health work, however, there is really no one below the DDHS. The DDHS’s office needs a person dedicated to supervising broader public health services including environmental health. And the Block Health Supervisors could be given more responsibility for supervising the Health Inspectors at local level.

# **_5. Has the Tamil Nadu system led to better public health and is it replicable?_**

The questions of greatest interest to researchers and policy-makers are of course (a) whether, and if so to what extent, public health outcomes in Tamil Nadu are better _because_ of its superior public health system, and (b) is the system replicable in other states.

# _a._ _<u>Does it lead to better health outcomes?</u>_

It is very difficult to formally evaluate the impact of having a better public health system, since health outcomes are also shaped by a multiplicity of other factors. These range from the population’s education and income levels, to how conducive the environmental conditions are to specific diseases. Regions differ, for example, in their conduciveness to breeding certain vectors, and in their preexisting disease foci. Some regions may be watered by fresh streams, while others may be watered by rivers that have meandered for thousands of miles, collecting pollutants of every kind along the way and poisoning the subsoil water as well.<sup>32</sup> There is no simple relationship between public health inputs and outcomes, making it difficult to identify good measures of the quality of the public health system. For example, disease incidence is difficult to measure reliably and, as discussed above, affected by many factors other than health system quality. Child mortality outcomes are good in Tamil Nadu (Table 3), but child mortality too is affected by many factors besides the quality of public health services. Reliable indicators are available for maternal and child health service delivery, and they show that Tamil Nadu’s Directorate of Public Health manages these services effectively. The state performs better than all other states in full child immunization coverage, as well as in the percentage of women receiving antenatal care, being informed of specific pregnancy complications, and receiving postnatal checkups (IIPS 2007: Tables 9.5, 8.10, and 8.22, see Figure 1). This is an exploratory analysis, and further analysis is needed.

What is clear is that Tamil Nadu is better organized than most Indian states to manage public health threats. This is illustrated, for example, by the state’s ability to respond swiftly to a major disaster like the tsunami, organize care for the survivors, and prevent epidemics breaking out as they often do when other states encounter a disaster. 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. Also, Tamil Nadu’s Health Department seeks actively to protect public health in urban areas, unlike most states.

It is also striking that Tamil Nadu has not figured as the main locus of any of India’s epidemics in recent decades, ranging from plague to SARS, from chikungunya to swine flu, supporting the premise that a better administrative approach has led to better public health. This is:

- despite being India’s third most urbanized state in 2001 (next only to Goa and Mizoram), with 44 percent of its population urban, compared with 28 percent for India as a whole

- despite being one of those least  endowed with reliable sources of fresh water

- in the case of bird flu, despite being one of the country’s main poultry producers with a major concentration of commercial poultry farms in Namakkal

- in the case of swine flu, despite being a state with 3 international airports and one of India’s largest numbers of travelers to and from North America

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