Kerala's Aardram Mission and universal health coverage: integrated time series evidence on mortality reduction and assessment of financial protection and equity gaps.

Introduction: Universal health coverage (UHC) requires simultaneous progress across health outcomes, financial protection, and service delivery dimensions. Kerala has achieved favorable mortality indicators, yet implementation gaps and financing barriers persist despite policy reforms. The Aardram Mission (2017) represents a major primary care strengthening intervention aimed at advancing UHC, but its association with multiple UHC dimensions has not previously been examined in an integrated way. Objective: The study aimed to assess the association between the implementation of the Aardram Mission and changes in maternal and infant mortality, health insurance coverage, immunization rates, and out-of-pocket expenditure patterns and to identify implementation gaps and health equity disparities within Kerala's health system.. Methods: The study analyzed secondary annual data from 2010 to 2024, covering the pre-policy (2010-2016) and post-policy (2017-2024) periods. Interrupted time series (ITS) with segmented regression was used as the primary analytical method to examine changes in the trajectories of the maternal mortality ratio (MMR), infant mortality ratio (IMR), and immunization coverage associated with the implementation of the Aardram Mission in 2017. Descriptive pre-post comparisons, correlation analysis, and multivariable regression were conducted as supporting exploratory analyses. The robustness of the ITS findings was assessed through sensitivity analyses accounting for the COVID-19 pandemic and a structural break test.. Results: Segmented regression indicated an acceleration in the declining trends of both mortality indicators following the 2017 policy implementation, after accounting for pre-existing trends. Between 2017 and 2024, the IMR declined by 43.8% and the MMR by 47.9% relative to pre-policy levels, corresponding to an estimated 2.46-fold increase in the rate of IMR decline. These findings are consistent with, but do not independently establish, a causal policy effect, given the observational single-group design and the absence of a comparator series. Insurance coverage expanded substantially over the same period. Implementation gaps persisted in relation to out-of-pocket expenditure, which remained high. Conclusion: The Aardram Mission's implementation coincided with meaningful improvements in mortality trends, but these findings do not, on their own, establish that the policy fully resolved Kerala's UHC dimensions. Financial protection remains incomplete, implementation barriers appear to constrain service quality, and equity gaps persist. Comprehensive UHC in Kerala likely requires complementary governance and financing reforms extending beyond primary care strengthening.