Although it is difficult to formally prove that strong population-wide health services such as those of Tamil Nadu improve health outcomes, the connection is strongly indicated by the fact that developed countries have continued to invest public funds in these services for over 125 years, and have successfully reduced exposure to communicable diseases.<sup>33</sup>

# _b._ _<u>Is Tamil Nadu’s system replicable in other states?</u>_

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 staff 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 and implementing the single-issue programs. There is a network of hospitals, staffed by government doctors, nurses, and other workers. At 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. This improves the efficiency of both the public health and the medical services. Coordination between these services is facilitated by the fact that all three Directorates (of Public Health, Medical Services, and Medical Education) report to the Health Secretary.

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. Of the 10,882 government doctors in Tamil Nadu in 2006-07, around 28 percent served under the Directorate of Public Health ― of which around 100 belonged to the cadre of public health managers, while the remainder serve as medical doctors in the Primary Health Centres.

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, which is no longer than the basic postgraduate medical specialization courses that many government doctors obtain. Gujarat state has already begun training some of its doctors in public health management.

Moreover, Tamil Nadu’s approach is affordable: the state spends less than the national average on health. The state-wise data on per capita expenditure on health for 2001-02 indicate that Tamil Nadu is just below the all-India average for public expenditure, and well below the average for private expenditure as well as for total health expenditure per capita (Table 3). This suggests that the public expenditures are efficiently used, reducing the need for citizens to spend on private health care. By contrast, Kerala is well above the average for public expenditure and its private expenditure is over twice the national average. Yet the child (under-5) mortality rate for Tamil Nadu for 2005-6 is less than half the national average (Table 3), lower than all the other states except Kerala and Goa.

Tamil Nadu’s success seems to lie in the major _efficiency gains which result from separate and well organized approaches to public health and medical care._ Effective delivery of preventive public health measures and primary health care reduces the need for (expensive) curative services, resulting overall in better value for public expenditure on health. Thus Tamil Nadu’s model is affordable within the health budgets currently prevailing in India, and also easy to replicate given that it hinges on better administration and management of resources that are within the reach of most states.

15