IMPROVING PUBLIC HEALTH SERVICES: INDIA’S BEST INVESTMENT DISCUSSION PAPER FEBRUARY 2025 MONICA DAS GUPTA IMPROVING PUBLIC HEALTH SERVICES: INDIA’S BEST INVESTMENT Monica Das Gupta February 2025 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors, or to the countries they represent. Citation and the use of the material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jung-Hwan Choi at jchoi@worldbank.org. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages the dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202- 522-2625; email: pubrights@worldbank.org. © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW, Washington, DC 20433 All rights reserved. i Health, Nutrition, and Population (HNP) Discussion Paper Improving Public Health Services: India’s Best Investment Monica Das Guptaa a Maryland Population Research Center, University of Maryland, College Park, Maryland, USA, formerly at the World Bank’s Development Research Group, Washington, DC, USA. Abstract: Reducing communicable diseases is a key plank of development infrastructure, and little effort is required to build a strong public health system in India, within its existing administrative structures and budgetary outlays. This would go far toward impro ving people’s well-being and productivity, and avert losses of billions of dollars annually due to poor health conditions. The national-level institutions required are already in place, with a network of apex technical and training institutions. However, their ability to function effectively is severely constrained by a lack of autonomy. State-level public health systems need much strengthening. The central government can do much to incentivize states to do this, using as leverage the substantial funds it transfers to states’ health sector. It can tie this budgetary support to action by states to achieve the following: • Create separate Directorates for Public Health and for Medical Services, with separate budgets to avoid marginalizing public health services in favor of medical services. A simple model for this is available in the state of Tamil Nadu, which has much better health outcomes than most states despite spending no more than the national average. • Adopt modern public health legislation, providing the legal basis for action to protect public health. • Revitalize the grassroots male health worker cadre, responsible for environmental and public health. This is the cadre parallel to Sri Lanka’s Public Health Inspectors, which offers an outstanding training curriculum, manuals, and supervisory guidelines. • Assure a steady flow of needed supplies, modeled on the Tamil Nadu Medical Services Corporation. Tamil Nadu and Sri Lanka offer simple low-cost models for strengthening public health systems across India, within current health budgets and administrative structures. These existing resources can be used to replicate Tamil Nadu’s impressive system of public health management, supported by ground-level workers modeled on Sri Lanka’s outstanding Public Health Inspectors. This would greatly improve people’s health in India and support the country’s effort to become a developed economy. Keywords: Public health, public goods, infrastructure, service delivery, disease control Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Monica Das Gupta, email: mdasgupta@gmail.com. Maryland Population Research Center, 2105 Morrill Hall, Bldg. 040, 7313 Preinkert Dr., University of Maryland College Park, MD 20742-6304. Tel: (301) 405-6403 ii TABLE OF CONTENTS ACKNOWLEDGMENTS ................................................................................................................ IV 1. INTRODUCTION ..................................................................................................................... 5 2. WHAT IS PUBLIC HEALTH? HOW DOES IT DIFFER FROM PUBLICLY-FUNDED MEDICAL SERVICES? ................................................................................................................... 9 FOCUS ON WEAK LINKS IN THE CHAIN ............................................................................................. 9 3. WHAT INSTITUTIONAL STRUCTURES DO PUBLIC HEALTH SYSTEMS NEED? ......... 11 NATIONAL LEVEL.......................................................................................................................... 11 STATE LEVEL ............................................................................................................................... 12 STAFFING: TECHNICAL AND GRASSROOTS WORKERS .................................................................... 13 4. LESSONS FROM THE TAMIL NADU MODEL OF MANAGING PUBLIC HEALTH SERVICES ..................................................................................................................................... 14 THE ORGANIZATION OF TAMIL NADU’S DIRECTORATE OF PUBLIC HEALTH ....................................... 14 Policy and Planning: A Separate Directorate of Public Health .............................................. 14 Dedicated Funding: A Separate and Substantial Budget ...................................................... 15 Legislative Underpinning for Public Health Services ............................................................. 15 Close Collaboration with the Whole State Administration ..................................................... 15 How Does Tamil Nadu’s Approach Strengthen the Delivery of Public Health Services? ..... 16 Long-Term Planning to Avert Outbreaks ............................................................................... 16 Eradicating Diseases and Preventing Their Resurgence ...................................................... 17 Management of Endemic Diseases ....................................................................................... 17 Citizen Outreach and Local Bodies ....................................................................................... 17 Ground-Level Staff: Health Inspectors .................................................................................. 17 5. SRI LANKA’S PUBLIC HEALTH INSPECTORS (PHIS): AN EXEMPLARY MODEL OF GROUND-LEVEL SERVICES ....................................................................................................... 19 6. SUMMARY OF COMPLEMENTARY LESSONS FROM TAMIL NADU AND SRI LANKA . 21 7. CONCLUSIONS .................................................................................................................... 23 8. REFERENCES ...................................................................................................................... 