13 Kutty (jl/d) 11/2/00 3:17 pm Page 103

HEALTH POLICY AND PLANNING; 15(1): 103–109 © Oxford University Press 2000

Historical analysis of the development of health care facilities

in Kerala State, India
V RAMAN KUTTY
‘Health Action by People’, Petta Trivandrum, India

Kerala’s development experience has been distinguished by the primacy of the social sectors. Traditionally,
education and health accounted for the greatest shares of the state government’s expenditure. Health sector
spending continued to grow even after 1980 when generally the fiscal deficit in the state budget was growing
and government was looking for ways to control expenditure. But growth in the number of beds and insti-
tutions in the public sector had slowed down by the mid-1980s. From 1986–1996, growth in the private sector

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surpassed that in the public sector by a wide margin.

Public sector spending reveals that in recent years, expansion has been limited to revenue expenditure rather
than capital, and salaries at the cost of supplies. Many developments outside health, such as growing liter-
acy, increasing household incomes and population ageing (leading to increased numbers of people with
chronic afflictions), probably fuelled the demand for health care already created by the increased access to
health facilities. Since the government institutions could not grow in number and quality at a rate that would
have satisfied this demand, health sector development in Kerala after the mid–1980s has been dominated
by the private sector.

Expansion in private facilities in health has been closely linked to developments in the government health
sector. Public institutions play by far the dominant role in training personnel. They have also sensitized
people to the need for timely health interventions and thus helped to create demand. At this point in time,
the government must take the lead in quality maintenance and setting of standards. Current legislation,
which has brought government health institutions under local government control, can perhaps facilitate this
change by helping to improve standards in public institutions.

Introduction attributed to inter-sectoral factors such as the spread of edu-

cation, political awareness, development of road networks
Though poor by standards of per capita income, industrial- and transportation, and social movements. However, the role
ization or agricultural production, the Indian state of Kerala of the health care sector itself cannot be ignored.
has shown that these constraints need not hinder the develop-
ment of social sectors. The state has achieved near universal Investment in education and health infrastructure has been a
literacy for both males and females and the health care consistent policy of all elected governments in Kerala, what-
indices are comparable to countries with more advanced ever their political leaning. The tradition of government
economies (Table 1). This ‘health development’ is generally support for health development has been a catalyst for the
advancement of health care in the state. In recent years, there
Table 1. Literacy, sex ratio, crude birth rate (CBR), crude death
has also been considerable growth in private health facilities,
rate (CDR) and infant mortality rate (IMR) for India and Kerala so much so that these now outstrip government facilities in
number. There may be a number of reasons behind this
growth, including changes in social and economic factors such
Indicator India Kerala
as increasing per capita income and the spread of literacy. So
far, there has been no attempt to describe the growth of the
Literacy % (males)a 64.13 93.62 state’s health sector, the pattern of distribution of public and
Literacy % (females)a 39.29 86.17
private facilities, and the circumstances contributing to this
Sex ratioa (females/1000 males) 927 1036
CBR (per 1000 population) 28.5 17.3 pattern.
CDR (per 1000 population) 9.2 6.0
IMR (per 1000 live births) 74 13
Objective
aRefers to year 1991. Other data are 1993. This paper seeks to describe the growth of health care facili-
Source: Health Monitor. Ahmedabad: Foundation for Research in ties in Kerala, with respect to: the increase in the number of
Health Systems, 1994. public institutions and beds, and the trends in government
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104 V Raman Kutty

expenditure on health; the current pattern of distribution of Health sector development in Kerala
health care facilities in the public and private sectors; and the
At the time of formation of the present Kerala state on 1
implications arising from these for the state’s future health
November 1956, the foundation for a medical care system
development. The paper is divided into four sections: (1) a
accessible to all citizens was already laid. One indicator of the
summary of the historical milestones in the growth of modern
government’s commitment to health services provision is the
medical care in Kerala; (2) health sector growth in Kerala
proportion of government expenditure set apart for health.
after the state’s formation in 1956; (3) current patterns of
From the time of the state’s formation, the government’s
distribution of health care facilities in the public and private
budget allocation for health was considerable. Social sectors,
sectors; and (4) the policy concerns arising out of these.
mainly comprising education and health, accounted for a
large share of the government development expenditure. The
History of western medical care in Kerala period from state formation to the early 1980s was character-
ized by great growth and expansion of the government health
Kerala has a long history of organized health care. Before the
services. Figures show the annual compound growth rate of
advent of European medicine, families of practitioners of
government health care expenditure for the period at 13.04%

