action is taken they can complain to the Deputy Commissioner. That Chennai ranked 13<sup>th</sup> of 423 cities surveyed for sanitary conditions in 2009-10 indicates that this system could work better (Table 1).

The public health and medical staff work very closely together on the ground. A few examples are their fortnightly joint review meetings, collaboration in disease surveillance and health camps, and joint inspections of the Urban Primary Health Centres. The collaboration runs throughout their work: for example, clusters of cases are referred by the medical staff to the Zonal Health Officer for the Sanitary Inspectors to trace contacts, and to address conditions that caused the outbreak.

The health department uses the CMC’s powers to improve disease reporting, including from the private sector which is widely viewed elsewhere in India as delinquent on this. They point out that private health facilities need the CMC for their licensing, so they have an incentive to comply with disease reporting requirements.

# **_(c) Professional support from the State Directorate of Public Health_**<sup>**_54_**</sup>

Tamil Nadu’s State Public Health Directorate plays an important role in providing technical support and oversight of the CMC’s public health services. Its Director has overriding powers across the state, to monitor outbreaks, ask local bodies about their disease control measures, and make technical suggestions. S/he can also offer technical expertise as needed, and send manpower if an outbreak is not under control. In the case of the CMC, the Director communicates directly with the Commissioner, to send orders to the CMC and to review progress, and will sit in the review meetings. The Directorate backs up the CMC’s public health work in many other ways, such as providing continuing training for CMC health staff, and help with emergencies.

This strong external technical support and oversight helps the CMC’s public health staff to maintain professional standards in their work, counter-balancing the elected representatives’ lay opinions and more politically-driven agendas. For example, they note that they can explain to their elected representatives that spraying insecticide in the air (“fogging”) is largely ineffective. They felt that ideally the City Health Officer and Zonal Health Officers would be line agency staff serving a term with the CMC and therefore interested in maintaining credibility with their peer group − instead of serving in the CMC for their lifetime, with the constraints imposed by elected representatives.

The State Public Health Directorate also forms a technical peer group against which the CMC health staff can measure themselves. It is easy for the CMC public health staff to communicate with counterparts in the Directorate, as they have the same training. The senior staff are from the public health cadre (medical doctors trained in public health administration), just like their counterparts in the Directorate. The Health Inspectors are also trained like the Sanitary Inspectors, who are their counterparts in the Directorate.

Tamil Nadu’s powerful technical Public Health Directorate contrasts sharply with other states, where such expertise is at best scattered, and independent oversight of public health conditions and services is at best weak. The Directorate raises awareness of public health issues across Tamil Nadu, sensitizing the state administration to these matters as described. Combined with the Directorate’s health education outreach, this helps raise broad awareness of public health issues and puts pressure on politicians to seek better services. This is reflected, for example, in local 12