Lessons from India’s Own Success Stories

TOWARDS UNIVERSAL HEALTHCARE

Lessons from India’s Homegrown Success Stories

Udit Singh* and Noor Ameena**

The Right to health is a basic human right which was first recognised in the WHO Constitution (1946): “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”1 .

The National Health Profile 2022 clarifies that healthcare is not simply medical care; it is allied with a cultural understanding of ill health and well-being, the extent of socioeconomic inequalities, the reach of health services and the quality and costs of care along with present bio-medical understanding about health and illness2 .

Right to Health and the Indian Constitution

The right to health is not expressly provided as a right under the Constitution. However, the Supreme Court of India repeatedly stated that the right to health is an inherent right3 within the meaning of the right to life under Article 21. Article 47 of the Constitution bestows upon the State the duty to raise the level of nutrition and the standard of living and to improve public health which has been placed under the State list of the seventh schedule of the Constitution.

And that is why the states exercise major control over health-related finance, organisation, and management. Although the Constitution has made healthcare services largely a responsibility of the state governments, it has left enough leeway for the Union Government as several allied items (for e.g. population control and family planning) are listed in the concurrent list4 . The Union Government exerts control over the states in areas of health policy and planning by tying health financing through Central Schemes.

Public Health In India

Public health is defined as “the science and the art of preventing disease…through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing service for the early diagnosis and preventive treatment of disease….”5 . It means assuring conditions in which the population can be healthy. It is the organised application of resources to achieve health to enable socially and economically productive life6 .

Healthcare services include

  • population-wide preventive services like sanitation, drinking water, and epidemic control;
  • clinical preventive services like screening and vaccination; and
  • clinical curative services. The first and second together constitute public health services7 .

The health policies in India delineated from a holistic public health approach by an array of policy decisions since the 1950s - public health resources were targeted to single-issue programmes like malaria/ polio eradication programmes, public health engineering services including water supply and sanitation were delinked from Health Department, and amalgamation of public health and medical services eventually resulting in cowing of public health services by medical services8 .

The inadequacies of the public health system were thoroughly exposed during the advent of the recent COVID-19 pandemic.

There is sufficient evidence in the existing literature on the subject to show that investing in public health services leads to better health outcomes9 . This also makes economic sense, making it a sound economic practice for low-income countries to sustain investment in public health, thereby preventing the possible outbreak of diseases10. The inadequacies of the public health system were thoroughly exposed during the advent of the recent COVID-19 pandemic.

India’s Own Best Practices

It is well-known that health outcomes vary significantly in different states of India. Kerala and Tamil Nadu (TN) emerged as the top performers in the overall health performance in the Annual Health Index released by NITI Aayog for 2019-2011 jointly prepared with the Union Health Ministry and the World Bank. Titled as “The Healthy States, Progressive India” the nationwide survey-based report has ranked Kerala and Tamil Nadu as the best-performing State in the health indicators while Uttar Pradesh remained at the bottom despite showing some incremental progress. The States’ ranking was done on multiple indicators such as neonatal mortality rate, under-five mortality rate, sex ratio at birth, maternal mortality ratio, modern contraception prevalence rate, full immunisation coverage, antenatal care, identification and cure of TB, among many others.

We are discussing in this article India’s own success stories in terms of the delivery of health services to show what is working well right here despite all odds and what isn’t. Things boil down, it seems, eventually to a combination of good policies, effective implementation and good governance. The development models of Kerala and TN are characterized by investment in the social determinants of health, including education, sanitation, food, and clean water, and better achievements in the health sector are a natural consequence. With a dedicated public health infrastructure and communityoriented development, these states have lessons for the rest of the country.

Public Health Governance in Tamil Nadu

TN’s approach towards public health governance is unique with a functional public health infrastructure distinct from medical care. The health governance in TN is executed through three axles - The Directorate of Medical Education, the Directorate of Medical Services, and the Directorate of Public Health and Preventive Medicine. The State’s Department of Public Health and Preventive Medicine was established in the erstwhile Madras province as early as in 1923, while the TN Public Health Service acquired statutory status in 1939 with the enactment of the Madras Public Health Act, in 1939. Postindependence, TN continued to be governed by the same and retained the separate public health infrastructure, despite the subsequent shift in the Union Government policies to merge the public health and medical services. Hence, TN became the first and only state with a legal framework for public health until recently. Rajasthan enacted a law on the right to healthcare in 2022, and Kerala passed a public health legislation in 2023.

