Joseph et al. BMC Public Health
(2023) 23:748
https://doi.org/10.1186/s12889-023-15632-9
BMC Public Health
Open Access
RESEARCH
Who are the vulnerable, and how do we reach
them? Perspectives of health system actors
and community leaders in Kerala, India
Jaison Joseph1*, Hari Sankar1, Gloria Benny1 and Devaki Nambiar1,2,3
Abstract
Background Among the core principles of the 2030 agenda of Sustainable Development Goals (SDGs) is the call
to Leave no One behind (LNOB), a principle that gained resonance as the world contended with the COVID-19
pandemic. The south Indian state of Kerala received acclaim globally for its efforts in managing COVID-19 pandemic.
Less attention has been paid, however, to how inclusive this management was, as well as if and how those “left
behind” in testing, care, treatment, and vaccination efforts were identified and catered to. Filling this gap was the aim
of our study.
Methods We conducted In-depth interviews with 80 participants from four districts of Kerala from July to October
2021. Participants included elected local self-government members, medical and public health staff, as well as
community leaders. Following written informed consent procedures, each interviewee was asked questions
about whom they considered the most “vulnerable” in their areas. They were also asked if there were any special
programmes/schemes to support the access of “vulnerable” groups to general and COVID related health services, as
well as other needs. Recordings were transliterated into English and analysed thematically by a team of researchers
using ATLAS.ti 9.1 software.
Results The age range of participants was between 35 and 60 years. Vulnerability was described differentially by
geography and economic context; for e.g., fisherfolk were identified in coastal areas while migrant labourers were
considered as vulnerable in semi-urban areas. In the context of COVID-19, some participants reflected that everyone
was vulnerable. In most cases, vulnerable groups were already beneficiaries of various government schemes
within and beyond the health sector. During COVID, the government prioritized access to COVID-19 testing and
vaccination among marginalized population groups like palliative care patients, the elderly, migrant labourers, as
well as Scheduled Caste and Scheduled Tribes communities. Livelihood support like food kits, community kitchen,
and patient transportation were provided by the LSGs to support these groups. This involved coordination between
health and other departments, which may be formalised, streamlined and optimised in the future.
Conclusion Health system actors and local self-government members were aware of vulnerable populations
prioritized under various schemes but did not describe vulnerable groups beyond this. Emphasis was placed on
the broad range of services made available to these “left behind” groups through interdepartmental and multi-
*Correspondence:
Jaison Joseph
jjoseph@georgeinstitute.org.in
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Joseph et al. BMC Public Health
(2023) 23:748
Page 2 of 11
stakeholder collaboration. Further study (currently underway) may offer insights into how these communities –
identified as vulnerable – perceive themselves, and whether/how they receive, and experience schemes designed for
them. At the program level, inclusive and innovative identification and recruitment mechanisms need to be devised
to identify populations who are currently left behind but may still be invisible to system actors and leaders.
Keywords Vulnerable Population, Health Equity, Sex Differences, Universal Health Coverage, Primary Health Care,
Health Systems, Primary Care Cost, Primary Care Utilization
Introduction
The core aim of the 2030 agenda of Sustainable Development Goals (SDGs) is to bring in transformation through
Sustainable Development which requires nations to
Leave no One behind (LNOB) [1]. Populations left
behind are defined as being “at greater risk of poor health
status and healthcare access, who experience significant
disparities in life expectancy, access to and use of healthcare services, morbidity and mortality” [2]. These populations sometimes experience multiple morbidities which
results in complex health care needs which are further
exacerbated by intersecting deleterious social and economic conditions [2]
Globally, each nation has the prerogative to define
“left behind” groups or communities based on the social,
economic, cultural and political factors, which in turn
may vary across geographies subnationally [3]. In India,
groups face vulnerability or marginalization on the basis
of age, disability, socio-economic status, which in turn
restricts the access of these communities to health and
healthcare [4]. Groups that are officially considered vulnerable in India according to the country’s main think
tank, the NITI Aayog, include persons who are classified as those in Scheduled Castes (SCs), Scheduled
Tribes (STs), Other Backward Classes (OBCs), Economically Backward Classes (EBCs), Religious Minorities,
Nomadic, Semi-Nomadic and De-Notified Tribes (NT,
SNT & DNTs), people who work in sanitation, known
in Hindi as Safai karmacharis (SKs), Senior Citizens/
the elderly, Transgendered persons, Persons engaging in
Substance Abuse, as well as those who are destitute and
involved with begging[4–6]These population subgroups
are prioritised for various government welfare schemes.
Across the country, participation of under-represented
groups in planning an decision-making is instituted
through affirmative action: SC, ST and Other Backward Classes (OBCs) are provided reservations in public
service.
In the health domain, Below Poverty Line (BPL) households are covered under Ayushman Bharat Pradhan
Mantri Jan Arogya Yojana (AB-PMJAY) providing insurance coverage in the amount of 500,000 INR (~ 6,050
USD) per family for secondary and tertiary care hospitalization expenditure through empanelled health care
providers [7, 8]. In the Southern Indian state of Kerala,
Ayushman Bharat benefits are extended to a broader
beneficiary group, comprising Mahatma Gandhi National
Rural Employment Guarantee Act (MGNREGA) households, households of unorganized workers and additional
population subgroups recognised as facing disadvantage
by the state.
Kerala has the lowest level of multidimensional poverty
according to the NITI Aayog, which suggests that the
population of “vulnerable” may be relatively lower in this
setting [9]. Overall, this bears out: the state’s development pattern also indicates relatively low inequalities in
health and education outcomes [10]. The state nonetheless takes seriously the process of identifying and catering to “vulnerable” population groups. It has a range of
programmes for people recognised as having Scheduled
Caste (SC) and Scheduled Tribe (ST) status, women,
children, elderly and persons living with disabilities
[11]. We identified no less than around 35 schemes and
population-specific programs introduced by the state in
the past half decade to support groups facing disadvantage: these include earmarked funds, subsidy schemes,
as well as reservations in education and employment
[3, 12]. Health programs have also been put in place by
non-health departments and agencies. For example, the
Scheduled Tribes Development Department implements
many programs to address the general healthcare needs
of tribal populations, which include allopathic health
care institutions, medical reimbursement through hospitals, a tribal relief fund for emergency expenditure,
assistance for sickle-cell anaemia patients, assistance to
traditional tribal healers and mobile medical units [13].
