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Research Brief on Tamil Nadu Public Health System

Introduction

The following table gives a comparison between the per capita Total Health Expenditure of Tamil Nadu vis-à-vis the
national average.

As can be seen, the expenditure is slightly

lower than Indian average over the years. But,
the interesting feature is that its health
outcomes are far superior than most of the
states in the country as reflected in the Infant
Mortality and Maternal Mortality Ratio in the
state vis-à-vis the national average.

The following table gives the comparative

figures of major health and demographic
indicators in Tamil Nadu:

(Source: National Health Mission, Ministry of Health

& Family Welfare)

Indicator Tamil Nadu India

Infant Mortality Rate (SRS 2011) 22 44

Maternal Mortality Rate (SRS 2007-09) 97 212

Total Fertility Rate 1.7 2.4

The data on expenditures and outcomes suggest

that the public expenditures are efficiently used,
reducing the need for citizens to spend on private
health care. While a part of the reason for such
outcomes could be attributable to rapid economic
growth, it is hard to identify the cause and effect
since improvements in health conditions by itself
improve the prospects of economic growth.
According to a research paper (by Monica Das et al
2009), it has been widely recognized that good
public health services are key to improving health
outcomes in both developing and developed world.

The power of such public health services is best

      
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illustrated by the example of Tamil Nadu, which has been able to respond swiftly to a major disaster like tsunami and
organize care for survivors. It is also illustrated by the fact that the state had the technical expertise to help control the
1994 plague outbreak in Gujarat, while other public health agencies were caught off balance. The comparisons with
other states also illustrate Tamil Nadu’s better organization for managing endemic diseases and anticipating and
averting health threats. The following section explains how the public health system in the state helped improve the
health outcomes.

The Public Health System of Tamil Nadu1

Health systems have three major sets of services:
1. Population wide preventive services to reduce the exposure to disease through health and sanitary regulations
and monitoring and averting health threats
2. Clinical preventive services provided to individuals such as vaccination and screening
3. Medical services to care for and treat individuals with injuries and diseases
The first two constitute public health services. While the great advances in Health outcomes in developed countries
come mainly from focus on environmental health, in most Indian states, focus has always been on single issue
programs for controlling specific diseases, delivering maternal and child health services etc. Following the 1946 Bhore
Committee Report, the medical and public health services were unified, and over time, the attention and resources
gravitated towards medical services leading to inadequate focus on public health component. Subsequently, with focus
on implementing the single-issue public health programmes, there was no focal point in the central Health Ministry for
public health services
Tamil Nadu is a rare example of a state which chose not to amalgamate its medical and public health services. The
system has the following key ingredients which helped re-vitalize their public health systems:
1. A separate Directorate of Public Health with
a. Its own budget
b. Legislative underpinning for its work
2. A professional public health cadre managing a team of non-medical specialists and lower grade staff working
solely on public health
With a dedicated Directorate of Public Health, Tamil Nadu has managed to deliver an integrated set of services that gain
from the synergies between different aspects of public health service delivery, and avoid fragmentation that results from
focus on single-issue programs.

Policy and Planning: A Directorate of Public Health with its dedicated workforce
Public health has its own dedicated Directorate in the State Health Department, in place since 1922. The department
has three key Directorates which are organizationally on an equal footing under the Health Secretary - the Directorates
of Public Health, of Medical Services, and of Medical Education. Each of these Directorates has its own dedicated
budget and workforce. Each service stream has its own career paths and incentives, and offers the possibility of rising
to the same level within the health department thereby precluding the status dominance of medical specialists over
public health specialists.
The Directorate of Public Health is staffed by a professional cadre of trained public health managers who are promoted
to the Directorate after long years of experience of planning and oversight of public health services in both rural and
urban areas.

                                                                                                                                   
1
“How to Improve Public Health Systems, Lessons from Tamil Nadu”, Monica Das Gupta et al 2009
      
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Dedicated funding: a separate and substantial budget

The Directorate has retained a separate budget, which has facilitated the planning, staffing and implementation of full-
scope public health services. Thus, for example, Tamil Nadu has about 120 entomologists (contrasted with just a
handful in most other states) who can contribute effectively to controlling vector-borne diseases. Apart from having a
separate budget for public health in Tamil Nadu, the size of the public health budget is large relative to spending on
secondary/tertiary medical care and medical education. The Directorate of Public Health has consistently had larger
budgets than the two other Directorates in the Health Department.

