Ahead in health, but a new set of challenges awaits Tamil Nadu Premium

Empirically, anecdotally, and historically, Tamil Nadu is among the top performers in the healthcare sector in the country, perhaps second only to Kerala, in terms of rankings on development indicators. With a robust public health system that brings quality and state-of-the-art services to all, irrespective of the ability to pay, and bolstered by a large private healthcare set-up that has spread itself across the cost and quality spectrum, Tamil Nadu has achieved a set of healthcare indicators far better than, and often exceeding, the national average.

This is quite clear if you look at the healthcare indicators: according to data released by the Health Management Information System, Tamil Nadu’s Infant Mortality Rate (IMR) dropped from 13 per 1,000 live births in 2020 to 8.2 per 1,000 live births in the period April-December 2023. The State’s Crude Birth Rate — a fundamental demographic indicator, calculated as the number of live births per 1,000 people in a population over a year — is 14.2, compared with the national mark of 19.7, as per the National Family Health Survey 5 (NFHS) findings. Read along with the declining Total Fertility Rate at 1.4/1.5, much below the replacement level of 2.1, it indicates a mature society in which the demographic transition has begun, though this is likely to bring its own set of challenges in the future. Tamil Nadu boasts 100% institutional deliveries, as against 94.5% nationally.

According to the Special Bulletin on Maternal Mortality in India 2021-2023, Tamil Nadu now has the second-lowest Maternal Mortality Rate (at 35 maternal deaths for every 1,00,000 live births) in the country, behind Kerala and Andhra Pradesh, both at 30. As per the NFHS 5 data, Tamil Nadu’s neonatal mortality rate dropped to 10 in 2018 (from 26.2 in 2005). Again, going by this data set, the stillbirth rate had dropped to 4 in 2018, among the lowest figures in the country. Tamil Nadu has consistently achieved high immunisation coverage, consistently exceeding 90% to 95% for many key vaccines such as diphtheria, tetanus, and pertussis (DPT), polio, and BCG (against tuberculosis). It has also, since 2008, remained a leader in the cadaver transplantation programme in the country.  

The data makes it clear that in the field of maternal and child health, Tamil Nadu’s performance currently makes it an exemplar. How was this achieved? 

Focus on public heath

At the heart of Tamil Nadu’s successes in healthcare lies a dedicated public health system — a wide, well-distributed network of primary health centres, ably supported by community health workers who remain integral influencers in the communities they frequent, being the first point of care, enforcing immunisation, and spreading the message of prevention. This is bolstered by a dedicated public health cadre of trained specialists who oversee and run operations under a special Directorate of Public Health in the State. This lower-level network branches into taluk, district headquarters, and medical college hospitals that deliver secondary and tertiary care services. 

The Public Health Act of 1939 is the fulcrum on which the entire public health superstructure has been built, explained public health expert T. Sundararaman in a conversation on the website of Right to Health Resources Collective. The Act then covered all regions of the original Madras Presidency, including present-day Tamil Nadu, Andhra Pradesh, Telangana, and the Malabar region of Kerala. Prof. Sundararaman further explained: “This continued after Independence as the Tamil Nadu Public Health Act. In India, only five States and one Union Territory have such a public health law in place — and all of these are modelled on the Tamil Nadu prototype.”

The Public Health Act is one of the more effective means of realising the right to the underlying determinants of health. But for this to happen, both public access to information and mechanisms for redressal must be strengthened, Prof. Sundararaman added. K. Mathivanan, retired Deputy Director of Public Health, further explained, as part of the same conversation, that the Act broadly covers two domains: sanitation and disease prevention, with an additional maternal and child health welfare aspect. 

But as R. Parthasarathi and S.P. Sinha recounted in their 2016 article in the Indian Journal of Community Medicine, Towards a Better Health Care Delivery System: The Tamil Nadu model, it was after 1980 that Tamil Nadu began to truly branch out on a forward-looking path. “During the later part of 1980s and 1990s, there was a significant transformation in the health infrastructure and health manpower of the State. The Government of Tamil Nadu implemented the Multipurpose Workers scheme intensively when it was launched by the Central government in the 5th Five-Year Plan to serve every rural community with a population of 5,000 with a multipurpose worker. These multipurpose health workers in Tamil Nadu … were labelled as village health nurses (VHNs). The role of the VHN was to make regular house visits and deliver maternal and child care services, including advice for contraception and immunisation. The VHN was also assigned the task of enrolling and keeping track of all pregnant women in her service area besides working synergistically with other grassroots workers like Anganwadi workers. Thousands of VHNs were trained and deployed proficiently in primary care services in rural areas, which yielded significant improvements in antenatal, postnatal care, institutional delivery, immunisation, etc.” There is, of course, no overstating the importance of a good women and child health programme and the emphasis on immunisation in improving the general health standards of a community.  

