Reaching beyond the Sustainable Development Goals targets: unfolding Kerala’s feat in reducing infant mortality rate

Sir,

Kerala has recorded the lowest infant mortality rate (IMR) in India with just 5 deaths per 1,000 live births, according to the sample registration system (SRS) report for 2023.¹

The state has steadily improved from an IMR of 7 in 2018 and 6 in 2019 to 5 in 2023, a record unmatched by any other state or Union Territory, all of which still report double-digit IMRs. Most importantly, the rate is consistent across urban and rural areas, marking a significant step toward realizing the goal of reducing inequalities and achieving Universal Health Coverage. This remarkable achievement is well below the Sustainable Development Goals target of 12 to be achieved by 2030.

Since the news broke out, various media platforms have been inundated with praise and discussions aimed at clarifying this extraordinary accomplishment. In our current era, news, whether in print, digital, or social media formats, serves as the initial way the public engages with an event. Although scientific literature takes time to develop, the constant presence of news media allows for the swift sharing of information. The media offers preliminary analyses and reasonable interpretations, influencing early public perception. Considering the resource limitations and the time-intensive nature of conducting an extensive on-ground survey, we adopted a qualitative exploratory approach, studying the online newspaper articles available in the public domain.²

This study is based on an interpretivist paradigm, viewing information as context-specific narratives shaped by media. We reviewed top newspaper articles as per the Indian readership survey 2019, containing relevant content.³ These articles were published on or after 06 September 2025, and were identified through official websites and Google searches. 10 such newspaper articles were used for analysis purposes. A grounded theory approach was employed, and given the limited empirical evidence on this topic, an inductive analysis was done to identify themes and subthemes.

Using an evidence-based approach, the state health department brought the IMR to single digits since 2010. Following a state-wide study in 2013 by the Indian Association of Paediatrics (IAP), identifying the major contributors to infant mortality. Based on the findings, the state employed the following major strategies.⁴ Firstly, targeted neonatal care focuses on reducing infant mortality through systematic infant death audits that ensure each case is thoroughly reviewed and corrective measures are implemented. This is supported by strengthening and standardizing clinical guidelines to make them uniform and easy to follow, alongside upgrading evidence-based quality neonatal care. To date, 16 public hospitals conducting deliveries have secured the Labour Room Quality Improvement Initiative (LaQshya) national accreditation, and six hospitals have achieved MusQan certification for child-friendly services and high-quality infant care.^5,6

Secondly, robust grass-roots level infrastructure was built by placing capacity building at the core of accountability, with regular and refresher trainings continuously updating caregivers’ knowledge. Equity was prioritized in program design, with investments guided by local context rather than uniform allocation, breaking the long-held norms of higher rural mortality, and moving towards achieving equity.^7,8

Thirdly, flagship health programs have been strengthened through effective implementation of existing policies, ensuring high uptake of schemes such as the Janani Suraksha Yojana (JSY) and the Universal Immunization Program (UIP). Institutional deliveries have reached 96.16% in rural and 99.88% in urban areas (2023), with immunization coverage at 78% (NFHS-5). In parallel, dedicated initiatives address key contributors to neonatal mortality, particularly congenital disorders and preterm births. These include universal newborn screening and the “Hridyam” Project (2017) for congenital heart disease, which has reduced related infant deaths significantly.

Complementary measures such as free maternal and newborn transport (Mathruyanam), neonatal ICUs in underserved areas, publicly funded treatment for rare genetic disorders, and a focus on nutrition and mental health in the first 1,000 days ensure continuity of care while reducing medical and financial burdens on families.^9,10

Fourthly, high female literacy has played a crucial role in sustaining health gains in Kerala. With the highest female literacy rate in India (94%) and the lowest birth rate at 10.8%, the state has effectively addressed key proximate determinants of maternal and child health.¹¹

Finally, strengthening community outreach and health education through a robust primary healthcare network supported by dedicated and fairly compensated ASHA workers who actively deliver effective health education. Simultaneously, informed communities take responsibility by discouraging harmful practices, influencing health-seeking behaviour, and supporting one another in adopting healthier choices.¹²

In conclusion, the true “Kerala model” represents an amalgamation of good policies and robust implementation based on the pillars of prioritizing equity, multipronged interventions and evidence-based planning. With a strong health systems approach as adopted in this case, “Kerala model” stands as a testament to what is possible when policymakers, non-government agencies, communities, and families work together to address complex challenges.