24 iii ACKNOWLEDGMENTS This paper pulls together a body of research supported by the World Bank’s Development Research Group. The author gratefully acknowledges the patient explanations given by innumerable people in institutions across India and Sri Lanka—in Delhi: the National Centre for Disease Control, the Health Ministry, and the Delhi Municipal Corporation: in Tamil Nadu: the Public Health Directorate at state and district level, the Health Department, and the Chennai Municipal Corporation; in West Bengal: the Health Department and the Panchayati Raj Department; the Health Departments of Karnataka and Kerala; in Sri Lanka: the Health Ministry, Provincial and Regional Directorates of Health, the Kalutara training institute, the College of Community Physicians of Sri Lanka. and the Institute for Health Policy, Colombo. The author gratefully acknowledges the intellectual support of colleagues at these institutions and at the World Bank, as well as feedback from the reviewers of the working papers and journal articles on which this paper draws. Especial thanks to Dr T.V. Somanathan (currently Cabinet Secretary, Government of India) for his insights into the Tamil Nadu administrative system, and to Dr. K. K. Bagchi (former Health Secretary, Government of West Bengal) for his advice to study the Tamil Nadu model of public health service delivery. The author is grateful to the World Bank for publishing this report as an HNP Discussion Paper. iv 1. INTRODUCTION “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 Garrett 2001) “Public health is about preventing disease … rather than treating the illnesses of individuals” (Canada’s Chief Public Health Officer, 2011) In 1871, Japan’s Meiji government set out to learn how to become a global power. It sent a large study tour to the industrialized world, to examine the best models for redesigning Japan’s institutions and infrastructure toward this end. This included designing a public health system to reduce exposure to communicable diseases, which constitutes an essential part of a country’s development infrastructure. As Nagayo Sensei, a health specialist on the Japanese 1871 study tour put it: When I arrived in Berlin, I heard the words “sanitary” and “health” everywhere … I eventually came to understand that these words referred to an entire administrative system that was organised to protect the public's health.…. and to improve the nation's welfare. 1 This enviably pragmatic approach to planning has served Japan well. Life expectancy at birth in Japan and its colonies (Korea, Taiwan) rose to 49 years by 1940, despite low per capita caloric availability similar to India, where life expectancy was 32 (Preston 1980). The average height of Japanese men also rose by 2 inches from 1900 to 1939.2 In the developed world, systematic public health efforts raised health and labor productivity well before the mass availability of antibiotics in the mid-1940s (Figure 1), helping set the stage for rapid economic growth. They were highly motivated to invest in communicable disease prevention and control,3 as there were few (if any) reliable cures for these diseases at the time. Since the 1950s, most countries in Asia and Latin America have built up their public health systems and reduced exposure to communicable diseases, as this is a low-cost and highly effective way to raise population health and productivity. Unfortunately, India was left behind in this process, investing primarily in increasing access to curative services. India bears massive costs as a result of neglecting public health services. Many communicable diseases continue to be endemic. Poor health imposes large costs on households and disrupts economic activity — 1 Cited in Jannetta 2001. 2 https://nbakki.hatenablog.com/entry/2014/05/30/173407. Accessed April 26, 2024. 3 This included efforts to upgrade housing to reduce crowding and install water, drainage, and sewer systems for slum dwellers. See Chadwick 1842; Lubove 1962; Rosen 1993; and Duffy 1971, 1990. 5 resulting in losses estimated at several billions of dollars annually. 4 Moreover, these estimates do not include the impact of childhood ill-health on lifetime loss in productivity and earnings.5 Climate change and newly emerging diseases will bring further challenges. There are unfortunately few incentives for politicians to invest in protecting public health. This is especially true in settings such as India, where citizens have not yet come to perceive this as a basic function of good governance.6 In the developed world, people no longer perceive communicable diseases as a threat and fail to appreciate how much continual vigilance their public health staff must exert to keep these diseases at bay. The main problem is that the results of good public health services are intangible, as success is defined by an absence of adverse events. It is difficult to reap credit with citizens by telling them that their probability of contracting typhoid has declined. As Michael Bloomberg (2024) puts it: Patients leaving a hospital after receiving emergency surgery are almost always grateful, and they know exactly whom to thank for saving their lives. By contrast, public-health interventions save lives every day, but those who are saved rarely even know it . Such interventions … do not produce grateful patients (or grateful policymakers, who could better fund them) …. We need voters who recognize the stakes and hold their representatives’ feet to the fire. (Parentheses mine). Figure 1: Infant Mortality Rate, United States, 1915 –1997 Public Health Measures Helped Reduce Mortality Mass availability of antibiotics Source: CDC 1999. 4 World Bank 2011; Naik et al. 2023; Hariharan et al. 2019; Gupta and Chowdury 2014; Goyanka 2021. The 1994 plague outbreak in Surat is estimated to have cost billions of dollars, including indirect costs such as declines in exports and tourism (Gani and Leach 2004). There are also substantial costs on forgone revenues from tourism (Roselló, Santana-Gallego, and Awan 2017). 5 Currie 2009. 6 Ban, Das Gupta, and Rao 2010. 