Why karuna medical college isn't getting enough patients and traction?

It's located in a rural area with no nearby medical colleges or major hospitals, yet Karuna Medical College Hospital is often mostly empty. There are good doctors practicing there, and the quality of medical education also seems to be good. Even so, most of the patients appear to come from Tamil Nadu, while people from Palakkad, even nearby Chittur, don't seem to use the hospital.

Why do you think that is? Is it because of poor accessibility, perceptions of substandard medical care, affordability, lack of awareness, or some other reason?