_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, _Betrayal of Trust_ ) _When I arrived in Berlin, I heard the words ‘sanitary’ and ‘health’ everywhere, but I really did not understand those words. What I eventually came to understand was that these words ...referred to an entire administrative system that was organized to protect the public’s health.... and to improve the nation’s welfare_ (Nagayo Sensai, architect of the Japanese public health system, c. 1871)<sup>2</sup>

# **1. What is public health, and why invest in it?**

Public health services are conceptually distinct from medical services. They have as a key goal reducing a population’s _exposure_ to disease ⎯ for example through assuring food safety and other health regulations; vector control; monitoring waste disposal and water systems; and health education to improve personal health behaviors and build citizen demand for better public health outcomes. Thus they involve such disparate activities as improving slaughterhouse hygiene and cattle-keeping practices, cleaning irrigation canals to discourage vector breeding, and applying public health regulations.

Public health services produce “public goods” of incalculable benefit for facilitating economic growth and poverty reduction. Consider, for example, the long-term growth possibilities generated by draining the swamps around which Washington DC was built. And conversely, consider the global economic costs imposed by the avian flu and SARS epidemics, emanating from poor poultry-keeping and health practices in a few Chinese localities. In India, the 1994 plague epidemic following poor municipal sanitation in Surat is estimated by the WHO (1999) to have resulted in losses totaling $1.7 billion.

Poor public health conditions take economic tolls in various ways, including reduced attraction for investors and tourists; continued expenditures on combating diseases which should have become history; and labor productivity foregone. The poor pay a high price in debility, reduced earning capacity, and death. The rich suffer little mortality from communicable diseases, but nevertheless suffer repeated episodes of morbidity which are reflected in high rates of stunting amongst their children.<sup>3</sup> It has long been accepted that the most effective approaches to improving population health are those that prevent rather than treat disease. Moreover, they account for a small fraction of the total health budget in most countries. It is the norm for public health services to be publicly funded, since the market has limited incentives to provide them. This applies even in the US, where medical services are largely privately financed. But in India public policies and programs have focused largely on the provision of curative care

> 2 Cited in Ann B. Jannetta (2001).

> 3 For example, estimates indicate that in 1998-99, 45 percent of children below the age of 3 in India were stunted — and even among the top wealth tertile over 28 percent of children were stunted (National Family Health Surveys I and II). See also Das Gupta et al. (2005).

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