# **_3. How does Tamil Nadu’s approach help protect urban health?_**

Urban areas have an especial need for well-managed public health services, given their crowding and high level of economic and social activities that can cause health threats.<sup>23</sup> Local governments have many political and other pressures on them which are not always compatible with good public health outcomes (see below). The situation can be different in large Corporations such as Chennai, which have the financial resources to support a full-fledged public health department, and are under pressure to protect public health given the attention any major mishaps receive from politicians and the media. Other municipalities, with fewer resources and scrutiny, benefit from Health Department oversight since that is an independent authority focused only on protecting public health.

# _a._ _<u>Directorate of Public Health seconds Health Officers to larger municipalities</u>_

In the 37 largest municipalities, public health services are managed by Municipal Health Officers (MHOs) seconded from the Directorate of Public Health. The MHOs are supported by a staff of Sanitary Inspectors. In smaller municipalities, public health services are managed by a Sanitary Officer (a promotee from the cadre of Sanitary Inspector), while the smallest towns are served only by a Sanitary Inspector.

The job descriptions of all these staff are oriented towards protecting environmental health, and other population-wide health services such as implementing the national disease control programs. Their main tasks include (a) disease prevention, control and management, (b) detection and abatement of nuisances, (c) food safety assurance, (d) monitoring environmental hazards and civic hygiene, e.g. management of solid and liquid wastes, and (e) collection of vital registration data.

The MHO and DDHS are also responsible for providing technical support and oversight of the urban maternal and child health services, which are provided by municipal hospitals and dispensaries. Government hospitals, which offer a wide range of clinical services, are under the Directorate of Medical Services.

By seconding MHOs to urban areas, the Directorate of Public Health provides municipalities with professional public health management. A key point is that they are accountable not to the municipality, but to the Directorate of Public Health which employs them and where the rest of their career lies. This means that they are focused primarily on protecting public health, not on the other agendas of municipal governments.

Sanitary Officers (SO) and Sanitary Inspectors (SI) belong to the Tamil Nadu Municipal Services. They are under the administrative control of the municipalities, whose first priority is not public health unless there is an outbreak which may be reported in the media. Municipalities gain revenues from issuing licenses, so it is not always in their interest to have sanitary staff conduct careful health inspections before recommending issuing of licenses. Municipalities also need help with miscellaneous tasks such as census-taking, and use these staff for various purposes unrelated to health.

Before 1989, the SOs and SIs were deputed by the municipal administration to work under the administrative control of the MHO and the Directorate of Public Health. This meant that the public health authorities had a say in their transfers, promotions, and capacity-building, and could initiate disciplinary action against them. When the administrative control of these staff was transferred to the municipalities in 1989,<sup>24</sup> there was a severe erosion of the MHO and the Directorate of Public Health’s power to get the municipal staff to focus on their public health duties.

# _b._ _<u>DDHS takes residual responsibility for municipal public health</u>_

The DDHS holds regular meetings with the person in charge of public health in all the municipalities in the district, i.e. the MHOs, SOs, and SIs as the case may be. They must report to the DDHS on all public health matters. S/he monitors their work and gives them technical support and additional human 11