One of the objectives of the Health and Family Welfare
Department’s recently launched Aardram mission was
to improve access of marginalized/vulnerable populations to comprehensive health services [14]. The state
is also implementing free health insurance scheme
called “Awaz” for interstate migrant workers, covering
Rs.15,000/- (~ 181.82 USD) for medical treatment per
year and an amount Rs.200,000/- Lakhs (~ 2424 USD) for
accident deaths [15]
Although the state has several welfare measures and
schemes to improve healthcare access for vulnerable
groups, challenges remain. For one, impoverishment due
to health is a major barrier that disproportionately affects
those already facing marginalisation: such groups cannot
rely on the public sector for services and end up impoverished due to health expenditures in the private sector
Joseph et al. BMC Public Health
(2023) 23:748
[16]. In fact, high Out-of-Pocket-Expenditure (OOPE)
and rising health care cost for hospitalization have
resulted in reducing health seeking [17]. Vulnerabilities
therefore, are changing almost continuously. This makes
the task of identifying vulnerable groups difficult – given
the dynamic, complex, historically, and contextually contingent nature of vulnerability [18]. And yet, both global
and national goals call for identification, responses and
monitoring of outcomes in these population groups [1,
19].
As part of a larger health systems study, we placed
emphasis on how vulnerability is defined in the state,
and how vulnerabilities are addressed through schemes
and equity-oriented reforms introduced in the state. It is
important to understand the perspective of primary care
health system actors on vulnerability and who are vulnerable, as they are at the forefront of delivering essential health care services and identification and catering
to the needs of vulnerable population. Such an exercise
has been carried out, for example in other regions with
the support of the World Health Organization, [20]. as
well as in other projects focused on equity integration
in health programming and planning [21–23]. Barring a
rare example published in 2015 [24], we were not able to
identify such initiatives or studies in the Indian context,
particularly ones that viewed “vulnerability” and efforts
at inclusion from an implementer’s perspective. Seeking to fill this gap, we undertook a qualitative analysis
of perspectives from Kerala’s health system actors, local
self-government representatives and community leaders
involved with Primary Healthcare Reforms (PHCR) in
Kerala about their definitions and understandings of who
is vulnerable in the state, what is being done to address
their vulnerabilities, both within and outside of the context of COVID-19.
Methods
This study is the qualitative component of a larger health
system research study in Kerala; our detailed methodology is reported elsewhere[25]. In summary, Kerala’s 14
districts were grouped into four categories using principal components analysis, using indicators from the fourth
round of the National Family Health Survey (NFHS)
(2015–16) [26]. One district was randomly selected from
each group, within which catchment areas served by two
randomly selected primary health facilities (one recently
upgraded by Aardram and one slated for later upgradation) were also randomly selected.
In-depth interviews (IDIs) were carried out in the
four selected districts between July and October 2021.
Participants for this study were staff from two primary
healthcare facilities per district and elected representatives from their corresponding Local Self Governments
(LSGs). We adopted purposive criterion sampling
Page 3 of 11
technique for the selection and recruitment of study
participants. For the identification and selection of participants we employed a two-pronged strategy. As an initial step we line-listed the potential health system actors
(HSAs) and community leaders who could be part of
this study. From each facility we enrolled HSAs including medical and public health staff, community leaders
and Local Self Government representatives to obtain a
comprehensive HSAs perception of vulnerable population their area. Medical and public health staff included,
Medical Officer (MO), Staff Nurse/Nursing Officer,
Health Inspector (HI), Junior Health Inspector (JHI),
Public Health Nurse (PHNs), Junior Public Health Nurse
(JPHNs), Palliative Care Nurse and Accredited Social
Health Activists (ASHAs). Community members eligible
for recruitment included Panchayat Presidents and Vice
Presidents, Health Standing Committee member and
Ward Members. We identified additional community
leaders from these areas through the HSAs, LSG members and non-governmental organizations to capture the
perspective of the community. On an average we enrolled
10 HSA per facility, a total of 83 HSAs were contacted for
this study and three of them could not participate due to
their busy schedule.
The Institutional Ethics Committee of the George Institute for Global Health (Project Number 05/2019) issued
ethical approval for this study. In each facility area, indepth interviews for this study were carried out by three
researchers trained in qualitative research methods (HS,
JJ & GB). The research team comprised of two male
research fellows and a female research assistant and was
supervised by a senior health systems researcher (DN).
Administrative approval was taken from the Department of Health and Family Welfare, Government of Kerala. The team met the District Medical Officers (DMO)
of four districts, shared the departmental permissions,
outlined the study objectives, and shared findings of an
earlier primary survey carried out in the same catchment areas. After the permissions were issued from the
DMOs, the team of three researchers (HS, GB, JJ) took
appointments with Medical Officers and briefed them
about the study and sought their permission for conducting IDIs with the staff under their institutions. Further,
each of the HSAs were met in person and appointments
for interviews were sought based on their convenience.
As per their convenience IDIs were carried out in-person
or through online platforms (i.e. Zoom). For carrying out
the IDIs with LSG representatives, the team met with the
panchayat presidents of the respective LSGs and briefed
on the purpose of study and sought their permission
to carry out the IDIs with other identified LSG members. Community leaders were contacted over phone, to
brief them on the purpose of the study and as per their
Joseph et al. BMC Public Health
(2023) 23:748
Page 4 of 11
convenience the researcher met them in person to carry
out the interviews.
All the participants were handed over with a hard copy
of the topic guides and Participant Information Sheet
(PIS) in English and Malayalam before the in-person
interviews. Each participant’s signed informed consent
was taken for participating in the study and for recording interviews. For those interviews conducted over
online platforms, a soft copy of the topic guide, PIS and
consent form were shared in advance with the participants. Before commencing the interview, the participants
shared the dully signed consent form with the researchers. Malayalam was the medium of conversation and
each of the IDIs lasted between 20 and 60 min. To obtain
context and perspectives of HSAs in various capacities
and geographies pertaining to each of the study sites
across four districts the interviews with all the pre-set list
of participants were completed even though achieving
early data saturation was reached with some of the study
topics.
Three participants could not participate in the interview due to their busy schedules and after multiple failed
attempts to schedule, we decided to remove them from
the study. All IDIs were recorded; interview recordings and field notes were stored and secured in a password protected database after the completion of each
interview and were accessible only to the research team
members. Recordings were transliterated into English by
a third-party agency empanelled by The George Institute
for Global Health, India, which signed confidentiality
agreements prior to accessing data. All the transliterated
transcripts were reviewed by a three-member research
team to ensure quality.
