Kerala’s NCD burden calls for social determinants of health approach

Kerala's NCD burden
Kerala's famed public health system is crumbling under the weight of non-communicable diseases, or NCDs, highlighting the need for a comprehensive approach to addressing the NCD epidemic.

The brewing public health crisis in Kerala is evident in the growing burden of non-communicable diseases. The state government has failed to comprehensively address the prevention and care needs of noncommunicable diseases. Labelling NCDs as lifestyle diseases reveals a superficial understanding of these illnesses by the policy makers, as lifestyle factors contribute minimally to the causes and consequences of NCDs. Social and structural determinants play a critical role in the prevention, control, and care of NCDs.

Hailed as a model of social justice and equity, Kerala’s health system, led by the public sector, is now a relic of the past. Currently, 70% of patients rely on private healthcare, with the government favouring selective healthcare over comprehensive primary care. The health sector began facing crises in the early 1980s. Diseases like malaria, once eradicated, resurfaced, along with new viral diseases like dengue and chikungunya. NCDs have since become the leading chronic disease burden in Kerala.

In Indian system, health is primarily the responsibility of state governments. Any analysis of care needs in India should also focus on unique prevention, care, and support needs. NCDs account for approximately 64% of all deaths in India, impacting not only health but also the financial stability of households due to increased out-of-pocket expenses for treatment and care. This leads to impoverishment of families and individuals.

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Kerala’s NCD burden

Kerala, often referred to as the diabetes capital of India, has a diabetes prevalence of 20% — double the national average. The state also records the highest burden of NCDs and related impoverishment due to treatment costs. In Kerala, 70% of patients rely on private care. Hospitalisation rates for individuals with NCDs increased significantly from 2014 to 2017–18. Out-of-pocket expenditure is a major cause of catastrophic health expenditure, driven largely by the neglect of primary healthcare needs.

The incidence of catastrophic health expenditure in Kerala is worrying, given the high burden of NCDs and extensive healthcare utilisation. Studies indicate that a significant proportion of households experience catastrophic health expenditure, particularly in the context of acute coronary events and COVID-19 hospitalisation.

Ronnie Thomas and colleagues from the Department of Community Medicine, Government Medical College Kottayam, assessed the financial burden and catastrophic health expenditure associated with COVID-19 hospitalisation in Kerala. A policy report highlighted the economic burden of ill health in Kerala and proposed a manifesto for reimagining health in the state, emphasising strengthening primary healthcare and addressing social determinants of health.

More than 100 panchayats in Kerala lack government hospitalisation facilities, forcing reliance on private healthcare and leading to catastrophic health expenditure. Definitions and thresholds for calculating catastrophic health expenditure vary in the literature. The likelihood of incurring catastrophic payments and distressed financing is notably higher for NCDs in India, particularly for rural residents and poorer households.

The economic loss attributed to NCDs in India (excluding mental health) is projected to reach $3.55 trillion between 2012 and 2030. The Ministry of Health and Family Welfare introduced the National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in 2010, updated in May 2023 to the National Programme for Prevention and Control of Non-Communicable Diseases 2023-2030 (NP-NCD). However, there is no realistic plan of action to address the social and structural determinants of NCDs and the catastrophic health expenditure they cause, either by the state or federal governments.


Verma, V.R., Kumar, P. & Dash, U. Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys. BMC Public Health 21, 881 (2021).

Stephen Jan, et al (2016) Catastrophic health expenditure on acute coronary events in Asia: a prospective study.  Bull World Health Organ 2016;94:193–200

Thomas R, Jacob QM, Raj Eliza S, et al.(2022) Financial Burden and Catastrophic Health Expenditure Associated with COVID-19 Hospitalizations in Kerala, South India. Clinico-economics and Outcomes Research : CEOR. 2022 ;14:439-446. DOI: 10.2147/ceor.s365999. PMID: 35813122; PMCID: PMC9270006.

Nandana Prakash & Manju S. Nair (2023) Catastrophic Health Expenditure due to Inpatient Medical Care in Kerala. IOSR Journal of Humanities and Social Science (IOSR-JHSS) Volume 28, Issue 3, Series 8 (March, 2023) 35-40. e-ISSN: 2279-0837, p-ISSN:

Joe Thomas (2021) Reimagining health: A people’s manifesto for Kerala.

Ronnie Thomas, Quincy Mariam Jacob, Sharon Raj Eliza, Malathi Mini, Jobinse Jose & Sobha A (2022) Financial Burden and Catastrophic Health Expenditure Associated with COVID-19 Hospitalizations in Kerala, South India, Clinico Economics and Outcomes Research, 14: 439-446, DOI: 10.2147/CEOR.S365999

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Dr Joe Thomas is Professor of Public Health, Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.