Kerala has long been hailed as a frontrunner in public health, and its latest achievement reinforces that reputation. With an infant mortality rate (IMR) of just 5 per 1,000 live births, the state now outperforms even countries like the United States. This milestone is not accidental — it is the result of decades of investment in maternal and child health, widespread literacy, strong public health foundations, and, more recently, targeted interventions for neonates. Nationally, we have reduced Infant and under-five mortality significantly. I had discussed some of these achievements in an article earlier. Today, in this article, let us discuss Kerala’s infant mortality rate achievement and challenges

Kerala celebrates; it must also prepare for the difficult road ahead. Reducing IMR further and sustaining it at these levels will be far more challenging than the journey so far. The state is entering a phase of diminishing returns in public health, where each additional reduction in mortality requires more complex, resource-intensive, and often more costly interventions.

What drove the success?

Several factors contributed to this success story:

• Infant death audits created a continuous feedback loop for learning and intervention.
• Targeted neonatal care has improved survival rates among preterm and low-birth-weight infants.
• Hridyam, Kerala’s pioneering program for congenital heart disease, enabled early diagnosis and treatment.
• Public-private partnerships ensured a wider reach, with both government and empanelled private hospitals providing specialised care.
• Foundational strengths — high female literacy, universal immunisation, and widespread institutional deliveries — provided the base on which these gains were built.

This mix of data-driven policies, clinical focus, and social determinants is what enabled Kerala to reach IMR levels rarely seen in developing contexts.

The risks that lie ahead

1. Data complacency
The IMR figure is based on sample surveys, such as the Sample Registration System (SRS). Without strong civil registration and disaggregation by district and community, under-reporting in tribal and remote pockets may mask persistent inequities.

2. Hidden inequities
Districts like Wayanad, Idukki, Palakkad, Kasaragod, and Malappuram still face higher infant mortality risks due to geography, tribal populations, or cultural practices.

3. Sustainability of high-cost care
Programs like neonatal ICUs and congenital heart surgeries are expensive and resource-heavy. Maintaining them consistently will test Kerala’s fiscal and workforce resilience.

4. Over-reliance on private hospitals
Empanelled private facilities have been crucial, but without proper guardrails, costs could spiral out of control, and the poorest families could be excluded.

5. Workforce shortages
Skilled neonatal nurses and neonatologists are in short supply. Burnout and attrition can compromise the quality of care over time.

6. Neglect of upstream determinants
As neonatal causes dominate, maternal nutrition, adolescent health, and non-communicable diseases in young women must be addressed, or future gains will plateau.

Mitigating the risks

Kerala’s leadership can take several steps to guard its achievement:

• Strengthen data systems: Reconcile SRS with Civil Registration System data, and publish district-level dashboards for transparency.
• Target vulnerable pockets: Mobile neonatal teams, transport vouchers, and community outreach in tribal/remote areas.
• Make care sustainable: Develop regional centres of excellence, expand tele-neonatology, and track the cost-effectiveness of interventions.
• Protect equity in private partnerships: Enforce price ceilings, mandate free slots for the poorest families, and track performance via KPIs.
• Build the workforce pipeline: Train more neonatal nurses, incentivise rural postings, and deploy task-sharing models.
• Address social determinants by integrating adolescent health, maternal nutrition, and preconception care into existing maternal and child health programs.

A balanced path forward

Kerala has demonstrated what is possible when political will, community engagement, and strategic clinical investments converge. But the work is not over. The next stage involves reaching the last child, sustaining costly programs, and building resilience into the healthcare system. Kerala infant mortality rate achievement and challenges must serve as a blueprint for other states going through their own program.

If Kerala manages to combine transparency, innovation, and social equity, it will not just remain India’s leader in child survival — it will also set a benchmark for middle-income countries worldwide. In many ways, the real challenge begins after the celebration.