Table 1 Participant characteristics
Category
Local Self
Government
Representatives
Health System
Actors
Designation
Female
Panchayat President
3
Panchayat Vice-President
0
Health Standing Com3
mittee Member
Ward Member
0
Community Leader
1
Medical Officer
5
Health Inspector (HI)
1
Public Health Nurse
4
(PHN)
Junior Health Inspector
0
(JHI)
Junior Public Health
11
Nurse (JPHN)
Nursing Officer
3
Palliative Nurse
1
Community Health
16
Worker
Total Participants
48
Male
4
1
5
Total
7
1
8
1
6
3
5
1
7
8
6
4
7
7
0
11
0
0
0
3
1
16
32
80
Transliterated transcripts were thematically analysed
using ATLAS.ti 9 software by a four-member research
team (DN, HS, JJ, GB). An inductive approach was used:
the thematic structure and code book were finalized
after multiple discussions among the four-member team.
Finally, the coded manuscripts from the team members
were merged using ATLAS.ti 9 software. Codes of interest for this analysis were indexed and themes consolidated based on further discussions and core questions of
interest (i.e., who is left behind? How are they reached?
and impact of COVID-19 among those left behind). A
narrative was then constructed around these questions
and compiled by the lead author with inputs, edits, and
review by other authors.
Results
Participant characteristics
Data for a total of 80 participants was included in the
study, of which more than half (60%) were women (see
Table 1). From this group of participants, we received
information on who they considered was being left
behind from health programming in Kerala, as well as
what was being done to support them and/or address
their needs (in general, and in the COVID context).
Who is left behind?
Participants in all districts would often first identify
Scheduled Caste and Scheduled Tribe communities
as vulnerable; these are nationally established categories defined as facing vulnerability. Apart from this, we
observed geographical variation across districts in who
was described as vulnerable population by stakeholders
(see Table 2). Migrant labourers were identified as vulnerable in the semi-urban areas, while fisherfolk in the
coastal areas (inland and seafaring).
It was found that most of the places where the vulnerable population were identified, faced challenges related
to living and working conditions - social determinants of
health like sanitation, nutrition, crowding/housing were
raised. According to a Medical Officer,
…there is the SC/ST community- they have colonies1here… they have drinking water issues, food
issues, improper waste management, and crowded
places. It is a dengue hotspot and communicable
diseases (hotspot). Also, COVID is a big issue there,
1
While system actors often mentioned colonies of SC and ST communities, in subsequent fieldwork, SC communities in particular felt offended by
the label of “colony” used to describe their places of residence. This could be
seen as being akin to what Wacquant has called “territorial stigma,” which
automatically assigns ignominy to a geographic category.(27) Although
Wacquant’s theorization referred to the urban context in Chicago and Paris
alone, we saw resonance of the concept for urban and rural residents of “colonies.” The concept of the “colony,” of course, has other problematic histories
and legacies.
Joseph et al. BMC Public Health
(2023) 23:748
Page 5 of 11
Table 2 Vulnerable Population Identified by Participants across
Districts
Thiruvananthapuram
People X
from
Scheduled
Tribe
People X
from
Scheduled
Caste
PalX
liative
Care
patients
Fisherfolk
Farmers
Migrants
Kollam
X
Alappuzha
X
Kasaragod
X
X
X
X
This view was held by another JPHN as well who took
the view that
There are no marginalised communities in my area.
All the people here are from similar backgrounds
since it is a coastal area. I do not know if they have
any issues. Most of the people over there depend
on their daily income and even when they must
undergo quarantine, the authorities have delivered
them essential commodities and resolved the problems that came up. So, there were no issues, all such
troubles were taken care of.
X
Programs to support those left behind
X
(inland)
X
(seafaring)
X
X
X
X
because if it affects one person, the spread will be too
much…because even the children run around and
enter all the houses.
We also found that climate change (subsequent floods in
the state) and COVID-19 pandemic had affected population subgroups and added to their vulnerability. Farm
workers were affected by the consequent floods in the
state and fisherfolk were affected by the COVID-19 pandemic. One Community Leader noted this:
…Especially when there were floods, farm workers were there…. the one who is mostly engaged with
paddy fields. Last financial year was a time when
the yield was maximum but there was a technical
difficulty in harvesting it. During such a situation,
the farmers had to face a lot of trouble.People turn
out to be marginalised when they cannot harvest their crop. The situation is similar in the case
of fisheries as well. Due to COVID, they could not
go fishing for several days. Even if they went, there
was a situation that people turned COVID positive because there were about 40 people in a fishing
boat...
On the other hand, a few people we spoke to also mentioned that nobody was vulnerable, because the needs of
all were catered to, as per need. A Junior Public Health
Nurse said: “I don’t think such a marginalised community
exists anymore in this era. We all are equal. I do not think
any community is being sidelined nowadays.”
We found that schemes and programmes targeting vulnerable populations were being implemented across the
state in most cases. The possible exception we found was
the case of fisherfolk and farmers, who were defined as
vulnerable, but were not described as being covered
by many government health schemes. Recently implemented primary health care reforms had reportedly
improved access to healthcare for vulnerable groups in
some areas. In many cases this involved interdepartmental coordination. A Panchayat president took the following view:
Our Family Health Centre works from 7 AM till 8
PM even now. The service of a gynaecology specialist
is provided twice a week. Then, we have an eye specialist. We have been getting the services of a physiotherapy specialist. People from the rural areas,
including the Adivasi community, were able to benefit from these changes. The Tribal Department has
been conducting camps in the places where Adivasis
[tribal persons] live
According to a Health Inspector, there was emphasis placed on going to where communities were to offer
them care/support and the role of labour department and
private employers in health service delivery:
We have a lot of migrants around here. The labour
office is holding special camps for them. Their
employers also sometimes book slots in bulk and get
the workers vaccinated. As far as we are concerned,
we go to their companies and conduct tests and provide other services there.
We also found that joint programs implemented by
LSGs and the Department of Social Justice, such as the
Joseph et al. BMC Public Health
(2023) 23:748
Kudumbasree2-self help program for women, as well as
programs focussing on the elderly population, migrants,
destitute and palliative care patients were intended to
increase access to healthcare and to improve quality
of life for groups facing these forms of disadvantage. A
Health Standing Committee Member added:
…for palliative patients, we provide support from
Panchayat and the FHC. Other than this, we have
a scheme called Ashraya for the destitute. We provide them with kits through Kudumbasree. We have
another scheme called Santhwanam. Under this,
through Kudumbasree we conduct an event once a
year. Ashraya scheme falls under the ambit of this
one. Ashraya is for people with no means of support.
