Kerala is known for its high availability of public health services and very high levels of utilization of health services in case of perceived illness (up to 85%). Yet, the private sector outstrips the public sector both in terms of number of institutions and density of beds per population by a wide margin (up to four times more) in most districts. This private dominance parallels high levels of private recourse to outpatient and inpatient care (77% and 60% respectively). But little is known about inequalities in access to care by social and economic groups in Kerala. This paper is a modest attempt to fill that gap in the context of urban health. An analysis of data from the most recent NSSO household survey on health care (1995-1996) suggests that poorer populations have highest odds of not accessing care than richer individuals and that public institutions are used mostly by the poor and by casual workers. Utilization of private care is related to the perception that public services are of poor quality. Further, higher utilization of private care is related to lower public density of beds and where private services outstrip public services. This has obvious consequences for poor populations since their burden of care in the private sector is very high, especially for chronic diseases. In the context of Kerala’s health transition, this calls for the reassessment of the public sector’s role to promote equity in access to health care.