wages, road expansion, strong trade and labor unions, land reforms, and investment in clean water, sanitation, housing, access to food, public health infrastructure, and education all contributed to the relative success of Kerala's public health system. In fact, declining mortality rates during this time period doubled the state's population, and immunization services, infectious disease care, health awareness activities, and antenatal and postnatal services became more widely available. In the 1970s, a decade before India initiated its national immunization program with WHO, Kerala launched an immunization program for infants and pregnant women. In addition, smaller private medical institutions complemented the government's efforts to increase access to health services and provided specialized healthcare. As a result, life expectancy continued to increase in Kerala, though household income remained low. Thus, the concept of the "Kerala model" was coined by development researchers in Kerala in the 1970s and the state received international recognition for its health outcomes despite a relatively low per capita income. In the mid-1970s to the early 1990s, a fiscal crisis caused the government to reduce spending on health and other social services. Reductions in federal health spending also affected Kerala's health budget. As a result, the quality and abilities of public healthcare facilities declined and residents protested. Eventually, private health services began to take over, enabled by a lack of government regulation. In fact, by the mid-1980s, only 23% of households regularly utilized government health services, and from 1986–1996, private-sector growth significantly surpassed public-sector growth. In 1996, Kerala began to decentralize public healthcare facilities and fiscal responsibilities to local self-governments by implementing the People's Campaign for Decentralized Planning in response to public distrust and national recommendations. For instance, new budgetary allocations gave local governments control of 35 to 40% of the state budget. Moreover, the campaign emphasized improving care and access, regardless of income level, caste, tribe, or gender, reflecting a goal of not just effective but also equitable coverage. A three-tier system of self-governance was established, consisting of 900 panchayats (villages), 152 blocks, and 14 districts. The current healthcare system arose from local self-governments supporting the construction of sub-centers, primary health centers that support five to six sub-centers and serve a village, and community health centers. The new system also allowed local self-governments to create hospital management committees and purchase necessary equipment. Present The basis for the state's health standards is the state-wide infrastructure of primary health centers. Under