According to a Community Health worker, the Panchayat
placed emphasis on palliation and also on the health and
welfare of guest or migrant workers:
Yes, Panchayat provides it. Even medicines and
hospital-related services are arranged by the Panchayat. Similarly, the Panchayat has appointed a
nurse for palliative care. We visit their homes along
with the palliative nurse and provide all possible
services to them. If any guest workers come here, we
treat them like our own people, and both the Panchayat and the FHC provide them with all kinds of
assistance.
This was corroborated by a Panchayat President in
another district as well:
We have proper facilities for ensuring the health of
people including migrant labourers. …. Grama Panchayat has facilitated the treatment for numerous
cancer patients in the area as well as for those with
other related diseases. The area has around 250 palliative patients. We have implemented various programs for helping all such patients.
There was seen to be, therefore, responsibility taken by
local leaders for vulnerable groups and the idea that these
were “our own people,” whose needs related to health and
beyond, were given due attention.
COVID Outreach for vulnerable populations
Many study participants felt that during the COVID-19
pandemic and consequent lockdowns, vulnerable populations were prioritised. Various health service design
2
Kudumbashree is the poverty eradication and women empowerment programme implemented by the State Poverty Eradication Mission (SPEM) of
the Government of Kerala.[28]. More information is available at: https://
www.kudumbashree.org.
Page 6 of 11
changes were described as being introduced to ensure
the delivery of essential health care and related services
under the stewardship of LSGs. A Junior Public Health
Nurse described them as follows:
We used to provide food to these side-lined people
from the community kitchen, and provide medicines
from our Tele-OP [out-patient services], when the
first wave of COVID started. When COVID started
and there were strict lockdowns, from the side of the
health department, every day there was one or two
vehicles that were arranged from the side of LSGD
and in that vehicle, our staff would take details from
each area of the positive cases, and create a calculation on how many of them need medicine, and
how many homes we need to put a sticker etc, and
both these vehicles would cover two different areas
without overlapping and delivered, medicine kit is,
NCD medicines and Tele OP medicines everywhere
promptly.
Another Panchayat President noted the greater risks of
exposure in certain populations and how they were prioritised commensurably, saying that “we have distributed
kits in every ward. Due to COVID and lockdown, people
were not able to go outside so we distributed kits to everyone. We especially distributed masks and sanitisers in the
S[cheduled] T[ribe] colonies and other marginalised colonies. Because they were residing in a densely populated
area and there is a high chance of spreading, we provided
the kits.”
A Nursing Officer also noted the role played by panchayat leaders in mobilising support during lockdowns,
“when migrants could not go back to their homes, volunteers intervened and helped them. Whatever needed,
from food to shelter was provided from the side of the
Panchayat.”
Vulnerable populations were prioritized for receiving COVID-19 vaccinations. There were efforts from the
health systems and LSGs to deliver vaccines at the doorsteps of these population. A community health worker
described how separate, priority vaccination drives were
held for fisherfolk, SC and ST groups. She said simply:
“They were given more preference.” A Medical Officer
noted that in their area, SC, ST, persons living with disabilities and migrants were the first to achieve complete
vaccination. This was echoed by a frontline worker in
another district who noted that
Bedridden patients were given vaccination doses
at their houses. Palliative patients were given
the vaccination at their places. We have also vaccinated people above 80 years of age after visiting
their houses. We visited the houses of those who
Joseph et al. BMC Public Health
(2023) 23:748
cannot come and got them inoculated. We also conduct health camps in colonies. A class on vaccination programs was also given for them and all these
were organised by the PHC.
Discussion
Our study sought to identify who was defined as vulnerable by health system and LSG actors in the state of
Kerala and what schemes and arrangements were in
place to address their health issues. In the current study,
we observed that a number of groups identified at the
national level as vulnerable were also identified by our
study participants, alongside other population groups
that were uniquely identified in Kerala. This is consistent with the findings of Kerala State Poverty Eradication
Plan presented to NITI Aayog, which reported that SC
populations were concentrated in colonies (including in
urban areas), ST populations continued to be sequestered
in remote and rural locations, consistent with nationally
identified groups in need [29]. However, this report also
indicated the need to support coastal populations like
fisherfolk who for economic reasons were also confined
to particular, hard to reach geographies [29]. Decentralized planning in Kerala has helped keep the issue of
inclusion and marginalisation on the agenda of decisionmakers and implementers, even as newer groups facing
vulnerability were being identified, like migrant workers
[11]. Migrant workers also faced confinement in their
work settings, while palliative care patients were confined
due to their health situation. This distance – physical or
social – was a defining feature of vulnerability from the
perspective of these supply side actors. This kind of a distance based vulnerability has been found in a national
studies from Uttar Pradesh, Madhya Pradesh, Bihar
Assam and Jharkhand during pre and post COVID-19
periods [30], although the view of health system actors
or decision-makers on this was not specifically indicated
in the literature. Other studies in LMICs have identified vulnerability on the basis of racial, ethnic and gender minoritization, economically disadvantage, having
chronic health issues, as well as those at extremes of age
[1, 31, 32]
It was also observed that it was not merely in the context of health, but the larger social determinants that vulnerable populations were “hard to reach.” The residential
areas of the marginalized population were underdeveloped: providing quality health service delivery remained
challenging without addressing the social determinants
of health. This is consistent with the findings of the 6th
Kerala Administrative Reforms Commission report
(2020) which noted lack of land, improper housing, inadequate infrastructure, poor quality of education, lack of
sanitation services and unsafe drinking water among the
Page 7 of 11
marginalized population [33]. This report also gave special emphasis on the condition of SC and other “backward” communities who continue to live and work in
highly dangerous and pathogenic conditions [33]. It has
been deemed vital to address social determinants among
the marginalized to improve their health status as they
are important factor in management and prevention of
communicable and non-communicable diseases alike
[34]. Studies conducted in LMICs have reported lower
access to safe drinking water, sanitation, and hygiene
(WASH), conditions which are fundamental to living and
working, are both reflective of vulnerability and are what
drive disparities in health burdens, health seeking, and
health outcomes [35–37]
We found that natural disasters (floods) and COVID-19
pandemic added to the vulnerabilities faced by farmers
and fisherfolk, suggesting that vulnerability is not a static
phenomenon. A study conducted by a panel of experts
in Kerala immediately after the 2018 floods reported
that the vulnerable population who were the victims of
floods lagged behind their peer groups in levels of human
development, in part because they faced differential and