6 Public funds for health services in India have been focused largely on medical services, while public health services have been neglected. This is reflected in a widespread absence of modern public health regulations, and of systematic planning and delivery of public health services. Funds for disease control in India are not rationally deployed. There is strong capacity for dealing with outbreaks when they occur, but not to prevent them from occurring. Impressive capacity also exists for conducting intensive campaigns, but not for sustaining these gains on a continuing basis after the campaign. This is illustrated by the near-eradication of malaria through highly organized efforts in the 1950s, and its resurgence when attention shifted to other priorities such as family planning. The costs of neglecting public health in India are reflected sharply in shockingly high levels of child stunting compared with other developing countries (Figure 2). The prevalence of child stunting among India’s highest wealth quintile is similar to that of Sri Lanka’s poorest quintile (Figure 3). Wealth is much less protective of child growth in India than in Sri Lanka, which has an ethnically similar population but a good public health system. The genetic potential for growth in height is in fact found to be similar across populations,7 and studies indicate a strong relationship between increases in height and decreases in disease burden. 8 Children in India’s top wealth quintile are stunted primarily because they are exposed to contaminated/polluted environments.9 This happens even if a child does not appear to be ill: Subclinical infections, resulting from exposure to contaminated environments and poor hygiene, are associated with stunting, owing to nutrient malabsorption and reduced ability of the gut to function as a barrier against disease-causing organisms (WHO 2014, 2). Access to medical care ensures low mortality among these children of wealthy households, but repeated infections expose them to stunting—which is associated with lower cognitive ability, earnings, and longevity.10 Unlike Japan in 1871, there is today no need to hunt for information on how to design effective public health systems. Simple well-tried models are available on our doorstep, which fit easily within our administrative structures and budgets. This paper summarizes lessons from the Indian state of Tamil Nadu and Sri Lanka, which show how public health systems can be greatly improved across India by simply using existing resources more effectively. 7 Natale and Rajagopalan (2014, 6). Some have argued that Indians are genetically shorter than other ethnic groups, and so the WHO growth standards are not applicable to them (see Panagariya 2013), but there is no evidence to support this argument. Cross-population differences in height seem related largely to nongenetic, environmental factors, while genetic factors play more of a role in intrapopulation differences (NCD-RisC 2016, 1). 8 Hatton 2014; Grasgruber et al. 2014. Average heights have also been found to decrease when conditions deteriorate, as in parts of sub-Saharan Africa today (NCD-RisC 2016, Figure 8). Grasgruber et al. (2014, 86) note this happened also in Lithuania when it was stressed after the collapse of the Soviet Union. 9 Child stunting can result from poor maternal health/nutrition, inadequate child feeding, infection, and limited access to effective health care (WHO 2014, 2; NCD-RisC 2016, 1). Of these, infection is the most applicable to children in the top wealth quintile. There are no gender differentials in child stunting in India (NFHS-5, Table 10.1). 10 Case and Paxson 2008; Crimmins and Finch 2006; Hoddinott et al. 2013; NCD-RisC 2016; and UNICEF, WHO and World Bank 2017 7 Figure 2: Child Mortality versus Child Stunting,* 2021 Source: Our World in Data, based on data compiled by the World Bank, accessed May 30, 2023. Note: * Child mortality is the share of children dying before age five. Child stunting is the percentage of children under age five with height-for-age more than two standard deviations below the median for the global reference population of that age. Figure 3: Child Stunting in India and Sri Lanka Percentage of Children Stunted in India's Top Wealth Quintile Is Similar to Sri Lanka's Bottom Wealth Quintile 30 % of children stunted (<2SD) 25 20 15 2006 10 2016 5 0 Sri Lanka lowest India highest wealth wealth quintile quintile Source: NFHS surveys India 2006, 2016; DHS surveys Sri Lanka 2006, 2016. Note: SD = Standard deviation. 8 2. WHAT IS PUBLIC HEALTH? HOW DOES IT DIFFER FROM PUBLICLY- FUNDED MEDICAL SERVICES? Health services comprise three broad sets of services (Figure 4): • Clinical services to treat an individual patient • Preventive services such as vaccination, which protect individuals and thereby also other people • Preventive services that provide “pure public goods” by reducing the whole population’s exposure to disease. Figure 4: Three Broad Types of Health Services Preventive health services focus heavily on communicable diseases, as one case can infect others. Preventive health includes activities such as “sanitation of the environment, control of infections, education in personal hygiene, and the organization of medical services for early diagnosis and preventive treatment.” (Paraphrased from Winslow, an architect of the US public health system [Winslow 1920, 30]). Even in the developed world—where noncommunicable diseases such as cancer predominate as causes of death—the public health system continually monitors potential sources of communicable diseases and takes action to prevent outbreaks (Chart 1). Sri Lanka’s Public Health Inspectors have a similar range of duties (Chart 2). Key services to reduce actual/potential threats to public health include the following: • Monitoring potential sources of disease • Informing and mobilizing the public to avoid and respond to threats • Enforcing public health laws to reduce threats • Addressing threats: • Reduce the threat, for example, through sanitation and vector control • Reduce spread, for example, through contact tracing, vaccination, and treatment Focus on Weak Links in the Chain The first principle of public health service provision is that outcomes are driven by the weakest links in the chain, as contagion spills between areas and across boundaries. This was a key motivation for municipal governments in the Western world to invest in improving sanitary conditions in their crowded and dirty slums: 9 The knowledge that the diseases of the workers who sewed clothes in their filthy tenement homes or who processed food could be spread to decent, clean, and respectable citizens served as a powerful incentive to the reform of public health (Duffy 1971, 809). In India, slum residents have inadequate access to water, solid waste removal, drainage, and sewerage/toilets (Government of India 2015). As a result, diseases remain endemic, and remain a source of infection for everyone, including the affluent. Chart 1: Duties of Public (Environmental) Health Officers in Europe, 1978 • Water safety • Food safety (food vendors, food processing / storage, slaughterhouses, markets) • Waste management • Vector control • Housing • Investigate & manage disease threats • Occupational health • Air quality • Control measures at borders and ports Source: WHO 1978 Chart 2: Duties of Public Health Inspectors in Sri Lanka • Investigate & manage disease threats (e.g., contact tracing, follow up with treatment defaulters) • Water safety (testing, disinfection) • Food safety (food vendors, food processing / storage, slaughterhouses, markets) • Waste management (supervision local bodies’ collection and disposal of refuse) • Housing inspections (supervise latrine construction, sanitation, vector control) • Vector control • Occupational health (factory inspections) • School health inspections (incl worm treatment) • Health education (plan & implement) • Disasters and epidemics: organize & supervise sanitation & other measures to prevent outbreaks • Sanitation of medical institutions: supervise and submit reports to head of the institution Source: Ministry of Health, Sri Lanka 2010, 2020, Das Gupta et al (2013) 10 3. WHAT INSTITUTIONAL STRUCTURES DO PUBLIC HEALTH SYSTEMS NEED? To function effectively, a country’s public health system needs some basic institutional structures at national and state levels, which are staffed by public health specialists and, importantly, have the autonomy to function effectively. National Level A national institution is needed, to oversee and guide the country’s public health decision -making. In addition to guidance based on information from within the country, its guidance also needs to be based on exchanging information with other countries’ apex public health institutions (such as the Centers for Disease Control of the United States, Europe, and China) and with international institutions such as the World Health Organization. Information from national and international sources needs to be processed and passed along to the central government and to the states. This exists in India in principle, in the form of the National Centre for Disease Control (NCDC), but the NCDC is woefully lacking in the authority to even manage its own staff. It is micromanaged by the Health Ministry, whose top officials rotate between ministries and rarely have a background in public health. A crippling lack of autonomy also affects the apex national public health agencies that provide technical inputs and train apex public health staff. For example, the central Health Ministry specifies that the diploma in public health is open not only to candidates with medical training, but also to those trained in the social sciences11—thereby showing a fundamental lack of understanding that public health administrators need to be trained doctors to understand how to recognize and respond to public health threats. This is just one of many examples of how sidelining public health specialists in the Health Ministry undermines the effectiveness of public health services. Another example is that financial transfers to states’ health activities are largely tied to single-issue programs such as polio, and require detailed reporting on progress on these specific issues. This forces state governments to focus primarily on these single-issue programs, instead of responding to the actual range of public health problems on the ground. An excessive focus on meeting international goals can also be damaging. For example, the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) set goals to reduce maternal and child mortality, but not specifically to reduce child stunting. T his can have perverse results in settings that do not already prioritize broader efforts to improve child health. As a result, child mortality in India has declined much more rapidly than child stunting (Figure 5). India is a strikingly negative outlier in child stunting, with levels comparable to countries with much higher child mortality levels (Figure 2). 11 https://web.archive.org/web/20120307200629/http://www.nihfw.org/Courses/PG_Diploma_In_PHM.html. Accessed April 1, 2024. 11 Figure 5: Child Mortality Declined Much Faster Than Child Stunting, India 1992–1993 to 2019–2021 110 100 <5 mortality per 1,000 live births 90 80 % stunted (<2SD) / 70 60 50 40 30 1992-93 1998-99 2005-06 2015-16 2019-21 Year Span % stunted (<2SD) <5 mortality Source: National Family Health Surveys India (NFHS 1–5). Note: SD = Standard deviation. State Level At the state level, Public Health Directorates are needed, with the mandate and resources to plan and coordinate public health services down to the local level. This was dealt a crushing blow by a central government directive in the mid-1950s that states should amalgamate their public health and medical services. Most states duly consolidated their services, and public health services atrophied as resources were increasingly diverted to upgrading medical services, the benefits of which are easily appreciated by citizens and politicians. Public health services are especially vulnerable to neglect. Not only are their benefits intangible, but also decision-making for public health services is highly technical in nature and needs to adapt in response to ever-shifting disease conditions. This is difficult to achieve if key decisions must be approved by nontechnical people. Adding to the damage was the 1993 Constitutional Amendment that devolved funds and responsibilities for many government services to local bodies, without strong arrangements for holding them accountable for outcomes. Key services to ensure healthy environments have also been devolved, such as for toilet design 12 and construction under the Swachh Bharat Program, 12 and for monitoring water quality under the Jal Jeevan Program.13 Tamil Nadu retained separation of public health and medical services, which gives it an enormous organizational advantage relative to other states. This is outlined in Part IV. Staffing: Technical and Grassroots Workers The national and state institutions’ public health doctors need to be supported by technical staff with a wide range of expertise on the various sources of threat to human health. Examples are specialists in entomology and in zoonotic diseases. State institutions also need to have effective cadres of grassroots workers, to monitor and respond to health conditions at ground level. Part V describes the model of Sri Lanka’s excellent Public Health Inspectors who have the training and the authority to assure good health conditions on the ground —including inter alia the training to supervise the construction and maintenance of toilets, and to monitor water quality. 