Legislative and regulatory underpinnings for public health services

Tamil Nadu has a Public Health Act, which specifies the legal and administrative structures under which a public health
system functions, assigns responsibilities and power to different levels of government and agencies.
Secondly, it sets out powers for protecting people’s health, including powers of regulation and of inspection - and the
responsibility to use these powers to monitor any situations or activities that could potentially threaten public health, and
seek to redress them if needed. The act empowers Health Officers and local bodies to contain any public health
“nuisance”, including by direct action if the offender does not take action as requested.
Thirdly, the act sets standards of food hygiene, water quality et cetera and specifies who is responsible for assuring that
these standards are met.
The Tamil Nadu Public Health Act provides the legislative basis for all the planning and policy implementation work of
the Directorate of Public Health. For example, the annual district plans for responding to public health threats posed by
floods are drawn up under the legislative authority of Public Health Act.

Workforce – training, incentives, and responsibilities of public health managers

There is a well-functioning professional public health cadre managing a team of non-medical specialists and lower-
grade staff working solely on public health. This cadre has faster promotion avenues than medical cadre and enjoys
considerable administrative responsibility and authority. After obtaining a medical degree, people who decide to enter
this service are given three months training in public health, and must within four years obtain a post graduate degree in
public health.
The first posting is that of a Municipal Health Officer (MHO) in which they are in charge of public health services of a city
or large town. Next promotion is that of a post of Deputy Director of Health Services (DDHS), which puts them in charge
of a whole district. Thereafter, they are promoted to Directorate of Public Health in which they assume various posts.
The DDHS and the Directorate of Public Health are trained to be oriented towards population wide health concerns, and
are responsible for only population-wide health services and primary health care services. There are not required to
manage secondary and tertiary medical services unlike the district health officers in other states.
The DDHS manage the workforce at district and block levels downwards including all the staff of Primary Health Centers
and Subcenters. The Block Medical Officer (BMO), at a Block Primary Health Center, and the Medical Officer of the
PHC (MO-PHC), at a Primary Health Center, are responsible for both primary health care and population-wide issues.
Even though belong to the medical cadre; they are given 15 days intensive training for their public health supervisory
duties and a BMO is expected to supervise all Block public health workers.

Is the Tamil Nadu’s system replicable in other states?

Tamil Nadu’s system is replicable in other states because its administrative foundations (and ingredients) are similar to
those of most other states. As in other states, Tamil Nadu’s health department is headed by an IAS officer and staffed at
state and district levels by medical officers. The state and district staffs work in a largely administrative and managerial
capacity, in charge of medical services at the primary, secondary and tertiary levels; as well as public health services. At
      
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the lowest level is a network of Primary Health Centers and subcenters, staffed by doctors, nurses, technicians, and
male and female outreach workers. These features are common across Indian states.
The difference is that Tamil Nadu organizes these ingredients differently from most states. The state (a) separates the
medical officers into the public health and medical tracks, (b) requires those in the public health track to obtain a public
health qualification in addition to their medical degree, and (c) orients their work towards managing population-wide
health services and primary health care ─ while those in the medical track obtain additional clinical qualifications and
are oriented towards providing hospital care.
The additional investment required to train a cadre of public health managers is not onerous, because the numbers
involved are very small. This cadre constitutes less than 1 percent of Tamil Nadu’s total government doctors. This
means that other states seeking to establish a public health managerial cadre would need to train only a tiny fraction of
their medical officers for this purpose. It takes two years of postgraduate training after the basic medical degree to
obtain a Diploma in Public Health in Tamil Nadu. The fact that per capita expenditure on health for Tamil Nadu is
consistently less than the nation average suggests that if public expenditures are efficiently used, it reduces the need for
citizens to spend on private health care.

Conclusion
There is much that other states can learn from Tamil Nadu’s public health system. Its key ingredients are a separate
Directorate of Public Health ─ staffed by a cadre of professional public health managers with deep first-hand experience
of working in both rural and urban areas ─ with its own budget, and with legislative underpinning. This robust system
can ensure a full complement of workforce, including the non-medical specialists and labourers who are critical
members of a public health team. While the general problems affecting a state bureaucracy do affect Tamil Nadu’s
health department, the very existence of a specialized cadre with a clear, focused mandate, means that it is much better
placed to protect public health than a more generalized cadre which is distracted by other (clinical) activities.

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