layered exposures and vulnerabilities compared to other
groups [38]. Another study by the Palliative Care Consortium on the effect of 2018 floods on elderly living
alone found serious after effects of the disaster especially
among the elderly women, also the palliative care services and medications were disrupted [39]. COVID-19
lockdowns imposed by the Government during the first
wave (2020) affected the coastal community in the state
in accessing healthcare and in resourcing the essential
commodities. Along with it the declaration of some of
the overcrowded coastal regions as containment zones,
with restriction of movement leading to reduced working hours and income further increased their vulnerability [40]. A study conducted by Kattungi et al. (2020)
assessing the impact of COVID-19 on the livelihood
of fishermen in Puducherry found loss of employment
among many fishermen which has resulted in increasing inequities and poverty [41]. Aura CM et al. (2020),
in their study which assesses the consequences of flooding and COVID-19 Pandemic among inland fisherfolk in
Kenya in East Africa, found that natural calamities and
pandemic affected the livelihood of fisherfolk, reduced
fishing time and trips, decline in consumables such as
boat fuel resulting low fish catches etc [42, 43]. COVID19 has negatively affected small scale farmers in LMICs
which resulted in low production, low income and higher
food insecurity which has increased their vulnerability
[44, 45]
There has been a fairly high degree of multisectoral
action and coordination to reaching the “vulnerable” in
Kerala. We found a fascinating convergence in the views
of those who identified vulnerable groups and those
Joseph et al. BMC Public Health
(2023) 23:748
who did not. Both noted that schemes existed and that
vulnerable groups (or everyone!) were taken care of the
state through schemes implemented by government
departments. This includes multisectoral action led by
the State government in prevention and control of Noncommunicable Diseases (NCDs) [46, 47], convergence
to support awareness of and enrolment in the Department of Labour’s health insurance scheme (supported
greatly by LSG leaders and Kudumbasree mission workers under Department of Social Justice), [48]. as well as
other schemes introduced by the Kerala Social Security
Mission [49–51]
The state’s response in handling the COVID-19 pandemic was another example of multi-sectoral coordination backed by decentralized governance, along with
whole of society approaches where community action
complemented the work of health system actors [52,
53]. During COVID-19, a community kitchen initiative was introduced through LSGs with the support of
Kudumbasree, which provided free meals to labourers,
people who were under quarantine, the destitute and
other needy marginalized population [54]. Grassroots
agencies were also involved with delivering free food
kits universally, which required a special focus on vulnerable population typically excluded from social security benefit programmes like transgender persons [53].
In a scoping review by Hasan et al. (2021) about the
response of LMICs in management of COVID-19 found
that decentralized governance coupled with stewardship
and multisectoral collaboration facilitated the delivery of
integrated health service delivery[55] ,which was found
through our study in Kerala.
Another interesting feature in Kerala was seen during COVID-19 in the context of vaccination. Initially
COVID-19 vaccination in Kerala followed global norms
by prioritising health workers followed by frontline workers [56], then national norms prioritising citizens above
the age of 60 years and citizens aged between 45 and 59
with specified comorbidities [57]. However, by April 2021
Kerala created state specific norms by way of 32 priority categories in the age group of 18–45 which included
other frontline workers, seafarers, field staff, teachers,
students and more [58]. This demonstrates the possibility
of defining and redefining those in need in the context of
a crisis. It is less clear, however, if such prioritization of
populations in need could be done on an ongoing basis,
helping the state to identify those who may face unique
disadvantages and may need to be reached by programming beyond the existing ambit. This is a clear area for
further research.
Beyond this, there are other areas warranting further
research: greater attention to how multi-sectoral policy
processes for the “vulnerable” take place, in what contexts, could offer lessons for their replication in other
Page 8 of 11
contexts, and also for their enhancement in Kerala.
Moreover, it is unclear, at present, how intersections of
vulnerability may be addressed in current programming,
for e.g. SC or ST populations receiving palliative care,
women involved with the fishing industry. Whether or
not such programs are catering to these intersectional
needs would be a critical area for future policymaking.
Finally, there is a very little understanding of those facing vulnerability as being more than “target populations”
or “beneficiaries” of services. Other research on UHC
has shown that just producing interventions and considering communities passive recipients can easily alienate
and exclude them from health reform processes[59]. Further study is needed – across all these and more groups
facing vulnerability – on how they perceive themselves,
and how they receive, and experience schemes designed
for them, and in the absence of such schemes, how they
manage their health and related needs. This would have
to be given more attention in research and policymaking
and is a limitation in the framing of our study as well.
Limitations
This analysis is based on the perceptions of government
health system actors. It therefore does not include the
perceptions of the general population as well as those
who constitute “those left behind.” Research is currently
underway to understand the care seeking experiences of
these, “demand side” actors and is a crucial part of our
understanding of vulnerability.
Conclusion
Our analysis sought to understand supply side perspectives in the health sector on who is left behind in the
southern Indian state of Kerala. Health system actors and
local self-government members were aware of vulnerable
population prioritized under various schemes but did not
describe vulnerable groups beyond this. Emphasis was
placed on the broad range of services available to these
“left behind” groups. Further study (currently underway)
may offer insights into how these communities – identified as vulnerable – perceive themselves, and how they
receive, and experience schemes designed for them.
Innovative sampling and recruitment mechanisms need
to be devised to identify populations who are currently
left behind but may also be invisible to system actors and
leaders.
While the Kerala government has shown initiative
in carrying out a mapping of poorest households in the
state, there are other critical forms of vulnerability that
affect residents in the state; continuous monitoring of
“who is being left behind,“ in partnership with academic
and civil society institutions, could help enhance such
initiatives.
Joseph et al. BMC Public Health
(2023) 23:748
List of abbreviations
SDGs
Sustainable Development Goals
LNOB
Leave No One Behind
SC
Schedule Caste
STs
Schedule Tribes
OBCs
Other Backward Castes
EBCs
Economically Backward Castes
SKs
Safai Karmacharis
BPL
Below Poverty Line
AB-PMJAY
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana
MGNREGA
Mahatma Gandhi National Rural Employment Guarantee Act
OOPE
Out-of-Pocket Expenditure
PHCR
Primary Health Care Reform
IDIs
In-depth Interviews
HSAs
Health System Actors
FHC
Family Health Centre
LSG
Local Self-Government
MO
Medical Officer
HI
Health Inspector
JHI
Junior Health Inspector
PHN
Public Health Nurse
JPHN
Junior Public Health Nurse
ASHAs
Accredited Social Health Activists
PIS
Participation Information Sheet
Acknowledgements
We are grateful to Mr. Santosh Sharma, Research Fellow, The George Institute
for Global Health, India, for his key reflections and critical inputs.
