the current system, the primary health centers and sub-centers were brought under the jurisdiction of local self-governments to respond to local health needs and work more closely with local communities. As a result, health outcomes and access to healthcare services have improved. There are over 9,491 government and private medical institutions in the state, which have about 38000 beds for the total population, making the population to bed ratio 879—one of the highest in the country. There is an active, state-supported nutrition programme for pregnant and new mothers and about 99% of child births are institutional/hospital deliveries, leading to infant mortality in 2018 being 7 per thousand, compared to 28 in India, overall and 18.9 for low- middle income countries generally. The birth rate is 40 percent below that of the national average and almost 60 percent below the rate for impoverished countries in general. Kerala's birth rate is 14.1 (per 1,000 people) and decreasing. India's rate is 17 the rate of the U.S. is 11.4. Life expectancy at birth in Kerala is 77 years, compared to 70 years in India and 84 years in Japan, one of the highest in the world. Female life expectancy in Kerala exceeds that of the male, similar to that in developed countries. Kerala's maternal mortality ratio is the lowest in India at 53 deaths per 100,000 live births. According to the India State Hunger Index, in 2009, Kerala was one of the four states where hunger was only moderate. The hunger index score of Kerala was 17.66 and was second only to Punjab, the state with the lowest hunger index. The nationwide hunger index of India was 23.31. Despite the fact that Kerala has a relatively low dietary intake of 2,200 kilocalories per day, the infant-mortality rate and the percentage of the population facing severe undernutrition in Kerala is far lower than in other Indian states. In early 2000, more than a quarter of the population faced severe undernutrition in three states—Orissa, Uttar Pradesh, and Madhya Pradesh—though they had a higher average dietary intake than Kerala. Kerala's improved nutrition is primarily due to better healthcare access as well as greater equality in food distribution across different income groups and within families. District-wise Hospital Bed Population Ratio as per the 2011 The Health Index, ranking the performance of the States and the Union Territories in India in Health sector, published in June 2019 by