12 https://vikaspedia.in/health/sanitation-and-hygiene/sanitation-and-hygiene-india-country-report. Accessed March 4, 2024. 13 https://jaljeevanmission.gov.in/sites/default/files/guideline/WQMS-Framework.pdf. Accessed May 13, 2024 13 4. LESSONS FROM THE TAMIL NADU MODEL OF MANAGING PUBLIC HEALTH SERVICES14 The critical lesson from Tamil Nadu is to separate the public health and medical services. This enables the state to have strong and professional public health administration. The Health Department has separate Directorates for Public Health and for medical services, each with its own dedicated budget and workforce. Each has its own career paths and incentives. The smooth functioning of all three Directorates is greatly facilitated by the Tamil Nadu Medical Services Corporation, which procures, stores, and distributes needed supplies in a timely way.15 The Director of Public Health is a high-status technical adviser to the Health Secretary. It is impossible to overstate the contrast between this and the situation in most state Health Departments, where the public health staff are in a highly subordinate position to the civil servants running the Health Department, as well as to the medical staff—and as a result marginalized in budgetary and policy decision-making. The Director has overriding powers across the State (including over powerful bodies such as the Chennai Municipal Corporation) to monitor outbreaks, ask local bodies about their disease control measures, make technical suggestions, and require follow-up to ensure action is taken. S/he provides technical expertise as needed and staff to supplement local manpower if an outbreak needs to be brought under control. Tamil Nadu’s powerful Directorate of Public Health contrasts sharply with that of other states, where such expertise is at best scattered, and independent oversight of public health conditions and services is at best weak. The Organization of Tamil Nadu’s Directorate of Public Health Policy and Planning: A Separate Directorate of Public Health The Directorate of Public Health has the authority to hire, train, and manage its own staff. The staff are organized in a tight management structure with clear allocation of responsibilities from the state level down to the grassroots level. This system makes possible the proactive planning and effective disaster management described below. It is staffed by a professional cadre of trained public health managers and technical staff, who are promoted to the Directorate after long experience of managing public health services in both rural and urban areas. The public health managerial cadre consists of just 1 percent of the state’s medical doctors, who are given additional training to orient them toward an administrative and management role rather than a clinical role, and toward examining health issues from a population-wide perspective. This cadre has faster promotion avenues than the medical cadre, and enjoys considerable administrative responsibility and authority ⎯all of which helps keep them incentivized. 14 This section draws on Das Gupta et al. (2009, 2010, and 2020) and Parthasarathi and Sinha (2016). 15 WHO-SEARO 2023. 14 This system helps to reduce the scope for the central government’s single-issue programs to dominate Tamil Nadu’s public health agenda, as they do in many other states—since the staff’s training and experience highlight the importance of services other than the single-issue programs. However, as discussed below, the single-issue programs have undermined the role of the Health Inspectors in providing environmental health services at the grassroots. Dedicated Funding: A Separate and Substantial Budget The Directorate is able to sustain its proactive public health work because it has a dedicated budget. Thus, for example, Tamil Nadu has over 100 entomologists, whereas many states have just a few, seriously hampering their efforts at controlling vector-borne diseases. The dedicated budget also enables maintaining needed technical units, such as the plague surveillance unit at Hosur, in an area known to have plague foci among wild rodents near the border with Karnataka and Andhra Pradesh. Although the last episode of plague in South India was in the early 1960s,16 the Directorate knows that plague can always reemerge if it is not actively monitored. This is in sharp contrast to other plague hotspots such as Maharashtra and Himachal Pradesh, where plague surveillance units were de-funded over time, and plague broke out in 1994 and 2002, respectively.17 Legislative Underpinning for Public Health Services The Tamil Nadu Public Health Act provides the legislative basis for the planning and implementation work of the Directorate of Public Health. Most states still lack an Act, making it harder to prevent health hazards, such as meat sellers dumping their waste in or near drinking water sources (Krishnan 2005, 70). Close Collaboration with the Whole State Administration Tamil Nadu’s civil servants are sensitized to the complexities of protecting public health. From the outset of their careers in the districts, they attend intersectoral meetings where the staff of the Directorate of Public Health discuss plans for responding to seasonal and other potential health threats, and highlight the intersectoral coordination required to respond to these threats. These issues are discussed at all levels of Tamil Nadu’s State administration, so all departments understand what they need to do in an emergency to protect public health. In case of a suspected outbreak, the District Collector calls a meeting with representatives from the Health Department and other departments as needed. They develop a coordinated response plan and assign responsibilities to each department⎯for which they will be held accountable. Most other state administrations lack such a technical Directorate to inform and guide them. The Directorate’s health education outreach also raises awareness of public health issues across Tamil Nadu, sensitizing everyone to these matters. 16 http://www.nicd.org/1997AnnRep04j.asp. Accessed May 13, 2024 17 Government of Maharashtra (http://maha-arogya.gov.in/diseasesinfo/..%5Cdiseasesinfo%5CPlague%5Cdefault.htm) Accessed April 23, 2024For Himachal Pradesh, see Gupta and Sharma (2007). 