Author contributions
Conceptualization: JJ Methodology: JJ, HS, DN Formal analysis and
investigation: JJ, GB Writing - original draft preparation: JJ, HS, GB Writing review and editing: JJ, HS, GB, DN Funding acquisition: DN Supervision: DN.
Funding
We wish to indicate that this work was supported by the Wellcome Trust/DBT
India Alliance Fellowship(https://www.indiaalliance.org) Grant number IA/
CPHI/16/1/502653) awarded to Dr. Devaki Nambiar. The funder had no role in
study design, data collection and analysis, decision to publish, or preparation
of the manuscript. The funder provided support in the form of salaries and
research materials and field work support for authors DN, HS, GB and JJ but
did not have any additional role in the study design, data collection and
analysis, decision to publish, or preparation of the manuscript. The specific
roles of these authors are articulated in the ‘author contributions’ section.
Data availability
All datasets used for supporting the conclusions of this paper are available
from the corresponding author on request.
Declarations
Ethics approval
of the study was received from the institutional ethics committee of George
Institute for Global Health (Project Number 05/2019). All participants gave
written informed consent before taking part in the study including Illiterate
participants in the survey who were read out and explained the consent
form in the local language. Thereafter, they were able to sign their names. The
ethics committee that approved the study also approved this procedure of
obtaining written informed consent from these participants. All methods were
carried out in accordance with relevant guidelines and regulations.
Consent to publish
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
The George Institute for Global Health, New Delhi, India
2
Faculty of Medicine, University of New South Wales, Sydney, Australia
Page 9 of 11
3
Prasanna School of Public Health, Manipal Academy of Higher Education,
Manipal, India
Received: 6 September 2022 / Accepted: 7 April 2023
References
1. United Nations Sustainable Development Group. Leave No One Behind
[Internet]. 2022 [cited 2022 Jun 9]. Available from: https://unsdg.
un.org/2030-agenda/universal-values/leave-no-one-behind
2. No authors listed. Vulnerable Populations: Who Are They? The American Journal of Managed Care [Internet]. 2006 Nov 1 [cited 2022 May 30]; Available
from: https://www.ajmc.com/view/nov06-2390ps348-s352
3. Balan PP, George S, Kunhikannan TP, Marginalisation. and Deprivation Studies
in Multiple Vulnerabilities [Internet]. Thrissur, Kerala: Kerala Institute of Local
Administration; 2016 [cited 2022 Jun 1]. Available from: http://dspace.kila.
ac.in:8080/jspui/bitstream/123456789/276/1/Marginalisation%20and%20
Deprivation%20Studies%20in%20Multiple%20Vulnerabilities.pdf
4. Agarwal M. Vulnerable Groups in India: Status, Schemes, Constitution of India
[Internet]. 2022 [cited 2022 May 30]. Available from: http://www.legalservicesindia.com/article/1079/Vulnerable-Groups-in-IndiaStatus,-Schemes,Constitution-of-India.html
5. Aayog N. Role of Social Justice & Empowerment Division [Internet]. NITI
Aayog; 2019 [cited 2022 Jul 9]. Available from: https://www.niti.gov.in/sites/
default/files/2019-08/Role-of-SJE-Division-in-NITI.pdf
6. George AA, Mechanisms. Laws, Institutions and Bodies for Vulnerable Sections [Internet]. Clear IAS. 2020 [cited 2022 Jul 9]. Available from: https://www.
clearias.com/mechanisms-laws-institutions-bodies-vulnerable-sections/
7. Karunya Arogya Suraksha Padahathi, State Health Agency Kerala. Schedules
for Service Contract of AB-PMJAY-KASP [Internet]. Department of Health and
Family Welfare, Government of Kerala; 2020 [cited 2022 Jun 9]. Available from:
https://arogyakeralam.gov.in/wp-content/uploads/2020/03/Schedules.pdf
8. Government of India. DPE-GM-15/0001/2016-GM-FTS-5921, Brochure on
Reservation for SCs/STs and OBCs [Internet]. Ministry of Heavy Industries &
Public Enterprises; 2016 [cited 2022 Jun 9]. Available from: https://dpe.gov.in/
sites/default/files/Reservation_Brochure-2.pdf
9. Board SP. Govt. of Kerala. Economic Review 2021 [Internet]. Thiruvananthapuram; 2021 [cited 2022 Jun 9]. Available from: https://spb.kerala.gov.in/sites/
default/files/2022-03/ECNO_%20ENG_21_%20Vol_1.pdf
10. Ghosh M. Regional Disparities in Education, Health and Human Development in India. Indian Journal of Human Development [Internet]. 2011 Jan
[cited 2022 Sep 6];5. Available from: https://www.researchgate.net/publication/302964390_Regional_Disparities_in_Education_Health_and_Human_
Development_in_India
11. Marginalisation. and Deprivation Studies in Multiple Vulnerabilities.pdf [Internet]. [cited 2022 Jun 1]. Available from: http://dspace.kila.ac.in:8080/jspui/
bitstream/123456789/276/1/Marginalisation%20and%20Deprivation%20
Studies%20in%20Multiple%20Vulnerabilities.pdf
12. Chatterjee CB, Sheoran G. Centre for Enquiry into Health & Allied Themes
(Mumbai I. vulnerable groups in India. Mumbai: Centre for Enquiry into
Health and Allied Themes; 2007.
