Palliative care involves prevention and mitigation of suffering related to incurable illness, old age, death, dying, and bereavement. Though increasingly getting viewed as a basic human right, majority of the needy globally do not have access to palliative care services. The successful community-based palliative care system in the South Indian state of Kerala assumes importance in this context. Palliative care in Kerala has been evolving over the last quarter of a century. Starting as an institution-based palliative care program with resource mobilization from the community and later attempting successfully to achieve higher levels of community participation, the story of Kerala’s evolving system of palliative care is the story of how primary care got integrated into social fabric. Palliative care program in Kerala owned and run by multiple civil society groups, political parties, religious groups, and local governments is in many ways unique. Thanks to the deep involvement of the community, Kerala now has more than 1000 palliative care units linked to local government institutions and more than 400 units run by local community groups. More than 300 of these civil society projects developed spontaneously over the last decade, “un-invited” and not as part of the original system. New community groups in palliative care continue to come up regularly. Local community groups own programs in a non-hierarchical system. All the local initiatives are organizationally and financially independent of each other. The situation is dynamic and still evolving. New players are entering the scene regularly. A recent phenomenon is the entry of political party led local palliative care initiatives. The process of development, evolution and outcome of Kerala’s palliative care system can be an interesting case study.