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indigenous systems like Ayurveda handed their traditions
(at current prices, without deflation), outstripping both the
from generation to generation. People were accustomed to
annual compound growth rate of total government expendi-
approaching caregivers when they were sick, rather than
ture at 12.45% and the annual compound growth rate of the
turning to self-treatment. When the colonial powers estab-
state domestic product at 9.81%.2
lished their presence in the region, they brought their medical
system with them. In the 19th century, the princely rulers of the
From 1961 to 1986, the state greatly expanded its government
erstwhile states of Travancore and Cochin (which later were
health facilities. The number of beds and institutions
integrated into the state of Kerala along with the Malabar dis-
increased sharply. The total number of beds in government
trict of the Madras presidency in British India) took the initia-
hospitals in the western medical sector increased from around
tive in making the western system of care available to their
13 000 in 1960–61 to 20 000 in 1970–71, and 29 000 in 1980–81.
subjects. A royal proclamation of 1879 made vaccination com-
By 1986, the total was 36 000. Estimates in 1996 put the
pulsory for public servants, prisoners and students.1
number at 38 000.3,4 Thus the major growth phase of facilities
in the government sector was before 1986, after which it
All heads of public departments were instructed to see that
slowed considerably.
those under their care and control were vaccinated. Adminis-
trative reports indicate that public health authorities were
also concerned about the spread of cholera during fairs and
Fiscal crisis in the government and its effect on
festivals, and initiated measures of containment.1 In 1928,
health services
under the auspices of the Travancore government and with
the help of the Rockefeller foundation, parasite surverys The period from the mid-1970s to the early 1990s has been
were conducted in Travancore which led to measures to termed a period of ‘fiscal crisis’ for the state government.
control hookworm and filariasis. A health unit incorporating There was unprecedented growth in revenue deficits – the
many of the concepts of primary health care was also started excess of government expenditure over revenue – which has
in a rural area. been well documented in recent studies.5 Though budgetary
deficit has become a common feature for all states in India,
Development of health services was not confined to the pro- the magnitude of the deficit in Kerala has been steadily
vision of preventive care – the general hospitals in Trivan- growing and is substantively higher than the All-States
drum and Cochin are about 150 years old. Initiatives were average in India as a whole. During this time, expenditure on
also taken to get members of the respective states who were health shows that after an initial slowing down of the growth
trained in western medicine into key posts in the government of average annual total expenditure in real terms from
service. The appointment of Dr Mary Punnen Lukose as the 1975–79 to 1980–84 (Figure 1), growth recovered from
surgeon-general of Travancore in the early years of the 20th 1985–89 through 1990–94. Plan expenditure, which is sup-
century is a case in point. A doctor trained in England, she ported by grants from central government, did not contribute
was the first woman to be appointed surgeon-general in an to the initial setback; in fact, plan expenditure grew from
Indian state, at a time when women doctors were still a rarity 1975–79 to 1980–84. Plan expenditure consists mainly of
in Europe and America. expenditure on central government schemes such as national
disease control programmes. As such, the component of
Development of health services was complemented by other capital expenditure is larger in plan expenditure. Non-plan
parallel events: initiatives to provide safe drinking water (in expenditure is the major chunk of government expenditure
the capital city of Trivandrum initially) and the provision of on health and is contributed by the state government.
state supported primary education, including education for Revenue expenditure, which includes a large component of
women. Though schooling had not reached today’s levels of salaries, constitutes the larger share of non-plan expenditure.
coverage, the first steps were taken. Another important factor By 1990–94 the central government severely curtailed spend-
was the establishment of mission hospitals in remote areas ing on health as a natural consequence of its own policies; this
under the auspices of Christian churches. Young girls from is reflected in the reduced plan expenditure in Kerala.
the Christian community in Kerala were keen to take up
nursing as a career. Examining government health expenditure under its different
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Historical development of health care in Kerala 105

infrastructure) stagnated by the mid-1980s before declining

rapidly, whereas revenue spending (salaries and consumables)
continued to grow into the 1990s.6 This is due to the salary
component in revenue expenditure, which showed no sign of
diminishing during most of this period. In view of the state’s
socio-political environment, characterized by a high awareness
of their political rights by the organized labour force, including
government employees, this is not surprising.