13. Scheduled Tribes Development Department., Govt. of Kerala. Healthcare
Schemes [Internet]. 2022 [cited 2022 Jun 9]. Available from: https://www.
stdd.kerala.gov.in/healthcare-schemes
14. Aarogyakeralam National Health Mission. Aardram [Internet]. 2018 [cited
2022 Jun 9]. Available from: https://arogyakeralam.gov.in/2020/04/01/
aardram/
15. Staff Reporter. 5.13 lakh migrant workers registered under Awaz scheme. The
Hindu [Internet]. 2022 Mar [cited 2022 Jun 10]; Available from: https://www.
thehindu.com/news/national/kerala/513-lakh-migrant-workers-registeredunder-awaz-scheme/article65223711.ece
16. Haddad S, Baris E, Narayana D. Safeguarding the Health Sector in Times of
Macroeconomic Instability: Policy Lessons for Low- and Middle-Income
Countries [Internet]. African World Press & International Development
Research Centre; 2008 [cited 2022 May 30]. Available from: https://www.idrc.
ca/en/book/safeguarding-health-sector-times-macroeconomic-instabilitypolicy-lessons-low-and-middle
Joseph et al. BMC Public Health
(2023) 23:748
17. Mukherjee S, Haddad S. Social class related inequalities in household health
expenditure and economic burden: evidence from Kerala, South India.
International journal for equity in health. 2011 Jan7;10:1.
18. Gallardo M. Identifying vulnerability to poverty: a critical survey. J Economic
Surveys. 2018;32(4):1074–105.
19. Ministry of Health and Family Welfare, Government of India. National Health
Policy India [Internet]. New Delhi; 2017 [cited 2022 Aug 4]. Available from:
https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf
20. Solar O, Valentine N, Castedo A, Brandt GS, Sathyandran J, Ahmed Z et al.
Action on the social determinants for advancing health equity in the time
of COVID-19: perspectives of actors engaged in a WHO Special Initiative.
International Journal for Equity in Health [Internet]. 2023 Jan 24 [cited 2023
Feb 8];21(3):193. Available from: https://doi.org/10.1186/s12939-022-01798-y
21. Brixi H, Mu Y, Targa B, Hipgrave D. Engaging sub-national governments in
addressing health equities: challenges and opportunities in China’s health
system reform. Health Policy and Planning [Internet]. 2013 Dec 1 [cited 2023
Feb 8];28(8):809–24. Available from: https://doi.org/10.1093/heapol/czs120
22. Chanchien Parajón L, Hinshaw J, Sanchez V, Minkler M, Wallerstein N.
Practicing Hope: Enhancing Empowerment in Primary Health Care through
Community-based Participatory Research. American Journal of Community
Psychology [Internet]. 2021 [cited 2023 Feb 8];67(3–4):297–311. Available
from: https://onlinelibrary.wiley.com/doi/abs/https://doi.org/10.1002/
ajcp.12526
23. Chin MH, King PT, Jones RG, Jones B, Ameratunga SN, Muramatsu N, et al.
Lessons for achieving health equity comparing Aotearoa/New Zealand and
the United States. Health Policy. 2018 Aug;122(8):837–53.
24. Nambiar D, Muralidharan A, Garg S, Daruwalla N, Ganesan P. Analysing
implementer narratives on addressing health inequity through convergent
action on the social determinants of health in India. Int J Equity Health
[Internet]. 2015 Dec [cited 2021 Aug 2];14(1):133. Available from: http://www.
equityhealthj.com/content/14/1/133
25. Nambiar D, Sankar H, Negi J, Nair A, Sadanandan R. Field-testing of primary
health-care indicators, India. Bull World Health Organ. 2020 Nov;98(1):747–53.
26. Ministry of Health and Family Welfare, Govt. of India. National Family Health
Survey (NFHS-4) [Internet]. IIPS Mumbai. ; 2015 [cited 2023 Feb 9]. Available
from: http://rchiips.org/nfhs/factsheet_nfhs-4.shtml
27. Wacquant L, Slater T, Pereira VB. Territorial Stigmatization in Action. Environ
Plan A [Internet]. 2014 Jun 1 [cited 2023 Mar 31];46(6):1270–80. Available
from: https://doi.org/10.1068/a4606ge
28. State Poverty Eradication Mission, Government of Kerala. Kudumbashree |
What is Kudumbashree [Internet]. 2023 [cited 2023 Mar 31]. Available from:
https://www.kudumbashree.org/pages/171
29. Kerala State Planning Board. Kerala State Poverty Eradication Plan [Internet].
2018 [cited 2022 Jun 10]. Available from: https://www.niti.gov.in/writereaddata/files/Kerala%20presentation.pdf
30. Bhattacharya M, Banerjee P. COVID-19: Indices of economic and health
vulnerability for the Indian states. Social Sciences & Humanities Open. 2021
Jan 1;4(1):100157.
31. 5 Vulnerable Populations in Healthcare [Internet]. AJMC. 2018
[cited 2023 Mar 30]. Available from: https://www.ajmc.com/
view/5-vulnerable-populations-in-healthcare
32. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M.
Poverty and Access to Health Care in developing countries. Ann N Y Acad Sci.
2008;1136(1):161–71.
33. Administrative Reforms Commission, Government of Kerala. Welfare to Rights
II, Implementation of Select Legislations, Review Phase II [Internet]. Kerala;
2020 Oct [cited 2022 Jun 10]. Report No.: 6. Available from: https://arc.kerala.
gov.in/sites/default/files/inline-files/Welfare%20to%20Rights%202%20-%20
File%20Copy%20-%2001-01-2020.pdf
34. Marmot M. Social determinants of health inequalities. The Lancet. 2005
Mar;19(9464):1099–104.
35. Hutton G, Chase C. Water Supply, Sanitation, and Hygiene. In: Mock CN,
Nugent R, Kobusingye O, Smith KR, editors. Injury Prevention and Environmental Health [Internet]. 3rd ed. Washington (DC): The International Bank for
Reconstruction and Development / The World Bank; 2017 [cited 2023 Mar
30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK525207/
36. Prüss-Ustün A, Wolf J, Bartram J, Clasen T, Cumming O, Freeman MC, et al.
Burden of disease from inadequate water, sanitation and hygiene for selected
adverse health outcomes: an updated analysis with a focus on low- and
middle-income countries. Int J Hyg Environ Health. 2019 Jun;222(5):765–77.
37. Sahoo KC, Dubey S, Dash GC, Sahoo RK, Sahay MR, Negi S et al. A Systematic Review of Water, Sanitation, and Hygiene for Urban Poor in Low- and
Page 10 of 11
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
Middle-Income Countries during the COVID-19 Pandemic through a Gendered Lens. Int J Environ Res Public Health. 2022 Sep 20;19(19):11845.