REFERENCES

1. 1. Office of the Registrar General & Census Commissioner, India. Sample Registration System (SRS) Bulletin. 2023;58(I). Available at: https://censusindia.gov.in/nada/index.php/catalog/46178. Accessed on 12 September 2025.
2. 2. Madhivanan A, Venugopal V, Dongre AR. Physical violence against doctors: A content analysis from online Indian newspapers. Indian J Commun Med. 2020;45(1):108-9.
3. 3. Media Research Users Council of India. Indian Readership Survey. 2019. Available at: https://mruc.net/uploads/posts/2ae140929953aed4f314ad5b2a4546ad.pdf. Accessed on 31 December 2025.
4. 4. The Times of India. Preterm births major cause of infant deaths. 2013. Available at: https://timesofindia.indiatimes.com/city/kochi/preterm-births-major-cause-of-infant-deaths/articleshow/19083175.cms. Accessed on 11 September 2025.
5. 5. ETHealthworld. Kerala achieves a milestone with 11 hospitals receiving national quality accreditations. 2025. Available at: https://health.economictimes.indiatimes.com/news/hospitals/kerala-achieves-milestone-with-11-hospitals-receiving-national-quality-accreditations/123230356. Accessed on 11 September 2025.
6. 6. Business Standard. India’s infant mortality rate hits historic low of 25; big states struggle. 2023. Available at: https://www.business-standard.com/india-news/kerala-infant-mortality-rate-lowest-india-imr-health-birth-death-up-bihar-125090500423_1.html. Accessed on 15 September 2025.
7. 7. Mathrubhumi English. Kerala’s infant mortality rate drops to 5, now lower than US: Health Minister Veena George. 2025. Available at: https://english.mathrubhumi.com/news/kerala/keralas-infant-mortality-rate-drops-to-5-now-lower-than-us-health-minister-veena-george-o7dtgnva. Accessed 11 September 2025.
8. 8. Directorate of Health Services, Kerala. National Family Health Survey (NFHS-1 to NFHS-5): Fact Sheet – Kerala. 2022. Available at: https://dhs.kerala.gov.in/wpcontent/uploads/2022/06/NFHS-1-to-5-Fact-Sheet-Kerala.pdf. Accessed 11 September 2025.
9. 9. Vikaspedia. Hridyam initiative of Kerala. 2017. Available at: https://health.vikaspedia.in/viewcontent/health/nrhm/state-health-programmes/hridyam-initiative-of-kerala?lgn=en. Accessed 16 September 2025.
10. 10. The Hindu. Mathruyanam scheme to be extended to all government hospitals where childbirth takes place. 2023. Available at: https://www.thehindu.com/news/national/kerala/mathruyanam-scheme-to-be-extended-to-all-govt-hospitals-where-childbirth-takes-place/article67608622.ece. Accessed 16 September 2025.
11. 11. The Telegraph India. Kerala feat on infant mortality: With 5 deaths per 1,000 births, state betters US. 2025. Available at: https://www.telegraphindia.com/india/kerala-feat-on-infant-mortality-with-5-deaths-per-1000-births-state-betters-us-prnt/cid/2121980. Accessed on 11 September 2025.
12. 12. The Indian Express. Top 10 Indian states/UTs with highest and lowest literacy rates: Mizoram becomes first fully literate state. 2025. Available at: https://indianexpress.com/article/trending/top-10-listing/top-10-indian-states-highest-lowest-literacy-mizoram-full-literate-2025-10018981/. Accessed on 16 September 2025.