Successive governments, being committed to growing expen-

diture on salaries because of increases both in jobs created
and in pay, resorted to cutting back supplies when faced with
growing fiscal difficulty. Spending on supplies shows a definite
downturn by the latter half of the 1980s (in state government

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accounting, ‘supplies’ includes drugs and other consumables
such as linen, minor equipment, suture materials, etc). This
had a major affect on the secondary sector, consisting of the
district and taluk (sub-unit or district) hospitals, and the
primary sector, consisting of primary health centres (Table 3).
Since these accounted for a majority of beds in the health ser-
vices most accessible to the common people, the quality of
medical care in the government hospitals must have been
affected. We can only arrive at this conclusion from indirect
evidence. An extensive survey of 10 000 households by a
voluntary organization in 1987 found that overall only 23% of
households regularly utilized the government health services.
Even in the poorest stratum this share was as low as 33%,
declining steadily to 8% among the most affluent households.
Figure 1. Average annual expenditure on health in Kerala under The reasons stated for not using government institutions
plan and non-plan sectors in the periods 1975–79, 1980–84, 1985–89 included ‘non-availability of drugs in the government hospi-
and 1990–94, adjusted to the rupee value in 1970 tals’, ‘lack of proper attention’ and ‘better behaviour in
Source: Government of Kerala. Economic review 199711 private insitutions’.7

The government has been well aware of the increasing

categories reveals the impact of the fiscal crisis. During scarcity of funds in the health sector. In government hospitals
1985–86 to 1995–96 the proportion of government expenditure in Kerala, only households with incomes below a certain level
on health was maintained in spite of a large fiscal deficit (Table are entitled to free services. The government has fixed user
2). However, adjustments were made in reaction to the fiscal charges for all others, and these have existed for a long time.
situation. Analysis shows that capital spending (buildings and In spirit, this law ensures that the benefit of subsidy goes to

Table 2. Total revenue expenditure, expenditure on health and revenue deficit as a proportion of total revenue expenditure in Kerala from
1985–86 to 1995–96

Year Total revenue Expenditure on Health expenditure Revenue deficit as

expenditure health including as % of total revenue % of total revenue
(million rupees) family welfare expenditure expenditure
(million rupees) (col. 3 as % of col. 2)

1985–86 14 453.4 1268.1 8.8 5.1

1986–87 16 547.7 1450.7 8.8 9.2
1987–88 17 806.5 1510.4 8.5 10.9
1988–89 20 610.0 1636.8 7.9 8.0
1989–90 22 930.9 1923.0 8.4 10.9
1990–91 28 249.5 2219.9 7.9 14.9
1991–92 32 164.6 2318.1 7.2 11.3
1992–93 36 561.4 2392.3 6.5 9.2
1993–94 42 933.6 2984.5 7.0 8.7
1994–95 50 663.0 3566.1 7.0 7.9
1995–96 58 363.7 4178.8 7.2 6.9

Source: Government of Kerala, Economic Review 1997.11

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106 V Raman Kutty

Table 3. Average annual expenditure by government on health one estimate, 22 out of 26 CT scan centres in Kerala were in
supplies in Kerala, in constant rupees (millions), under primary, the private sector in 1995.9
secondary and tertiary sectors, and growth of expenditure in these
sectors
Many factors outside the health sector could have facilitated
the growth in the private sector. Two of the most important
Period Primary Secondary Tertiary are rising disposable incomes and the lack of barriers to
sector sector sector
opening a private hospital. While on the one hand the state
government was under the pressure of fiscal difficulties, there
(i) 1977–78 to 1979–80 –24.58 86.63 37.05 is some evidence that household disposable income was rising
(ii) 1980–81 to 1984–85 –26.16 104.39 41.87 steadily. Calculations based on data from household con-
% change from (i) to (ii) – 6.4 20.5 13.0
(iii) 1985–86 to 1989–90 –25.71 113.22 57.41
sumer expenditure surveys in 1977 and 1993 show that while
% change from (ii) to (iii) –1.7 8.5 37.1 in 1977, 50% of the population accounted for just over 20%
(iv) 1990–91 to 1992–93 –21.52 101.02 56.7 of the state’s total consumer expenditure, their share
% change from (iii) to (iv) –16.3 –10.8 –1.2 increased to over 30% in 1993 (Figure 2). Greater disposable

