- **_Considered approach to devolution and management:_** Tamil Nadu state does not transfer all control over funds and line agency staff to local bodies. The CMC Act empowers the state government to sanction errant elected representatives. The CMC’s work is overseen by elected representatives, but is managed by a few professional administrators from the Indian Administrative Service and by technical professionals below them. These managers hold regular meetings to review their staff’s work.  Such monitoring is facilitated by tight organization of services, with clearly-specified responsibilities.

The CMC field staff is helped to maintain professional standards by monitoring and support from the CMC’s Headquarters and from the Tamil Nadu State Public Health Directorate. Public health and medical services are kept separate so that both sets of services can focus on their quite distinct tasks, but they work in close collaboration to maximize their joint product.

- **_Clear understanding of and support for public health services:_** Tamil Nadu has a strong State Public Health Directorate, whose head is empowered to monitor and support the CMC’s public health services. It provides crucial support to the CMC.

This Directorate is unusual in India in its strong capacity for public health administration, with a clear mandate and budget. Its staff are experienced in managing public health services. At all levels of the state administration, the Directorate staff participate in inter-sectoral meetings to discuss current and potential public health threats, raising administrators’ awareness of the complexities involved in generating good public health outcomes. In most other states, State Public Health Directorates are too weak to do this.

- **_Active approach to service delivery, especially to vulnerable populations._** The CMC’s Health Department provides active outreach to vulnerable populations, including setting up camps in slums and visiting homeless shelters.  They screen slum residents for diseases, to treat them, as well as to collect disease prevalence data to inform service planning and avert outbreaks. Such outreach is crucial given the high externalities of communicable diseases.

This approach goes far towards improving health outcomes in Chennai, as suggested by lower levels of child stunting than in other major Indian metropolises. Child stunting levels in Chennai’s slums are much lower than among Delhi’s _<u>non-slum</u>_ population. Maternal and child health service coverage in slums is also very high in Chennai, and far lower in Delhi.

The CMC’s approach is fairly successful in mitigating the negative impacts of devolution and of neglecting vulnerable groups. However, its health department needs to be given more authority to ensure better environmental sanitation in Chennai, to further improve health outcomes.

These lessons from Chennai can be used in other Indian cities, since they share the same overall administrative system. Chennai should not be dismissed as an irrelevant outlier, as was Kerala’s success in improving human development indicators. Some might argue that Tamil Nadu is “different” because of its bureaucracy’s strong work culture. This misses the point that a strong work culture can be generated by systematically applying standard management methods. Staff are motivated to work well if they are trained, supported in their work, given clear responsibilities and held accountable for them. It also helps to work in a team with a shared mission, such as to protect people’s health. Conversely, work cultures unravel with pervasive lack of accountability and responsiveness from above, as is starkly evident in Delhi.

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