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Key messages

• TamilNaduhasmadegreatprogress inimprovingmaternal,newbornand childhealth,performingconsistently abovetheIndiannationalaverage.

• Astablebureaucracyandeffective managershaveensuredcontinuityand haveformulated,implemented, evaluatedandadaptedgovernment policiestoimprovehealthoutcomesand equity.

• TamilNadutrainedanddeployed villagehealthnursestoserve ruralcommunitiesmorerapidlythanin mostotherpartsofIndia.

• Anewdrugdistributionsystem hasrationalisedthepurchase anddistributionofmedicinestoall publichospitalsandprimaryhealthcare centres.

• Byfocusingonthepublicsector,the Governmenthasbeenabletoensure thatpeoplehaveaccesstolower-cost alternativestoprivatesectorhealth services.

• Otherfactorsthathavecontributed tobetterhealthoutcomesinclude alowerfertilityrate,improvedgender equality,ahigherliteracyrateand economicgrowth.

First published in 1985, the Good health at low cost report sought todescribe how some developing countries were able to achieve betterhealth outcomes than others with similar incomes. An iconic publicationof its day, it highlighted the linkages between the wider determinantsof health and their impact on health outcomes using country casestudies. In an extension to the original analysis, recent research exploresfive new countries asking why some developing countries are able toachieve better health outcomes. With chapters focusing on Bangladesh,Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand, ‘Good healthat low cost’ 25 years on has identified a series of inter-linking factors,within the health system and beyond. This fourth briefing in the series focuses on findings from Tamil Nadu.

‘Good health at low cost’ 25 years onTamilNadu’sruralhealthcaredeliverysystemwasrestructuredinthelate1970sandearly1980sinresponsetothe1978Alma-AtaDeclaration.Modernmedicalservicesarecomplementedwithindigenousmedicalprovision,offeredthroughprimaryhealthcarecentres.TamilNadu’shealthsectorhasbenefittedfromanumberofcommittedHealthSecretarieswhohavebeenthedriversofinnovativeinitiatives.Forexample,vigoroussupportformaternalandchildcareinthelate1990sandearly2000swasduetothevision,commitmentandleadershipofseniorcivilservants.

Economically,TamilNaduisrelativelyprosperous.ItranksthirdamongallstatesinIndia,withanaveragepercapitaincomein2007ofRs32733(Intl$3522),whichissubstantiallyabovethenationalaverage.Bothitsliteracyrateanditshumandevelopmentindexarealsosignificantlyabovethenationalaverage,asareseveralothersocioeconomicindicators.

‘Good health at low cost’ 25 years on What makes an effective health system? Page 01

‘Good health at low cost’ 25 years onWhat makes an effective health system?

Thestate’stotalhealthbudgetincreaseddramatically,fromRs4108million(US$167.9million)in1991/1992toRs14870million(US$335.9millionin2005/2006).Innominalterms,spendingincreasedby3.6timesbetween1993/1994and2005/2006.Medical,publichealthandfamilywelfareisthesecond-largestexpenditurecategoryinthestatebudgetbehindeducation.Since1990,centralgovernmenthascontributedapproximately20%ofthestate’sannualhealthbudgetandtheHealthandFamilyWelfareDepartmentofTamilNaduhasconsistentlyspentabout45%ofitsannualbudgetonprimaryhealthcare.By2005publicspendingonhealthcarehadbecomemorepro-poorthanitwasadecadeearlier.

Achieving better health in Tamil NaduTamilNadu’shealthcareachievementsareconsistentlyabovetheIndiannationalaverage.LifeexpectancyatbirthformenandwomenishigherthantherestofIndia.Between1980and2005,theinfantmortalityrateinTamilNadudecreasedby60%,comparedwith45%forthecountry

Copyright © Westminster European 2011

Chennai

Mumbai

New Delhi

Calcutta

INDIA

Tamil Nadu

SRI LANKA

Karnataka

Kerala

Andhra Pradesh

Maharashtra Orissa

Tamil Nadu 1980s - 2005: A success story in India

Credit: © 2007 Pradeep Tewari, Courtesy of Photoshare

‘Good health at low cost’ 25 years on What makes an effective health system? Page 02

Further readingChapter 6, Tamil Nadu 1980s-2005: A success story in India. In Balabanova D, McKee M and Mills A (eds). ‘Good health at low cost’ 25 years on. What makes an effective health system? London: London School of Hygiene & Tropical Medicine, 2011. Available at http://ghlc.lshtm.ac.uk

AcknowledgementsThe authors of the Tamil Nadu country case study wish to thank everyone they interviewed for this research. They also wish to thank colleagues at the London School of Hygiene & Tropical Medicine.The opinions expressed are those of the authors and do not necessarily reflect the views of the London School of Hygiene & Tropical Medicine.

Readers are encouraged to quote material from this briefing in their own publications by acknowledging the original source.

This policy briefing was edited by Pamoja Consulting. www.pamoja.uk.com

asawhole.Theunder-5mortalityrateinTamilNadufellby53%between1992/93and2005/06,comparedwith32%forthecountryoverall.However,themostdramaticdifferencebetweenTamilNaduandtherestofIndiahasbeeninthenumberofwomenwhodieasaresultofpregnancyorgivingbirth.Between1982and1986,thematernalmortalityrateinTamilNaduwasestimatedat319deathsper100000livebirths,comparedwithanationalaverageof555.By2004-2007,thematernalmortalityrateinTamilNaduhaddroppedto111deathsper100000livebirths,lessthanhalfofIndia’saverageof254andisthesecondlowestofallthestatesinthecountry.