Thummarukudy M, Peter B. Leaving no one behind: Lessons from the Kerala
disasters - India [Internet]. Perumbavoor, Kerala: Centre for Migration and
Inclusive Development; 2019 Oct [cited 2022 Jun 10]. Available from: https://
reliefweb.int/report/india/leaving-no-one-behind-lessons-kerala-disasters
Kerala State Disaster Management Authority, India P, Indian Association of Palliative Care. Addressing the Needs of Elderly and People Under
Palliative Care in Disaster Management [Internet]. Trivandrum; 2019 Jun
[cited 2022 Jun 10]. Available from: https://sdma.kerala.gov.in/wp-content/
uploads/2020/11/Report-Palliative-Care-Consultation-cum-Workshop.pdf
Sumitha TS, Thelly AS, Medona B, Lijimol AS, Rose MJ, Rajagopal MR.
Response to COVID-19 Crisis with Facilitated Community Partnership among
a Vulnerable Population in Kerala, India - A Short Report. Indian J Palliat Care.
2022;28(1):115–9.
Sekhar KV, Sutha DAI, Devi DRU, IMPACT OF COVID-19 ON THE LIVELIHOODS
OF FISHERMEN COMMUNITY IN YANAM., PUDUCHERRY: AN ANALYSIS. European Journal of Molecular & Clinical Medicine. 2020 Nov 30;7(8):869–80.
Aura CM, Nyamweya CS, Odoli CO, Owiti H, Njiru JM, Otuo PW, et al.
Consequences of calamities and their management: the case of COVID-19
pandemic and flooding on inland capture fisheries in Kenya. J Great Lakes
Res. 2020 Dec;46(6):1767–75.
Love DC, Allison EH, Asche F, Belton B, Cottrell RS, Froehlich HE, et al. Emerging COVID-19 impacts, responses, and lessons for building resilience in the
seafood system. Glob Food Sect. 2021 Mar;28:100494.
Löhr K, Mugabe P, Turetta APD, Steinke J, Lozano C, Bonatti M, et al. Assessing
impacts of COVID-19 and their responses among smallholder farmers in
Brazil, Madagascar and Tanzania. Outlook Agric. 2022 Dec;51(4):460–9.
Hammond J, Milner D, van Wijk M. How COVID controls hit farmers in 7 low-income countries, most in Africa [Internet]. 2022 [cited
2023 Mar 30]. Available from: https://www.preventionweb.net/news/
how-covid-controls-hit-farmers-7-low-income-countries-most-africa
Sen S, Gautam P, Kerala Wins UN, Award For. “Outstanding Contribution”
Towards Control of Non-Communicable Diseases. The Logical Indian Crew
[Internet]. 2020 Sep [cited 2022 Jul 29]; Available from: https://thelogicalindian.com/uplifting/kerala-un-award-23980
Arora M, Chauhan K, John S, Mukhopadhyay A. Multi-Sectoral Action for
Addressing Social Determinants of Noncommunicable Diseases and Mainstreaming Health Promotion in National Health Programmes in India. Indian
Journal of Community Medicine. 2011 Dec 1;36(5):43.
Joy J. The Impact of RSBY-CHIS on utilisation of Healthcare Services in Kerala
[Internet]. Cochin: SCMS Cochin School of Business; 2019 [cited 2022 Jul 29].
Available from: https://spb.kerala.gov.in/sites/default/files/inline-files/RSBYCHIS.pdf
Kerala Social Security Mission., Govt. of Kerala. Schemes [Internet]. 2022 [cited
2022 Jul 9]. Available from: https://socialsecuritymission.gov.in/scheme_info.
php?id=2
Kerala Social Security Mission., Govt. of Kerala. Samashwasam [Internet].
2020 [cited 2022 Jul 9]. Available from: https://socialsecuritymission.gov.in/
scheme_info.php?id=MTk=
Madhavan M, Ravindran RM, Shinu KS. Functioning of Arogyakiranam
programme in Kerala: a qualitative study. J Family Med Prim Care. 2021
Nov;10(11):4117–23.
Rahim AA, Chacko TV. Replicating the Kerala State’s successful COVID-19
Containment Model: insights on what worked. Indian J Community Med.
2020;45(3):261–5.
Solomon N, K A G, Krishnan A, Cicily Joseph A, Dhanuraj D. Kerala Model of
Respone to COVID-19 [Internet]. Kochi: Centre for Public Policy Research
(CPPR); 2020 [cited 2022 Jun 10]. Available from: https://www.cppr.in/wpcontent/uploads/2020/10/KERALA-MODEL-OF-RESPONSE-TO-COVID-19.pdf
World Health Organization. Responding to COVID-19 - Learnings from Kerala [Internet]. 2020 [cited 2022 Jun 10]. Available
from: https://www.who.int/india/news/feature-stories/detail/
responding-to-covid-19---learnings-from-kerala
Hasan MZ, Neill R, Das P, Venugopal V, Arora D, Bishai D et al. Integrated
health service delivery during COVID-19: a scoping review of published
evidence from low-income and lower-middle-income countries. BMJ Global
Health. 2021 Jun 1;6(6):e005667.
IANS. Kerala vaccination drive: Focus now on frontline workers in 2nd
phase. Business Standard India [Internet]. 2021 Feb 11 [cited 2022 Jun 10];
Available from: https://www.business-standard.com/article/current-affairs/
Joseph et al. BMC Public Health
(2023) 23:748
kerala-vaccination-drive-focus-now-on-frontline-workers-in-2ndphase-121021100593_1.html
57. Health and Family Welfare Department. Guidelines for COVID-19 Vaccination
for the priority groups [Internet]. Government of Kerala; 2021 [cited 2022 Jun
10]. Available from: https://dhs.kerala.gov.in/wp-content/uploads/2021/03/
Guideline-for-COVID19-Vaccination-for-the-priority-groups_compressed.pdf
58. Health and Family Welfare Department. Government of, Kerala GO. (Rt) No.
1114/2021/H&FWD, Health & Family Welfare Department: Prioritization for
Vaccination in the age group of 18–45 years, Modified Orders issued [Internet]. 2021 [cited 2022 Jun 10]. Available from: https://arogyakeralam.gov.in/
wp-content/uploads/2020/03/Prioritization-of-vaccinnation-in-18-45.pdf
59. George MS, Davey R, Mohanty I, Upton P. “Everything is provided free, but
they are still hesitant to access healthcare services”: why does the indigenous
Page 11 of 11
community in Attapadi, Kerala continue to experience poor access to
healthcare? International Journal for Equity in Health [Internet]. 2020 Jun
26 [cited 2022 Jul 22];19(1):105. Available from: https://doi.org/10.1186/
s12939-020-01216-1
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.