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Background: Kerala, a southern state in India, is known to be atypical due to its high literacy rate and advanced social development indicators. Facing competition from a dominant private healthcare system, recent government health system reforms have focused on providing free, high-quality universal healthcare in the public sector. We carried out an analysis to ascertain the initial impacts of these measures among 'hard to reach groups' as part of a larger health policy and systems research study, with a focus on public sector health service utilisation. Methods: We conducted Focus Group Discussions (FGDs) among identified vulnerable groups across four districts of Kerala between March and August of 2022. The FGDs explored community perspectives on the use of public healthcare facilities including enablers and barriers to healthcare access. Transliterated English transcripts were coded using ATLAS.ti software and thematically analyzed using the AAAQ framework, supplemented with inductive code generation. Results: A total of 34 FGDs were conducted. Availability and cost-effectiveness were major reasons for choosing public healthcare, with the availability of public insurance in inpatient facilities influencing this preference. However, accessibility of public sector facilities posed challenges due to long journeys and queues. Uneven roads and the non-availability of public transport further restricted access. Gaps in acceptability were also observed: participants noted the need for the availability of special treatments available, reduced waiting times for special groups like those from tribal communities or the elderly mindful of their relatively greater travel and need for prompt care. Although quality improvements resulting from health reform measures were acknowledged, participants articulated the need for further enhancements in the availability and accessibility of services so as to make public healthcare systems truly acceptable. Conclusion: The 'Kerala Model of Development' has been applauded internationally for its success in recent years. However, this has not inured the state from the typical barriers to public sector health care use articulated by participants in the study, which match global evidence. In order to deepen the impact of public sector reforms, the state must try to meet service user expectations– especially among those left behind. This requires attention to quality, timeliness, outreach and physical access. Longer term impacts of these reforms – as we move to a post-COVID scenario - should also be evaluated. [ABSTRACT FROM AUTHOR]

Background The People’s Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. Methods We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. Results Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM’s frontline health workers, ASHAs, emerged as leaders in LSGs. Conclusion The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation – these contradictions may vex progress going forward and warrant further study. [ABSTRACT FROM AUTHOR]

Introduction: Non-Communicable Diseases (NCDs) place a significant burden on India's healthcare system, accounting for approximately 62% of all deaths in the country in 2017. The southern Indian state - Kerala - has some of the highest rates of NCDs. Within the state, the fisherfolk community has a high prevalence of risk factors such as tobacco use and alcohol consumption. Working in the fisheries industry demands physical exertion, night shifts alongside extended periods of time at sea (for seafaring fisherfolk). Evidence is scant on how these conditions relate to the health-seeking experiences of fisherfolk, particularly in the context of NCDs. We conducted a qualitative study in two districts of Kerala to fill this gap., Methods: In-depth individual and small group interviews- as per participant preference -  with male and female fishing community members living with NCDs were conducted between October 2022 and February 2023 in two districts of Kerala. Interviews were conducted to explore community members' experiences with health-seeking for NCDs. Transliterated English transcripts were coded using ATLAS.ti software and analysed using thematic analysis with inductive generation of codes, with indexing against Levesque, Harris, and Russell's 2013 access to healthcare framework., Results: Thirty-three interviews with 42 participants were conducted. We found that NCDs were usually diagnosed late- either when admitted/consulted for other illnesses or when the symptoms became unbearable. Health-seeking patterns differed between seafaring and inland fishing subgroups, who were sampled from two districts in the state. Seafaring fisherfolk preferred public facilities for regular checkups and medicines while in-land fisherfolk relied on private facilities, although it was considered expensive. Ability to seek care was impacted by the working hours of the health centre which did not suit their working hours. Health constaints and related expenses also impacted their financial status and occupation, with some opting for less strenuous jobs., Conclusion: This study highlights the NCD-related health-seeking experiences of the fisherfolk community in Kerala, India. Fisherfolk reported self neglect, delayed diagnosis, cost and livelihood constraints owing to the onset of NCDs, even as dual practice and medicine access in the public sector were appreciated. Overall, larger studies and policymaking processes should consider in depth the experiences faced by particular economic groups like fisherfolk, who may face unique health and care-seeking challenges., (© 2024. The Author(s).)