15 How Does Tamil Nadu’s Approach Strengthen the Delivery of Public Health Services? Through its management of public health services, Tamil Nadu is able to respond proactively to avert potential health threats, and respond quickly and effectively when confronted with disasters and emergencies. A few examples of this follow. Long-Term Planning to Avert Outbreaks The hallmarks of effective public health service delivery are (1) planning to reduce exposure to potential disease threats, and (2) continued vigilance to ensure nonrecurrence of disease. This approach manifests itself in the anticipatory planning undertaken annually to prepare for controlling disease in the wake of potential recurring natural disasters such as floods and cyclones. This seeks to avert a public health disaster instead of scrambling to respond to it once the disaster has struck. Such routine preparation is also very helpful when freak disasters strike, such as the tsunami that hit Tamil Nadu in 2004. The state was able to respond to this quickly because the annual planning exercise creates a high level of clarity among all members of the team about the needed actions and the roles of the different actors, including how to guide other public agencies in supporting this effort. This is reflected in the clear narrative by the state’s Chief Entomologists:18 When the tsunami hit, there was contamination everywhere our main focus was on water source chlorination, disinfection of the environment around all habitations using bleaching powder and lime, and all actions for assuring sanitation and hygiene in the camps for displaced people. We selected the sites for the Revenue Department to construct latrines, and oversaw the arrangements for the safe disposal of waste. We provided the Revenue Department the technical expertise on how deep to dig the graves and prepare them with lime to minimize the scope for contamination. Fly breeding began, and we undertook fly control measures. We checked donated food for basic safety. Health Department staff from other areas were brought in to help with the environmental sanitation arrangements as well as providing outpatient care. The World Health Organization (2006) noted that despite the scale of the tsunami, the state public health authorities’ response was rapid and highly organized, and the state government was able to carry out relief measures largely on its own (WHO 2006, 19): The presence of a well-trained public health cadre enabled massive mobilization and deployment of people and material in a smooth manner … this resulted in one of the truly remarkable achievements of the relief effort—the complete avoidance of any kind of epidemic (WHO 2006, 81, 83). This is in sharp contrast to most other states’ disaster response, where the health authorities are trained to deliver medical services, not public health. For example, after a major hurricane in West Bengal, that state’s health authorities reported that—aside from providing medical treatment—their role was just to provide chlorine and other disinfection agents.19 Not surprisingly, disease outbreaks followed the hurricane. 18 Interviews with Dr. Sridhar and Dr. Selvaraj, Chief Entomologists, Tamil Nadu, June 2009. 19 Field interviews in a coastal district, June 2009. 16 Another example of anticipatory action to avert health hazards is that Health Inspectors are deputed to government medical colleges (tertiary hospitals), to assure adequate sanitary conditions and vector control. This protects patients and helps avert spreading diseases from the hospital to the general population. Eradicating Diseases and Preventing Their Resurgence Tamil Nadu seeks to prevent potential resurgence of diseases. For example, to sustain its early success in eliminating polio,20 the Directorate routinely posted staff at railway stations to vaccinate incoming migrants. The importance of maintaining the state plague surveillance unit has been mentioned above. When the plague outbreak took place in western India in 1994, Tamil Nadu sent a team to help control the outbreak, along with plague laborers experienced in finding rats and isolating their fleas. They were among the sole remaining repositories in India at the time, of hands-on expertise of how to deal with plague.21 Management of Endemic Diseases The strength of Tamil Nadu’s public health management is illustrated also by its routine work to contain endemic diseases. For example, when cases of communicable diseases present themselves in the primary health centers, the Health Inspectors follow up to investigate contacts and sources of infection, to prevent further spread of the disease. Malaria control emphasizes proactive measures to reduce malaria, such as including monitoring vector density and anti-larval measures, instead of focusing primarily on treating malaria cases. Citizen Outreach and Local Bodies The Directorate of Public Health’s outreach sensitizes citizens and local bodies to the need for proactive measures to protect public health. This puts pressure on politicians to seek better services. This is reflected, for example, in local politicians in Chennai reporting the location of stray cattle to the Zonal Health Officers and asking them to have them removed to satisfy the citizens who reported this public health nuisance. Ground-Level Staff: Health Inspectors A major deficiency in Tamil Nadu’s public health services is the erosion of the focus of its Health Inspectors. Public health work requires substantial autonomy to monitor issues at a highly localized level to answer questions such as “Where do the cases of illness cluster, and what are the conditions nearby that could be causing this?” Instead, much of this cadre’s time is spent in implementing the various national disease control programs, instead of monitoring the overall disease conditions of the population they serve. Across India, the central government encouraged the use of this post for accommodating staff originally hired for other central programs that were terminated (such as smallpox eradication), thereby diluting the capacity of Health Inspectors. They have also been sidelined by the higher status granted to female health 20 https://main.mohfw.gov.in/sites/default/files/Pulse%20Polio%20Programme.pdf. Accessed April 23, 2024. 21 Dr. K. K. Datta, who was at the time a senior officer at the National Institute of Communicable Diseases (NICD), says that the NICD had very limited capacity to respond to the 1994 plague outbreak, and the Indian Council of Medical Research (ICMR) stated that it had no capacity for handling plague. In recent years, the capacity to anticipate and respond to plague has been upgraded in India (WHO 2002) 17 workers, who implement programs of interest to the central government, notably the family planning program and the maternal and child health initiatives. 