The TN public health department is instrumental in the early achievements in immunisation coverage, high couple protection rate and institutional deliveries, and eradication of epidemics way ahead of the rest of the country. The very fact that TN survived two major disasters, a tsunami in 2004 and the floods in 2015 without being followed by a major epidemic outbreak, and how these were effectively managed in the times of crisis indicates the strength of the system.

In the wake of the National Health Policy 2017 proposal to create a Public Health Management Cadre in all states, the Tamil Nadu experience is worth studying. Tamil Nadu Public Health Service is an elaborate system with a cadre of non-practicing doctors supported by dedicated cadres for Entomologists, Public Health Nurses, Statisticians, Health Inspectors, Village Health Nurses, and administrative cadres.

Medical graduates who choose public health as their specialty forego their private practice and become part of TN Public Health Services after acquiring the necessary qualifications. Once in service, they are posted as Municipal/City Health Officers, Assistant Professors in Medical Colleges, Principals of Training Colleges, etc. Upon promotion to Deputy Director, they are posted as District Health Officers in charge of National Health Programs, Primary Healthcare,

By absorbing existing maternity assistants and training new entrants as village health nurses, TN created a women force for penetrating rural healthcare.

and Environmental Hygiene promotion, including drinking water and sanitation, prevention and control of infectious diseases, prevention and control of non-communicable diseases, implementation of Tamil Nadu Public Health Act 1939, COPTA, Birth and Death Registration, etc. They are promoted as Joint or Additional Directors with statelevel responsibilities and deputed to National Missions like NHS, ICDS, TANSACS, TNHSP, or UN Agencies12.

During the 1980s, the TN deployed thousands of village health workers across the state under the Central Scheme of Multi-purpose Health Workers. Innovating on the Scheme, all the village health workers deployed by the state were women; by absorbing existing maternity assistants and training new entrants as village health nurses, TN created a women force for penetrating rural healthcare. This period also saw dedicated efforts to expand the primary healthcare facilities by collating resources from the Centre and the State, philanthropists, industrialists, and the community, often by contributions in kind (land, labour, etc.). In 1996, 24- hour primary healthcare was introduced to provide outpatient services in the evening and emergency and obstetric care to women. Together, these contributed to the early success of immunisation drives and the reduction of infant and maternal mortality rates. Another innovative measure was the setting up of Tamil Nadu Medical Services Corporation in 1995 as an autonomous body to purchase and distribute drugs to public hospitals and primary health centres, thereby ensuring the availability of essential medicines by eliminating middlemen and promoting generic drugs. This service was further expanded to provide lab-testing facilities, such as ultrasound scanning, etc., within the primary health centres. The TN model, coupled with a good public health infrastructure and penetration of primary healthcare in the 1980s, came to be lauded as a model of good health at low cost13, indicating its achievements in the health sector at relatively lesser percapita spending on the health sector.

TN is also known for its higher doctor-patient ratio in the country. It has more than 900 super-specialty doctors in the government sector14. The unique policies developed by the state in medical admission have led to the continuous supply of doctors to the government without urban-rural differentials. The TN Government reserves 50 percent of postgraduate and super-specialty seats for government doctors. To avail of this reservation, one must have served at least three years in a government facility. The government also mandates a superannuation bond to these candidates to serve the government hospitals till retirement. This ensures the continuous supply of doctors in government health facilities including super-specialists.

