The Tamil takeaway

It is unfair to compare the charms of a beach resort in Mamallapuram on a summer day with that of a government primary health centre (PHC). But the field visit to the upgraded Medavakkam PHC in the outskirts of Chennai on a hot, humid afternoon was necessary to fully grasp the nuances of the speeches and slides that preceded it.
The focus in the previous days had been on health service delivery, health finance and the health workforce — key issues which determine health outcomes but are not as much in the public eye as they ought to be. The occasion, the International Conference on Health Systems Strengthening, organised by the Tamil Nadu Health System Project (TNHSP), government of Tamil Nadu, in collaboration with other national and international agencies including the World Bank, World Health Organisation, United States Agency for International Development, National AIDS Control Organisation earlier this month. The place, magical Mamallapuram.
One of the prime attractions of the conference was its choice of venue — Tamil Nadu. Tamil Nadu is not India’s richest state by gross domestic product but it is a shining example of a state that has prioritised strengthening its health systems, and as a result, can be proud of the positive trend in the health of its people.
The 30-bedded PHC we visited had spotlessly clean wards, staff on duty, an air-conditioned labour room, operating theatre, blood storage facilities, a centralised oxygen supply, an X-ray unit and solar water heaters. It showcased what political will combined with non-governmental organisation (NGO) involvement and private enterprise can achieve. To someone used to visiting PHCs with leaky roofs, few drugs, poorly maintained equipment, and often no doctor on site, it vividly brought home the essence of the Tamil takeaway — health programmes cannot be effectively sustained if mounted on weakly functioning health systems.
Tamil Nadu has done better than other states in health because it has paid attention to this cardinal principle.
Inside a post-operative ward for mothers and newborns, 31-year-old Benazir Satyamurthy, a nurse, explained why she chose to deliver in this PHC. “My first child was born in a private clinic because I was covered by insurance. I have a new job and am not yet entitled to such benefits. I have seen a lot of hospitals I checked out this place thoroughly. It maintains hygienic practices. It has all the facilities and it is free. What more can anyone want? This is like any well-run private hospital.”
Taking a tour of the PHC, I quickly got Benazir’s point. But how did such a heavenly place manage the crowds? Surely, everyone would come in, all at once, to taste the marvels of this PPP or public-private partnership.
The uncomprending stares that greeted me made me realise this was Tamil Nadu. And the question, well, not hugely relevant.
“Every one has to register first. Then, we prioritise according to the expected date of delivery. People are admitted strictly according to their registration number. There is no question of breaking the queue here”, a ward nurse explained.
That there are many more people out there who agree with Benazir is affirmed by the hospital data.
Out patients per day are steadily going up in the Medavakkam PHC — from 355 in 2008-’09 to 395 in 2009-’10. Deliveries per month are also increasing from 31 to 45 during the same period.
One of the reasons why one does not get the oppressive feel of crowds milling round in this PHC is because it has an outreach programme. Village health nurses attached to the PHC make home visits. Usha Jayaram, a village health nurse, spelt out her weekly schedule — Every Monday is spent conducting ante natal check-ups for pregnant women in four villages surrounding Medavakkam. Tuesdays and Wednesdays are spent at the PHC. Wednesdays are also designated “immunisation days”. Thursdays were spent in government-aided schools. Fridays were “village health nutrition days” and Saturdays were spent again on home visits, focusing on minor ailments.
There are many reasons behind the Medavakkam PHC’s success. But one key contributory factor has been the successful leveraging of resources in cash and kind from a variety of public and private institutions. The PHC has signed MOUs (memorandum of understanding) with several agencies. The Lifeline group of hospitals, for example, provides the services of specialists. The Catalyst Trust, a Chennai-based NGO, and a key partner of Medavakkam PHC, has put in substantial funds for infrastructure development. The president of the local panchayat supports the maintenance of the PHC as well as the reverse osmosis system which provides safe drinking water to the patients coming to the PHC. A private foundation assists the PHC with screening of breast cancer and a local dental college and hospital has set up a dental clinic at the Medvakkam PHC. And so on.
The Medavakkam PHC is a role model but its approach is not unique. Other government institutions follow similar strategies leading to Tamil Nadu’s enviable health indicators — its infant mortality rate is 31 (per 1,000 live births) compared to the all-India figure of 53 and its maternal mortality ratio is 111 (per 100,000 live births) compared to the national average of 254. The HIV and AIDS epidemic made its debut in Chennai in 1986 but the state has shown admirable deftness in reversing the pace of the spread of HIV.
The Tamil takeaway is simple — public health matters and it is cost-effective in the long-run to put money in strengthening health systems than in disease-specific programmes.
While, over time, most state health departments have de-prioritised their public health systems, Tamil Nadu resolutely kept its focus on public health. Tamil Nadu is that rare example of an Indian state that chose not to amalgamate its medical and public health services. Indeed, it has a separate Directorate of Public Health, staffed by a cadre of professional public health managers with deep firsthand experience working in both rural and urban areas, and complemented with non-medical specialists with its own budget, and with legislative underpinning.
This lies at the heart of Tamil Nadu’s impressive record in averting outbreaks, managing endemic diseases, preventing disease resurgence, managing disasters and emergencies, and supporting local bodies to protect public health in rural and urban areas.
In these cash-strapped times, the Tamil Nadu model has a huge advantage. The state spends less per capita on health while achieving far better health outcomes.

Patralekha Chatterjee writes on development issues in India and emerging economies and can be reached at patralekha.chatterjee@gmail.com [2]