18 5. SRI LANKA’S PUBLIC HEALTH INSPECTORS (PHIS): AN EXEMPLARY MODEL OF GROUND-LEVEL SERVICES22 India has available in Sri Lanka a superb model for strengthening its ground-level public health services. It is a highly pertinent model, as India and Sri Lanka (1) face similar tropical health conditions, and (2) have the same grassroots cadre of Male Health Workers, known in Sri Lanka as Public Health Inspectors (PHIs). Sri Lanka’s PHIs are responsible for monitoring a wide range of health conditions within the clearly defined area allocated to each PHI. Their main tasks are to (1) prevent disease outbreaks by ensuring healthy living conditions, and (2) minimize the spread of any disease outbreaks that may occur (Chart 2). Their work contributes to the low levels of child stunting in Sri Lanka (Figure 3). Public Health Inspectors are given comprehensive training in a wide range of subjects, using an impressive curriculum. 23 The detailed manual they are issued for their work is available online 24 and should be compulsory reading for anyone interested in revitalizing ground-level public health services in India. The most striking contrast between India’s Male Health Workers and Sri Lanka’s PHIs is that the latter are trained to work confidently. They are treated with respect by others in the health system and by the citizenry. Just one small example of this is that medical doctors training in Community Medicine work with Public Health Inspectors to understand how to ensure population health at the ground level. PHIs have considerable autonomy in identifying and resolving problems in their daily work. In their monthly supervisory meetings, they discuss problems with others in their team and their supervisors, and think through the problems jointly. This combination of autonomy and teamwork also keeps them incentivized. The PHIs play a crucial role in assuring environmental health. For example, when toilet coverage was being expanded in Sri Lanka, PHIs were put in charge of this at ground level. Engineers trained them in how toilets should be constructed given the specific groundwater level and other conditions of their local area, enabling the PHIs to ensure that toilets are correctly constructed in the area they serve, and that they are then correctly maintained. They also monitor water quality. Sri Lanka’s PHIs are explicitly viewed as the front line against any disease facing the area they serve. For example, when there is an outbreak of leptosporiasis, people are told to obtain the medication from their PHIs. They ensure compliance with tuberculosis (TB) treatment by discreetly telephoning patients in their service area, to remind them to take their medicines. They are involved with new and emerging diseases, including COVID-19 (Chart 3). Now that the prevalence of communicable diseases has declined in Sri Lanka, the PHIs are spending more effort on controlling noncommunicable diseases. However, they remain focused primarily on communicable disease control, including remaining and emerging infectious diseases. 22 This section draws on Das Gupta et al. 2013. 23 See training outcomes at https://medicine.kln.ac.lk/depts/publichealth/index.php/learning-centres/phi. Accessed May 10, 2024 24 This manual is online at https://phi.lk/Manual_for_the_Sri_Lanka_PHI.pdf. Accessed April 20, 2024. 19 Chart 3: Sri Lanka’s Public Health Inspectors The Front Line for Disease Prevention and Control Source: The Public Health Inspector's Union of Sri Lanka Facebook page, accessed April 28, 2024. 20 6. SUMMARY OF COMPLEMENTARY LESSONS FROM TAMIL NADU AND SRI LANKA The public health systems of Tamil Nadu and Sri Lanka offer simple lessons that could greatly improve the effectiveness of India’s public health services. These lessons are easily replicable across India, as they require only a re-tweaking of the arrangements already in place across the country. Tamil Nadu offers an excellent example of public health administration, using the same components as exist in other states: • The same facility structure (state hospitals, district hospitals, and primary health centers) • The same staffing structure (doctors, nurses, technical staff, and male and female grassroots workers) Tamil Nadu organizes these components differently. It trains 1 percent of its medical doctors to manage its public health services, and gives the Directorate of Public Health the authority and dedicated budget it needs for its work. This enhances the efficiency of not only the public health services but also the medical services—since the public health services reduce the prevalence of disease in the population through their management of epidemic and endemic diseases and disasters such as floods. Tamil Nadu’s public health system is more effective than that of other states that have experienced decades of gradual erosion of their public health systems. Its health outlays are around the average for Indian states (Figure 6), but the funds are spent more effectively —as reflected, for example, in levels of child stunting (Figure 7). Outcomes in Kerala are also good, but health expenditure per capita is twice as high (Figures 6 and 7). Sri Lanka offers an excellent model of how to train and organize India’s existing cadre of Male Health Workers into a formidable force to protect people’s health. Their PHIs play a crucial role in disease prevention and control. They also monitor water quality, and the correct construction and maintenance of toilets, instead of leaving these tasks to local bodies as in India. Sri Lanka’s PHIs also do much to enhance the health-related work of local bodies, for example, by supervising the local workers responsible for waste removal and management. In India, these roles have largely been delegated to local bodies with little training or oversight to perform them effectively. 25 Waste removal and management is often poorly overseen by local bodies. Toilet construction and maintenance has been delegated to local bodies, with little technical information and instruction, and weak accountability mechanisms. The health benefits of outlays on water and toilets may thus be underrealized in India. A study in Pakistan indicates that rapid toilet construction without a professional cadre trained to supervise this, can result in groundwater contamination and increase the spread of disease: 25 Das Gupta et al 2020. 