Community-led Healthcare Model of Kerala

The Kerala model of the public health delivery system shows that collaborative governance by coproduction between government and civil society can improve health services, efficiency, equity, and better health outcomes15. Kerala’s unique development model with higher human development indices at a lesser per capita income level is internationally recognised16. The achievements

Strengthening local selfgovernments and grassroots networks is something the rest of the country can emulate from Kerala.

of Kerala in the public health sector are partly attributed to historical events, including the public health and disease control interventions in the Princely State of Travancore17, which was expanded to the erstwhile provinces of Cochin and Malabar. The continued investments of successive governments in Kerala in health and education, and decentralised and community-oriented development practices sustained the momentum of public health interventions.

The 73rd and 74th Constitutional Amendments brought in the introduction of Panchayati Raj institutions in governance, Kerala treated it as an opportunity rather than a challenge. Between 1996 and 2001, a People’s Campaign for Decentralised Planning, at the instance of the government, was a radical attempt at decentralisation aimed to deepen the democratic participation of the public by devolving 40 percent of the funds to local self-governments and empowering them to plan their development accordingly18.

This has led to improvements in public health and healthcare services by creating latrines, safe drinking water facilities, and improvements in PHCs and taluka hospitals catering to local requirements.

The episodes of the Nipah outbreak in 2018, 2019, and 2023 and the state response during the COVID-19 pandemic reflect how decentralised development and community participation contribute to combatting health emergencies. The strong public health infrastructure built through decentralised governance has contributed to social behaviour conducive to preventing communicable diseases, improved healthcare-seeking behaviour, and state-wide disease surveillance. The state was quick to respond by creating protocols for contract tracing containment strategies through quarantine and social surveillance, and people’s trust and cooperation were augmented by accurate information dissemination, community mobilisation, and

It includes home-based services, institutionalised services outside hospitals, and hospital-based services.

decentralised enforcement mechanisms of social protocols.

Kerala’s strong grassroots-level network of women’s selfhelp groups (locally termed “kudumbashree”19), Anganwadi workers (outreach workers from the Integrated Child Development Service Scheme), and Accredited Social Health Activists (ASHAs) (group of women recruited through the National Health Mission) formed the axle of epidemic control by conducting door-to-door symptom surveys. This ensured the quarantine of suspect cases, provided psychosocial support and care of the elderly and palliative care patients. They were instrumental in establishing the ‘community kitchen’, which, along with the public distribution system, ensured an uninterrupted food supply to quarantined people, the destitute, and migrant labourers20. The role of community health workers in the pandemic is not an isolated event but the result of an effective, coordinated grassroots system in place. In an evaluation of ASHA among the states in India, Kerala stood at the top, with 85 percent of the potential users reporting that they have availed the services of ASHA workers (Lowest being 50% in Andhra Pradesh), and 97 percent of the ASHA workers reported making household visits (lowest being 57% in Jharkhand).21 Strengthening local self-governments (LSGs) and grassroots networks is something the rest of the country can emulate from Kerala.

Pain and Palliative Care Program in Kerala is a community-led initiative supported by the Government. What began as a community-run neighbourhood network, through local donations in Kerala today constitutes 2/3rd of the palliative services in India. It includes home-based services, institutionalised services outside hospitals, and hospitalbased services. The NRHM has also integrated communitybased palliative care with the Government of Kerala through the Arogyakeralam Palliative Care Project22, implemented with the support of LSGs – an example of integrating community services into central schemes. The continued supply of volunteers is ensured by innovative programs to extend this network to educational institutions like Our Responsibility to Children and Students in Palliative Care23. This movement has transformed a purely medical model of care into a socially responsible model with the active involvement of democratic institutions and people’s participation.

The newly launched AARDRAM Mission and Haritha Kerala Mission are set to rejuvenate primary health centres and improve environmental health.

The Way Forward

At a time when we discuss universal healthcare and right to health for all, it is important to shift our focus towards a holistic approach – a public healthbased universal healthcare. What has worked for improving healthcare in Kerala and TN is a combination of creating a designated public health cadre, streamlining public health education, training adequate public health professionals, incentivising the frontline health workers, greater decentralisation and community participation. It is important to note through the Kerala and TN success stories that good public health is a long-term goal in which the community’s participation is as crucial as good public health governance by the State.