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incomes for the lower income groups could have encouraged
Source: computed from various budget documents, Government of more and more of these people to seek health care services in
Kerala. the paying private sector. The absence of government legis-
lation relating to hospital start-up, running and profit gener-
ation was a feature Kerala shared with most states in India,
the poorest households. However, in practice this rule is sys- but the high demand for health care in Kerala probably pro-
tematically breached. There is no mechanism to verify the vided the impetus for the growth in its private health sector.
self-declared income of patients. Moreover, even those who
are willing to declare their true income and pay for services Another important demographic phenomenon taking place
are discouraged from doing so because of administrative in Kerala during the same period also influenced the demand
delays consequent on such declaration. Most people there- for health care: the ageing of the population. Life expectancy
fore prefer to understate their incomes when seeking services for men during the decade 1971–81 was 60.6 years; for women
in the public sector. This has resulted in very low cost-recov- it was 62.6 years. For the period 1991–96, these figures rose to
ery in government hospitals, under 5% (Table 4). The 70 and 76 years, respectively.10 The contribution of the
Resources Commission, which was appointed by the state growing numbers of elderly to the demand for health care is
government to look into the reasons for the fiscal problems reflected in the higher proportion of chronic diseases among
and to suggest ways out of them, did recommend enforcing them and their higher spending on health care (Table 6).
the collection of user charges more actively. But successive
governments have been unable to implement the suggestion All these factors, the growing number of people with long-
fully because of politically motivated popular resistance. standing illnesses and the growth in disposable incomes,
meant that an ever greater number of people were prepared
to pay money for health care. The private health sector poss-
Growth and distribution of private facilities in
ibly exploited this demand in its growth.
health care
Private hospitals now surpass government facilities in the The pattern of distribution of facilities in the private as well
density of beds and employment of personnel. The number of as the government sector in health in Kerala provides some
beds in government institutions grew from around 36 000 to insights into the dynamics of the growth. Though compre-
38 000 in the 10 year period from 1986 to 1996; in the same hensive statistics are not available on all aspects of health
period, beds in private institutions grew from 49 000 to 67 500 care, some of the broad indicators computed from available
(Table 5).8 This amounts to nearly 40% growth in private data are reproduced in Table 7. One variable which can func-
sector beds compared to only 5.5% growth in the government tion as a proxy for available facilities is the density of beds
sector. More significantly, private hospitals have far outpaced (number of beds per 100 000 population) in each sector by dis-
government facilities in the provision of hi-tech methods of trict. There are more than 300 hospital beds per 100 000 popu-
diagnosis and therapy, such as computerized tomography lation in Kerala, which is probably one of the highest ratios in
(CT) scans, endoscopy units, magnetic resonance imaging the developing world. The average density of beds in the
(MRI), neonatal care units, coronary units, etc. According to private sector is almost twice that in the government sector,

Table 4. Cost of medical and public health services in Kerala and percentage of subsidies involved, 1977–78 and 1989–90 (million rupees)

Year Cost of public Cost recovery Cost recovery as % of Subsidy %

services cost of public services

1977–78 327.60 8.20 2.5 97.5

1989–90 1760.60 31.70 1.84 99.16

Source: Kutty and Panikar.6

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Historical development of health care in Kerala 107

Table 5. Growth of private medical facilities in the western medical All told, there are around 1.5 insitutions per 10 km2 in the
sector in Kerala, 1986–95 modern medical sector. Geographical density of private hos-
pitals (hospitals/10 km2) in the districts is highly correlated
1986 1995 growth with both literacy (Spearman r = 0.79, p < 0.01) and geo-
(n) (n) (%) graphical density of government hospitals (Spearman r =
0.85, p < 0.01). The latter correlation is not surprising since
(1) Institutions with beds 1864 1958 5.0 both government and private hospitals tend to congregate in
(2) Number of beds 49 030 67 517 37.7 areas of high population density. Geographical density of
(3) Institutions without beds 1701 2330 37.0 private hospitals is also correlated with density of beds
(4) Doctors 6345 10 388 63.7 (number per 100 000 population) in the government sector
(5) Paramedics 13 921 25 256 81.4
(Spearman r = 0.73, p < 0.01). Thus private hospitals have
been established in districts with high investment in the public
Source: Government of Kerala.8 sector.

