These organizational factors underlie Tamil Nadu’s better capacity than most Indian states to conduct long-term planning to avert outbreaks, manage endemic diseases, prevent disease resurgence, manage disasters and emergencies, and support local bodies to protect public health in rural and urban areas. This better capacity is illustrated in many ways. For example, the state was able to respond to a major natural disaster like the tsunami without the disease outbreaks that commonly accompany even lesser disasters in other states. This is helped by the annual district-level exercises in planning for the event of a river flooding, which serve like fire drills to remind the whole public health team of what must be done in a natural disaster. Another example is that the state maintains services to ensure that plague does not break out near the wild plague focus around Hosur ─ enabling that area to now seek to become an industrial hub. When the 1993-4 plague outbreak took place in Maharashtra and Gujarat, Tamil Nadu sent its team to help, being among the only repository of plague management skills in the country at the time. Having a separate budget enables the Directorate of Public Health to maintain its plague control services without being told that the absence of plague deaths makes these services cost-inefficient. Like their counterparts in the developed world, Tamil Nadu’s public health managers are in a position to maintain services as long as there is a serious _potential_ threat ─ not merely the manifested threat that the lay public is able to perceive.

The interesting feature is that Tamil Nadu’s Health Department achieves this within the same overall organization (and resources) as that of other states, with medical and nonmedical staff organized into a similar network of services at state, district, and subdistrict levels. The difference is that Tamil Nadu separates out a mere 1% of its government medical doctors to be public health managers in the Directorate of Public Health, and trains and incentivizes them accordingly. Tamil Nadu’s system also has some key flaws which need to be addressed in order to use this organizational capacity to greater effect ─ including frayed capacity of grassroots workers in both rural and urban areas to ensure environmental health (Das Gupta et al 2009).

Tamil Nadu’s per capita public expenditure on health is similar to the Indian average ― and private expenditures are considerably lower ― but its health outcomes are superior, as reflected in more rapid infant mortality decline than that of India (Figures 3 and 4). Figure 4 could be viewed as indicating that Tamil Nadu has benefited from not participating fully in the health policy changes undertaken by the central government between the 1950s and the 1970s. 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. Of course, part of the superior health outcomes may be attributable to more rapid economic growth. However, this causality works both ways and is hard to disentangle, since improvements in health conditions improve the prospects for economic growth, not only by raising labor productivity but also by creating development infrastructure and helping attract investment.

It is widely recognized ─ in a large literature spanning many disciplines ─ that good public health services are key to improving health outcomes in the both the developed and developing world.<sup>**33**</sup> That public health interventions in the developed world helped 12