study proposal was obtained from the Institutional Ethics Committee (Human) at Government Medical College, Thiruvananthapuram, Kerala, India (HEC.NO.03/65/2020/MCT). Free and informed consent was obtained from all study participants.

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University of Kerala: Rankings

Updated: February 29, 2024

The University of Kerala ranked 43rd in India, 2114th in the global 2024 rating, and scored in the TOP 50% across 72 research topics. The University of Kerala ranking is based on 3 factors: research output (EduRank's index has 7,535 academic publications and 86,102 citations attributed to the university), non-academic reputation, and the impact of 41 notable alumni .

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Biology rankings

The University of Kerala ranked 67th for Biology in India and 1540th in the World with 5,054 publications made and 68,214 citations received. Main research topics: Biochemistry, Genetics, Botany, Paleontology, Nanotechnology.

University of Kerala Biology Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Biology.

Chemistry rankings

The University of Kerala ranked 64th for Chemistry in India and 1421st in the World with 4,989 publications made and 71,055 citations received. Main research topics: Organic Chemistry, Biochemistry, Materials Science, Chemical Engineering, Nanotechnology.

University of Kerala Chemistry Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Chemistry.

Engineering rankings

The University of Kerala ranked 87th for Engineering in India and 1619th in the World with 4,186 publications made and 55,390 citations received. Main research topics: Materials Science, Optical Engineering, Metallurgical Engineering, Chemical Engineering, Nanotechnology.

University of Kerala Engineering Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Engineering.

Physics rankings

The University of Kerala ranked 84th for Physics in India and 1586th in the World with 3,996 publications made and 51,966 citations received. Main research topics: Quantum and Particle physics, Materials Science, Optical Engineering, Nanotechnology, Astrophysics and Astronomy.

University of Kerala Physics Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Physics.

Environmental Science rankings

The University of Kerala ranked 65th for Environmental Science in India and 1597th in the World with 3,882 publications made and 47,275 citations received. Main research topics: Geology, Ecology, Geography and Cartography, Paleontology, Environmental Chemistry.

University of Kerala Environmental Science Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Environmental Science.

Medicine rankings

The University of Kerala ranked 79th for Medicine in India and 1901st in the World with 2,404 publications made and 30,651 citations received. Main research topics: Pathology, Pharmacology, Immunology, Public Health, Psychiatry.

University of Kerala Medicine Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Medicine.

Computer Science rankings

The University of Kerala ranked 130th for Computer Science in India and 2246th in the World with 2,065 publications made and 16,498 citations received. Main research topics: Artificial Intelligence (AI), Machine Learning, Computer Vision, Telecommunications, Cognitive Science.

University of Kerala Computer Science Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Computer Science.

Liberal Arts & Social Sciences rankings

The University of Kerala ranked 128th for Liberal Arts & Social Sciences in India and 3142nd in the World with 1,827 publications made and 12,159 citations received. Main research topics: Philosophy, Political Science, Sociology, Law, History.

University of Kerala Liberal Arts & Social Sciences Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Liberal Arts & Social Sciences.

Mathematics rankings

The University of Kerala ranked 96th for Mathematics in India and 2168th in the World with 1,050 publications made and 7,486 citations received. Main research topics: Statistics, Applied Mathematics, Econometrics and Mathematical Economics, Blockchain and Cryptography, Math Teachers.

University of Kerala Mathematics Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Mathematics.

Economics rankings

The University of Kerala ranked 91st for Economics in India and 2452nd in the World with 584 publications made and 3,101 citations received. Main research topics: Finance, Development Studies, Econometrics and Mathematical Economics.

University of Kerala Economics Publications & Citations

The following table provides academic rankings for The University of Kerala in various areas of Economics.

Other rankings

Non-core subjects for the University of Kerala

KCHR Pattanam Campus

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Monsoon reaches Kerala two days ahead of schedule

The imd has forecast above-normal rains at 106% of the 50-year or long-period average this year.

 New Delhi/Mumbai: Amid a searing heatwave in parts of India and landslides and floods in others, the south-west monsoon marked an early entry Thursday, two days ahead of schedule.

The monsoon has set in over Kerala in southern India and already advanced into most parts of northeast India, the India Meteorological Department (IMD) said in a statement Thursday afternoon. The monsoon’s entry was preceded by widespread rains over the past few days in these states.

The four-month long monsoon season, beginning June, is a lifeline for much of the country, particularly for rural areas dependent on farming. It brings in three quarters of India’s annual rainfall--watering crops, filling up reservoirs, and boosting farm incomes and consumer demand.

Also read: Mint Quick Edit | Will heat deliver a torrential monsoon this year?

The monsoon is never a straight story and its distribution over time and geographies will be key, said Dharmakirti Joshi, chief economist at Crisil . “The good news is that rains are forecast to be above normal," said Joshi. “Farm and wage incomes are likely to improve. A good harvest will cool food prices, particularly cereals like rice and some varieties of pulses." Food inflation has been hovering at over 8% for the past six months.

Typically, after entering Kerala and touching the northeast, the monsoon gradually progresses through the country, reaching the northernmost parts between end-June and early July.

The IMD has forecast above-normal rains at 106% of the 50-year or long-period average (LPA) this year. Rains are likely to be above normal in most rain-fed farming areas, the weather office said earlier this week in an updated forecast. It attributed a 61% probability to above normal (105-110% of LPA) and excess rains (over 110% of LPA), which raise the risk of possible floods in some parts of the country.

Also read: Above-normal rains seen, says IMD; monsoon over Kerala in five days

The monsoon is critical for India’s vast farm economy, which employs over 45% of its workforce and contributes about 15% to its gross domestic product (GDP). Uneven rains were a reason why farm sector growth rate plummeted to a low of 0.7% in 2023-24, compared to 4.7% in the previous year.

Rural markets have been weak for the past six quarters for the home appliances industry, said Anuj Poddar, managing director and chief executive, Bajaj Electricals Ltd. “Coming on the back of an intense summer, a favourable monsoon will imply a strong second half of the year vis-à-vis demand. The outlook will be much better than last year," he said.

Combating food inflation, with non-food inflation already being low, can provide policy room for interest rate cuts, Crisil Research said in a note Thursday.

It added that above-normal temperatures predicted in June, when planting for the Kharif crop season begins, could impact the availability of labour or the ability to work under extreme conditions. High temperatures can also deplete reservoir levels, which are already 24% below capacity.

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