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Many factors in the social milieu of Kerala were conducive to
the high growth of demand for health care (Table 8). The high
level of education, especially female education, ensured that
people were easily sensitized to the newer developments in
treatment. The settlement pattern in Kerala, with compara-
tively easy accessibility to the towns and other centres where
medical institutions were situated, was another contributory
factor. The rapid proliferation of health facilities in the
government sector during the 1960s and 1970s ensured a
growing awareness of modern methods of medical care,
which people then became used to. The change in income
distribution in the state, reflected in the increasing consumer
expenditure of lower income households, could also have
fuelled the growing demand for private health care. This is
borne out by data from primary surveys: the proportion of
births taking place in private hospitals increased from 42% in
a 1987 survey7 to 63% in a re-survey in 1996 (unpublished
observation).

Policy lessons
The growth of health facilities in Kerala offers many lessons
in development. The active role of the state government has
Figure 2. Distribution curve of monthly per capita consumer
expenditure in the years 1977 and 1993 in Kerala been a key factor in the expansion of health care facilities.
Sources: Government of Kerala, Statistics for Planning 1980;12 The initial period of rapid growth in health facilities was
Government of Kerala, Statistics for Planning 1988;13 ‘Sarvekshana’ dominated by the public sector, up to the 1980s. By the mid-
Journal of the National Sample Survey Organization 1996 1980s, because of fiscal and other problems, there was a slow-
down in the growth of government health institutions. This
affected not only the growth in absolute number of beds, but
indicating the proliferation of facilities in the private sector. probably the maintenance of quality as well. However, by this
Density of beds in the private sector has a high correlation time, the private sector was poised for growth and it took the
with literacy (Spearman r = 0.64, p < 0.05) and with per capita lead in the growth of health care facilities in Kerala. The
income in the district (Spearman r = 0.60, p < 0.05). This is not growth of the private sector in Kerala should not be seen as
surprising since both these variables are known to be associ- an independent phenomenon. The public sector paved the
ated with growth of demand for health care. way for its development by sensitizing the population to the

Table 6. Acute illness reported in the last 14 days (episodes per 100 persons), chronic illness lasting >3 months (persons affected per 100)
and average per capita health expenditure in the preceding 14 days in rupees, in a household health survey in Kerala, 1993–94

All persons Subjects >60 years old

Acute illness in the last 14 days (per 100 persons) 5.96 9.40
Chronic illness lasting >3 months (per 100 persons) 5.55 22.38
Average medical care expenditure per affected person in the last 14 days (rupees) 102.47 165.78

Unpublished data courtesy of Professor P G K Panikar.

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108 V Raman Kutty

Table 7. Distribution of government and private health care facilities by district, Kerala

District Population Literacy Income Private beds Private Government Government

density (%) per capita per 100 000 hospitals beds per hospitals per
(per km2) (rupees) population per 10 km2 100 000 pop. 10 km2

Thiruvananthapuram 1437 89.22 8147 153 1.97 220 0.52

Kollam 1019 90.47 7831 283 1.48 81 0.35
Pathanamthitta 463 94.86 8094 359 0.97 77 0.23
Alapuzha 1468 93.87 7026 175 2.60 193 0.64
Kottayam 862 95.72 7429 402 2.15 177 0.38
Idukki 227 86.94 9586 346 0.48 74 0.13
Emakulam 1237 92.35 12 665 383 2.25 131 0.47
Thrissur 959 90.13 8126 287 0.95 141 0.40
Palakkad 577 81.27 6943 81 0.40 80 0.24

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Malappuram 1006 87.94 4933 93 0.67 60 0.34
Kozhikode 1214 91.10 7768 130 1.59 154 0.40
Wynad 350 82.73 9875 237 0.52 109 0.18
Kannur 824 91.48 7940 162 0.89 86 0.34
Kasergode 602 82.51 7321 108 0.79 56 0.30
State 806 89.81 8007 216 1.10 122 0.32

Computed from: Government of Kerala.4,8,14

Table 8. Factors affecting the growth of health services in the government and private sectors, Kerala