Endnotes

  • World Medical Association. (2023, October 30). Right to Health: An Inclusive Right for All. Right to Health. Retrieved November 10, 2023, from https://bit.ly/3tzPnf6
  • CBHI. (2023, October 30). NHP 2022. Central Bureau of Health Intelligence. Retrieved November 5, 2023, from https://bit.ly/3tzSYK7
  • State of Punjab & Ors. v. Mohinder Singh Chawla Etc. AIR 1997 SC 1225
  • Desai, M., & Mahabal, K. B. (2023, October 30). Health Care Case Law In India A Reader. ESCR. Retrieved November 11, 2023, from https://bit.ly/3tzsngo
  • C.-E. A. Winslow, The Untilled Fields of Public Health, 51 SCIENCE 23 (1920).
  • MoH&FW, GoI. (1996, June). Report of the Expert Committee on Public Health System. People’s Archive of Rural India. Retrieved November 08, 2023, from https://bit.ly/48vuKQ2
  • Desikachari, B. R., Datta, K. K., Gupta, M. D., Padmanaban, P., Shukla, R., & Somanathan, T. V. (2010, Mar 6). How Might India’s Public Health Systems Be Strengthened? Lessons from Tamil Nadu. Economic & Political Weekly, 45(10). https://bit.ly/47gNLVA
  • Ibid.
  • Academy Health. (2023, October 30). The Return on Investment of Public Health System Spending. Academy Health. Retrieved October 31, 2023, from https://bit.ly/3REnmLn
  • Ibid.
  • NITI Aayog. (2023, October 30). Incremental Performance (Health Index). NITI Aayog. Retrieved November 11, 2023, from https://bit.ly/3RHZIgX
  • NITI Aayog. (Oct, 2023). NITI Aayog. NATIONAL HEALTH SYSTEMS RESOURCE CENTRE. Retrieved November 12, 2023, from https://bit.ly/3txFGxT
  • V.R. Muraleedharan, Umakant Dash & Lucy Gilson, Tamil Nadu 1980s to 2005: A Success Story in India, in GOOD HEALTH AT LOW COST: 25 YEARS ON 159 (2011), https://bit. ly/41E7zkg. How To Improve Public Health Systems : Lessons From Tamil Nadu, POLICY RESEARCH WORKING PAPERS (2019), https:// bit.ly/3TKepDa
  • CHELLAMUTHU, S., & RAMANATHAN, S. (2022, Jan 27). The Dravidian model of public health. The Hindu. Retrieved November 11, 2023, from https://bit.ly/48m5gVS
  • Jacob, M., & John, J. (2016). Local governments and the public health delivery system in Kerala: Lessons of collaborative governance. Cambridge Scholars Publishing.
  • United Nations. (1975). UN Department of Economic and Social Affairs, Poverty, Unemployment and Development Policy : A Case Study of Selected Issues with Reference to Kerala /: Department of Economic and Social Affairs. United Nations Digital Library. Retrieved November 12, 2023, from https://bit.ly/4aEUhIl
  • The first vaccination for small pox was introduced in 1813, in 1879 vaccination was made compulsory for students, prisoners, and public servants. Anand Lali Seena, Evolution of Health System in Travancore, UNIVERSITY (2011), https://bit.ly/3vkfyqP
  • Elamon, J., Franke, R. W., & Ekbal, B. (2004). Decentralization of health services: the Kerala People’s campaign. International Journal of Health Services, 34(4), 681-708.
  • https://bit.ly/48dqBQZ
  • Prajitha, K. C., Babu, V., Rahul, A., Valamparampil, M. J., Sreelakshmi, P. R., Nair, S., & Varma, R. P. (2023). Combatting emerging infectious diseases from Nipah to COVID-19 in Kerala, India. Public Health Action, 13(1), 32-36.
  • Ministry of Health and Family Welfare, GoI. (2015, February 27). Evaluation of Accredited Social Health Activists (ASHA). PIB. Retrieved November 15, 2023, from https://bit.ly/48vuTD4
  • Aayog, N. (2015). Social Sector Services Delivery: Good Practices Resource Book 2015.
  • Ibid.

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