The crude death rate of Kerala in 1991 was 6 (per 1000 population), compared to the national average of 11, and an average of 10 for low-income and 8 for middle-income countries. It is significant to note that the crude birth rates and death rates in a ‘low-income country’ like China and a ‘middle-income country’ like the Philippines exceeded the corresponding rates in the ‘least developed’ region of Kerala. Kerala’s demographic experience has attracted wide research attention (eg (i) Zachariah, 1983; (ii) Zachariah & Irudaya Rajan, 1994; (iii) Bhat and Irudaya Rajan, 1990; (iv) Ratcliffe, 1984; (v) Zachariah & Irudaya Rajan, 1997).

The period during 1971-’81 witnessed the most rapid growth of medical care institutions, especially government hospitals and dispensaries under the Allopathic system; the total number of public sector medical care institutions registered steady increase at the rate of 17.5 per cent during 1955-1960, 58.2 per cent during the 1960s, and 74.3 per cent during the 1970s. The number of medical care institutions and the populationtion coverage of health care facility in the major States is given in Table 4.10.

One important feature emerging from table Table 4.10 is that of the total number of hospitals in India, about two-thirds are in the private sector. The share of private hospitals in Kerala works out to be about 93 per cent. Of the total number of private hospitals among the States, one-fifth is located in Kerala.

The population coverage of health care facilities, ie the ratio of population to total number of medical care institutions, is far better for Kerala than in all the other States. That is, the number of persons per hospital works out to be 14,264 here as compared to the all-States average of 61,810. Except in Andhra Pradesh, Assam, Gujarat, and Punjab the ratio exceeded one lakh people per hospital. The high growth rate of medical care institutions in Kerala has naturally claimed an increasing share of the State Government’s budget. The total expenditure of this sector rose by around three-and half times between 1969 and 1971 and by over four times during the 1970s. The trends in the State government expenditure on medical and public health in Kerala in recent periods may be observed in Table 4.11

Health transition comprises three components, viz demographic transition, epidemiological transition, and health care transition. Kerala has apparently made significant advances in all the three components. Thus, the State has entered the final phase of demographic transition as exemplified by the low death and infant mortality rates, comparable to those of developed countries. The fall in death rates has resulted in a rise in expectation of life at birth, and increase in the proportion of the elderly-persons above 60 years - in the total population. These developments have major implications. Kerala has also been going through an epidemiological transition as reflected in its morbidity profile.

The picture emerging from a scrutiny of available data on morbidity pattern is a mixed one. On the one hand, the dominant disease group comprises acute infectious diseases including fever, diarrhoea, and worm infestation, resembling the morbidity profile of a typical underdeveloped country. On the other hand, the emergence of chronic diseases like diabetes mellitus, blood pressure, heart disease, and cancer as the major causes of death of the adult population, resembles the situation in developed countries which have gone through the epidemiological transition.