Factors affecting demand Factors affecting supply

(1) Growth of education, especially female education and (1) Tradition of government-provided health care services
awareness about health related matters (2) Government policy that continued to fund health sector even
(2) Settlement patterns and growth of roads and communication during times of financial stress
favouring easy accessibility (3) Subsidized medical and nursing education supplying a steady
(3) Government provided facilities sensitizing the public to the need stream of personnel
for sophisticated care (4) Comparative lack of regulation that made health sector
(4) Enhancement of income for a good proportion of households attractive as an investment opportunity
(5) Access to funds for investment: foreign charities, repatriation
from gulf countries, and industrial credit

need for sophisticated care and creating demand. The protection act (COPRA). More and more cases of alleged
government continues to play a leadership role in the training malpractice or negligence are coming before the consumer
of all strata of health professionals, who are then largely courts. This is perhaps a reflection of the failure of pro-
absorbed by the private sector. Factors outside the health fessional and statutory organizations like the IMC and the
field, such as growing incomes, improvement of literacy and IMA to maintain standards of practice. As a reaction to this
population ageing, all contributed to this trend. trend, there is some indication that the professional bodies
have become more vigilant. Recently, the IMA strongly
The present appears to be the right time to reassess the role of indicted doctors who were receiving commissions from scan-
the government in the health sector in Kerala. It need not, and ning centres under the euphemism of ‘referral fees’. This is a
perhaps cannot, contribute greatly to the growth in infrastruc- welcome development. The Indian government must set the
ture from now on. However, it needs to take on the mantle of example by weeding out such practices from its hospitals and
the guardian of standards in health care. It can do this only if raising the standards of care.
it concentrates on providing top quality care at government
institutions. The government must also continue to play a The state government must also take the lead in setting pri-
leadership role in the training of health personnel. By main- orities and framing policies which ensure that these goals are
taining high standards in medical and other professional train- met. So far its attitude in policy making has been rather
ing, it can contribute greatly to quality in health care. passive. A recent development in Kerala which may facilitate
a more active role for government is the transfer of more
Quality maintenance should also depend on agencies other powers to the local councils at the panchayat and district
than the government. Other players with a stake in this are the levels, with the recognition that health is one area where such
Indian Medical Council (IMC), the Indian Medical Associ- local control can work most effectively. The outcome of this
ation (IMA) and the legal machinery through the consumer social experiment must be closely monitored.
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Historical development of health care in Kerala 109

References 11 Government of Kerala. Economic Review 1997. Thiruvanantha-

1
puram: State Planning Board, 1998.
Panikar PGK, Soman CR. Health Status of Kerala, the Paradox 12 Government of Kerala. Statistics for Planning 1980. Trivandrum:
of Economic Backwardness and Health Development. Trivan- Department of Economics and Statistics, 1980.
drum: Centre for Development Studies, 1984: 39. 13 Government of Kerala. Statistics for Planning 1988. Trivandrum:
2 op cit: 91.
3
Department of Economics and Statistics, 1988.
op cit: 93. 14 Government of Kerala. Economic Review 1996. Thiruvanantha-
4 Government of Kerala. Government allopathic medical insti- puram: State Planning Board, 1997.
tutions, Kerala 1996. Thiruvananthapuram: Health Information
Cell, Directorate of Health Services, 1996.
5 George KK. Limits to the Kerala model of development. Trivan- Acknowledgements
drum: Centre for Development Studies, 1993. The author wishes to place on record his debt to Professor P G K
6 Kutty VR, Panikar PGK. Impact of fiscal crisis on the public sector Panikar and the Kerala Sastra Sahitya Parishad who have generously
health care system in Kerala – a research report. Trivandrum: permitted the use of their data. Comments by an anonymous
Achutha Menon Centre for Health Science Studies, 1995. reviewer were extremely helpful in revising this paper.
7 Kannan KP, Thankappan KR, Kutty VR, Aravindan KP. Health
and development in rural Kerala. Trivandrum: Kerala Sastra

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Sahitya Parishad, 1991. Biography
8 Government of Kerala. Report on the survey of private medical V Raman Kutty, MD, MPH, is a paediatrician and epidemiologist.
institutions in Kerala 1995. Thiruvananthapuram: Department His areas of interest are health policy in relation to development,
of Economics and Statistics, 1996. maternal and child health, and health economics. He currently works
9 Sara Abraham. Diffusion of medical technology: the case of diag- for ‘Health Action by People’, a not-for-profit organization working
nostic imaging in Kerala. Trivandrum: Centre for Development in the area of health and development in Kerala, India.
Studies, 1995: 67.
10 Rudaya Rajan S, Zachariah KC. Long term implications of low Correspondence: V Raman Kutty, Executive Director, ‘Health
fertility in Kerala. Working Paper no. 282. Trivandrum: Centre Action by People’, Opposite Mutharamman Kovil, Petta Trivan-
for Development Studies, 1997: 8. drum 695024, India. Email: [email protected]