21 Despite a substantial decline in poverty, an increase in access to water and sanitation and a large decline in open defecation, diarrhea and stunting rates in Pakistan show few signs of a decline. This report provides evidence that the policy focus on eliminating open defecation rather than the safe management of fecal waste has been largely responsible for this (World Bank 2018). Figure 6: Per Capita Annual Expenditures on Health (Rs) in Tamil Nadu No Higher Than the Average of Indian States, 2019–2020 12,000 Per capita annual expenditures on health 10,607 10,000 8,000 6,000 4,863 4,605 (Rs) 4,000 2,588 2,013 2,040 2,000 - Government Total health health expenditure expenditure India Tamil Nadu Kerala Source: Government of India 2023. Figure 7: Child Stunting in Tamil Nadu and Kerala Is Much Lower Than the Indian Average, 2019 - 2021 40 36 % of children stunted (-2SD weight-for-age) 35 30 25 25 23 20 15 10 5 0 India Tamil Kerala Nadu Source: NFHS-5, India report, Figure 10.2. Note: SD = Standard deviation. 22 7. CONCLUSIONS The choice is simple. Does India prefer to reorganize the use of its current budgetary outlays on health to improve people’s health and productivity, or to continue to forgo billions of dollars annually in losses due to poor health conditions? Reducing communicable diseases is a key plank of development infrastructure, and little effort is required to build a strong public health system in India, within its existing administrative structures and budgetary outlays. The national-level institutions required are already in place: the National Centre for Disease Control for apex technical expertise, the apex public health training institutions, and a network of apex technical institutions. However, their ability to function effectively is severely constrained by a lack of autonomy. State-level public health systems need strengthening. The central government can do much to incentivize states to do this, using as leverage the substantial funds it transfers to states’ health sectors. It can tie this budgetary support to action by states to do the following: • Create separate Directorates for Public Health and for Medical Services, with separate budgets to avoid choices between public health services and upgrading medical facilities. Each Directorate should recruit, train, and manage its own staff. The burden of additional training for the public health managerial cadre is not onerous―in Tamil Nadu it comprises only 1 percent of government doctors. The training curriculum for public health managers can be drawn from Tamil Nadu. • Adopt modern public health legislation, providing the legal basis for action to protect public health. Model legislation has been prepared and updated regularly by the central government, but little has been done to encourage states to put them in place. • Revitalize the grassroots Male Health Worker cadre responsible for environmental and public health. This is the cadre parallel to Sri Lanka’s Public Health Inspectors. Men are best suited for this since the work involves being mobile and entering unfamiliar (and occasionally hostile) places for inspection. Their training can be modeled on the outstanding curriculum for Sri Lanka’s Public Health Inspectors, along with clear job descriptions, manuals, and supervisory guidelines modeled on those in Sri Lanka. • Assure a steady flow of needed supplies, modeled on the Tamil Nadu Medical Services Corporation. Tamil Nadu and Sri Lanka offer simple replicable models for strengthening public health systems across India, within existing administrative structures and health budgets. These existing resources can be used to replicate Tamil Nadu’s impressive system of public health management, supported by ground-level workers modeled on Sri Lanka’s outstanding Public Health Inspectors. This would greatly improve people’s well-being in India, and support the country’s effort to become a developed economy. 23 8. 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Workshop of the Public Procurement Agencies in the WHO South-East Asia Region on Improving Access to Medicines, Chennai, India, July 11–13. Accessed February 16, 2025. https://cdn.who.int/media/docs/default-source/searo/essential- medicines/workshop-of-the-public-procurement-agencies-in-the-who-south-east-asia-region-on- improving-access-to-medicines-july-2023.pdf?sfvrsn=a3cfe8cc_1&download=true. 27 Reducing communicable diseases is a key plank of development infrastructure, and little effort is required to build a strong public health system in India, within its existing administrative structures and budgetary outlays. This would go far toward improving people’s well-being and productivity, and avert losses of billions of dollars annually due to poor health conditions. The national-level institutions required are already in place, with a network of apex technical and training institutions. However, their ability to function effectively is severely constrained by a lack of autonomy. State-level public health systems need much strengthening. The central government can do much to incentivize states to do this, using as leverage the substantial funds it transfers to states’ health sector. It can tie this budgetary support to action by states to achieve the following: • Create separate Directorates for Public Health and for Medical Services, with separate budgets to avoid marginalizing public health services in favor of medical services. A simple model for this is available in the state of Tamil Nadu, which has much better health outcomes than most states despite spending no more than the national average. • Adopt modern public health legislation, providing the legal basis for action to protect public health. • Revitalize the grassroots male health worker cadre, responsible for environmental and public health. This is the cadre parallel to Sri Lanka’s Public Health Inspectors, which offers an outstanding training curriculum, manuals, and supervisory guidelines. • Assure a steady flow of needed supplies, modeled on the Tamil Nadu Medical Services Corporation. Tamil Nadu and Sri Lanka offer simple low-cost models for strengthening public health systems across India, within current health budgets and administrative structures. These existing resources can be used to replicate Tamil Nadu’s impressive system of public health management, supported by ground-level workers modeled on Sri Lanka’s outstanding Public Health Inspectors. This would greatly improve people’s health in India and support the country’s effort to become a developed economy. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Jung- Hwan Choi (jchoi@ worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256). For more information, see also www.worldbank.org/hnppublications. 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org