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Editor-The Kerala model in health, cited by Bhutta et al in the theme issue on health in South Asia as replicable for South Asian countries, 1 is facing serious threats. The state has a triple burden of communicable, non-communicable, and traumatic diseases. Stupendous growth of the private sector has resulted in skyrocketing healthcare costs. Lured by the hi tech sophistication of the private sector, people are abandoning basic principles of primary health care. Even poor people prefer private hospitals, and a major reason for sustaining poverty is healthcare cost. 2 The government is reducing its investments in health and education due to fiscal crises and pressure from funding and lending agencies. The opening up of the medical education sector to private entrepreneurs, lack of guidelines for the private practice of government doctors, and shortage of doctors for rural areas are all disturbing developments. Transfer of healthcare institutions under local self-governments is yet to show the desired benefits. The state is developing a long term plan, "Health Vision Kerala 2025," and a health policy. To equip the primary healthcare workforce to face the emerging challenges, 3 job responsibilities were redefined recently. Factors that determined the successful Kerala model, among others, include historically prevalent social justice, commitment of governments to health and education, land reforms, an organised public distribution system, streamlined primary health care, and an organised labour sector. Deterioration in these determinants is likely to have strong negative impact. Kerala should learn from its past to avoid the sad plight of some other Indian states.