_Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running_ (Paraphrased from Laurie Garrett 2001, _Betrayal of Trust: The Collapse of Global Public Health_ )

# **_Introduction_**

India suffers a staggering toll of ill-health from communicable diseases, largely resulting from poor environmental health conditions. Outbreaks of diseases such as dengue, diarrhoeas, hepatitis, and even cholera are commonplace, affecting all from the richest to the poorest. This imposes heavy costs on people and on the economy. Economic losses arise from many sources, such as lost labor-force productivity, business disruption, and the costs of treatment for people who should not have been exposed to disease in the first place. The World Bank estimates that the costs of communicable diseases amount to several percent of GDP in developing countries.<sup>**1**</sup> The WHO estimates that improved sanitation in developing countries would sharply reduce overall morbidity and child mortality (Pruss-Ustin et al 2008). They also estimate that half of malnutrition is attributable not to lack of food but to infections arising from poor sanitation. Half of India’s children are stunted (IIPS 2007: Table 10.1), and the fact that 25 percent of those in the highest wealth quintile are stunted reflects the burden of disease even among the more affluent.

Health systems have three major sets of services, of which the first two constitute public health services: (1) _population-wide preventive services_ to reduce exposure to disease through measures such as implementing health and sanitary regulations to ensure environmental health, monitoring health conditions, acting to avert potential health threats, and controlling outbreaks if they occur; (2) _clinical preventive services_ provided to individuals, such as screening and vaccination for maternal and child health; and (3) _medical services_ to care for and treat individuals with injuries and disease. In this paper, the first two of these sets of services together are referred to as ‘public health’, while the first alone is called ‘environmental health’.

India’s Health Ministry and states’ health departments have done much to improve health services, building an enormous infrastructure of publicly-funded medical services, medical education facilities, high-quality laboratories, and research institutions. However, central public health interventions are focused largely on single-issue programs for controlling specific diseases, delivering maternal and child health services, disease surveillance, etc.<sup>**2**</sup> This approach does not adequately address the need for development of public health systems, capable of planning and implementing a much broader range of services to _anticipate_ and reduce exposure to disease.

This can be detrimental for health outcomes as well as for the prospects for economic development. Public health services in general, and environmental health services in particular, constitute a pure public good, and form a basic part of a country’s developmental infrastructure. Countries with limited health budgets per capita need to 2