facilitating the clear identification of project inputs and outcomes — but discouraging the building of health systems which seek to use resources as they are needed to improve public health outcomes.

- The spread of democratic institutions also affected public health services, because electorates typically prefer public funds to be used to provide private goods (such as medical care), rather than public goods (such as sanitary measures to protect the health of the population as a whole).<sup>11</sup> Selling a public health success electorally requires creativity, since the successes are by nature negative (“no cases of typhoid last year” does not hit the headlines, while advances in surgical techniques is big news). In the developed world, this means that public health authorities have to fight to ensure adequate funding,<sup>12</sup> while in the developing world it can lead to serious neglect of public health services. It is notable that the non-democratic regimes of East Asia were the most successful in the developing world in improving health outcomes, by focusing their scarce resources on public health measures rather than on providing advanced medical care.

- Elite capture also plays a role. In India, even more than most developing countries, public funds for health and education have been funneled towards tertiary rather than primary levels. Substantial proportions of the health budgets have been spent on expanding subsidized medical training, public sector employment for medical graduates, and high-end tertiary medical services — all of which largely benefits the middle classes and detracts from the provision of public health services.

Several policy thrusts of the newly-independent India also detracted from public health service provision. To begin with, the overarching policy vision emphasized developing heavy industry rather than health and education. Public health services were merged with the medical services in the 1950s. Qualifications in specialty curative skills became far better rewarded than public health qualifications, and attracted the best talent. Gradually senior positions were filled by people with no training or experience in public health, poorly-equipped and poorly-motivated to manage public health activities. The demand for as well as the supply of public health training atrophied. The atrophy was further fuelled by the fact that it is politically much easier to respond to budget constraints by cutting (the relatively invisible) public health positions and activities, while expanding the curative services for which there is strong electoral demand.

Moreover, an inconsistency between Constitutional provisions starved public health systems of funds. Public health services were designated as the responsibility of the state governments, except for issues such as port quarantine and provisions relating to the spread of diseases between states. At the same time, the constitutional fiscal provisions require states to hand over the bulk of their tax revenues to the central government. The central health authorities leverage their funds by requiring states to provide co-financing for many of their programs. This leaves little fiscal room for states to operate programs for which there is little support from the central government, such assuring environmental sanitation and other core functions of a public health system.

> 11 Khaleghian and Das Gupta (2005).

> 12 Institute of Medicine (1987, 2002a and 2002b).

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