Since1980,theHealthandFamilyWelfareDepartmentoftheGovernmentofTamilNaduhasreportedreductionsinpoliomyelitis,tuberculosis,malaria,leprosy,whoopingcough,measlesandtyphoid.Guineawormdiseasewaspracticallyeliminatedbythemid-1980sandnopoliocaseshavebeenreportedinthestateduring2000-2005incontrasttosomeotherpartsofthecountry.

Paths to SuccessConsistentpolicyandfinancialsupporttostrengtheningprimaryhealthcarehavebeenvital.HealthSecretariesandseniorcivilservantshavebeendriversofimprovementsinstatewidehealthinterventions.Healthauthoritieshavecreatedautonomousbodies(quasi-governmentalinstitutions)tobypassthebureaucratichurdlesthatwouldotherwiselimittheeffectivedeliveryofessentialcare.Improvedaccesstoprimary

healthcare,availabilityofessentialmedicinesandtrainedvillagehealthworkershasledtoamarkedincreaseintheuseofprimaryhealthcareservicesbywomen,childrenandpoorfamiliesfromruralareas.Thishasledtoanincreaseinantenatalcareandtotaldeliveriesinprimaryhealthcentres.

ThemultipurposeworkersschemewasimplementedpromptlyinTamilNaduandbythelate1980’snearly8000villagehealthnurseswereworkingintheruralareas.Duringhomevisits,thenursesprovideantenatalandpostnatalcare,vaccinations,contraceptionandotherbasicmaternalandchildhealthservices.

AnetworkofprimaryhealthcarecentreswasconstructedfasterinTamilNaduthaninalmostallotherIndianstates.Intheearly1980s,therewereonly400primaryhealthcentres;thisincreasedto1500by2005.By2008,nearlyallcentresoffered24-hourservices,includingoutpatientcareintheeveningsandincreasedaccesstoroutineessentialandemergencyobstetriccare.

Thesuccessfulimplementationofthenationaluniversalimmunizationprogrammemeantthatbytheearly1990sTamilNadurankedfirstamongallstatesinIndiainthenumberofchildrenfullyimmunized:60%ofchildreninruralareasand75%ofchildrenincities.

ThemostinnovativedevelopmentconceivedbytheGovernmentofTamilNaduistheMedicalServicesCorporation.Createdin1995,thisautonomousbodyexiststopurchaseanddistributemedicinestohospitalsandhealthcaresettings.Itseffectivenesshashelpedmanyotherstatestobeginsimilardrugmanagementsystems.

OutsidethehealthsystemseveralculturalandsocioeconomicfactorscontributedtoTamilNadu’sachievementssuchas;alowfertilityrate,betterliteracyratesandprogressonwomen’sempowerment.Thishasbeenessentialinreducingmaternalandchildmorbidityandmortality.Extensiveimprovementsinroadsandotherinfrastructureandhigherincomeshavealsohadabeneficialeffect.

Lessons learned and future challengesSeverallessonscanbedrawnfromTamilNadu’sexperiencethatmaybehelpfultoothercountries.Astrongfocusonprimaryhealthcareandsubstantialinvestmentsinhealthinfrastructurewereimportantfactors.Theimplementationofanautonomousdrugdistributionsystemandotherinnovatedeliveryinitiativessuchas24hourhealthfacilities,haveplayedtheirpartinimprovinghealth.Otherenablingfactorsincludepoliticalcommitmentatthenational

levelandtheinvolvementofstateanddistrictadministrationsinthedesignandimplementationofstrategicpoliciesandprogrammes.

Theseriesofinter-linkingfactors,asintheotherstudycountries,thathavemadeTamilNadu’shealthsystemsuccessfulinrealisingbetterhealthforitspopulationcanbeexpressedbyfourwordsallbeginningwithC–referredtoasthe4C’s.TheyareCapacity(theindividualsandinstitutionsnecessarytodesignandimplementreform),Continuity(thestabilitythatisrequiredforreformstosucceed),Catalysts(theabilitytoseizewindowsofopportunity)andContext(theabilitytotakecontextintoaccountinordertodevelopappropriateandrelevantpolicies).

EvenwiththeseimpressivehealthoutcomesTamilNaduhasmanyhealthchallenges.Themostpressingoftheseisthealarminglylownutritionalstatusofadultsandchildren,asinotherstatesofIndia.Inaddition,morecouldbedonetolowerthematernalmortalityrateandtheinfantmortalityrate.About60%ofinfantdeathsoccurattheearlyneonatalandpost-neonatalstagesandmostcouldbeprevented.TamilNadu,likeallotherstatesinIndia,needstofacetheincreasingburdenofnon-communicablediseases.AlthoughTamilNadustillhasalongwaytogotoaddressthesechallenges,thesignsarethatitismovingintherightdirection.Itssuccessestodateprovideusefullessonsforthefuture.

© London School of Hygiene & Tropical Medicine, 2011

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