Digital systems and surveillance

While a multi-layered surveillance system was put in place even as part of the Public Health Act, it was in the last two decades that Tamil Nadu sharpened its game by adopting, in 2004, the Integrated Disease Surveillance Programme (IDSP), which was launched by the Ministry of Health and Family Welfare, with World Bank assistance. Along with the Tamil Nadu Health Systems Project, it signalled growing faith in digital Health Management Information Systems (HMIS) and e-health, and also marked a shift towards an integrated approach for monitoring epidemic-prone diseases. Over these two decades, it has remained a vanguard, flagging emerging epidemics and the earliest hints of alarming infectious disease spread, which can then be addressed appropriately to prevent further transmission. Tamil Nadu was an early adopter of telemedicine, using mobile vans equipped with devices to take quality, specialised healthcare to the nooks and corners of the State. Specialists sitting in urban centres would be available for consultation via telemedicine in rural areas. Today, Tamil Nadu has a template that many other States have tried to emulate.  

Centralised drug procurement

Another sterling example of what makes Tamil Nadu tick at an advanced pace in healthcare is the long-standing focus on procuring and distributing quality drugs within the State. The Tamil Nadu Medical Services Corporation (TNMSC) started functioning in January 1995, and was established with the goal of centralising and streamlining the procurement, storage, and distribution of quality, affordable medicines and surgical supplies for all government health facilities in Tamil Nadu. This was meant to ensure quality medical products at all institutions, reduce the costs significantly, and prevent artificial shortage of drugs. From mid-2023, when stockouts of key drugs for tuberculosis and drug-resistant TB hit the country, as the Central TB division failed to provide the drugs, it was the TNMSC that sprang into action and procured the drugs locally, averting the dire situation faced by other States. 

Non-communicable diseases

In recent years, the State has recognised the need for and activated a structured response to the threat posed by a burgeoning epidemic of non-communicable diseases (NCDs), as rates of diabetes, hypertension, cardiovascular diseases soar, along with the mortality and morbidity they cause. The Makkalai Thedi Maruthuvamscheme, launched in 2021, sends trained teams to households to screen for blood pressure and blood sugar, offer cancer checks for eligible age groups, provide palliative care and physiotherapy, and deliver medicines, especially for those with limited mobility. This home-based model, linked to a digital Population Health Registry, aims to identify these conditions early and treat people at home, thereby relieving the burden on hospitals and catching conditions like diabetes and hypertension before complications arise.

A financing model

In this context, it is important to mention the assistance and financing of health services in Tamil Nadu. Central to this is the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), which originated in 2000 as the Kalaignar Kaapeetu Thittam. Its primary objective at the time was to offer free treatment for serious ailments at empanelled government and private hospitals, with coverage of up to ₹1 lakh per family. Today, the CMCHIS is aligned with national insurance schemes and represents a far more sophisticated version than the original, covering more procedures, including certain diagnostic procedures, cancer care, transplants, and even the cost of life-long immune suppression drugs for transplantees. For many households in the State, the CMCHIS card has been the passport to surgeries and care that would otherwise be completely beyond their means. However, with complaints from private hospitals about delays in being compensated by the insurance, and concerns about package rates, it is clear that the government needs to pay it a tad more attention than it currently does.

The Muthalvar Marunthagamis a network of pharmacies that provide drugs at a subsidised cost and have been effectively harnessed by people from all income categories, recent surveys indicate.Reportedly, these pharmacies manage to sell drugs at prices lower than the Centre’s Jan Aushadhi pharmacies (though these units stock a wider range of drugs), with the TNMSC working with private pharmacies on a public-private-partnership model. The 108 ambulance, a free government-sponsored service, has by now become the first port of call for most residents of Tamil Nadu; it is ubiquitous and ensures quick access to emergency care for all using its ambulances.

Welfare and well-being

It was not just health schemes that influenced Tamil Nadu’s positive health indicators. The Dravidian commitment towards building an equitable society through welfare schemes also had a definite role to play. They are often dismissed by critics as populist ‘cash assistance’ schemes, but the truth is, they have had a positive impact in the long run, besides being of immeasurable value to each beneficiary. Among these are primarily the mid-day meal scheme, initiated by former Chief Minister K. Kamaraj, but prioritised and enhanced by nearly every Chief Minister that followed him, with Chief Ministers M.G. Ramachandran and Jayalalithaa playing key roles. The 2022 introduction of the Chief Minister’s Free Breakfast scheme, implemented by Chief Minister M.K. Stalin, is a further strike toward the goal of ensuring good early childhood development. Significant from a health point of view is the Muthulakshmi Reddy Maternity Assistance scheme, which offers ₹18,000 in equal instalments to pregnant women from economically weaker backgrounds, rather cleverly tying up the entire assistance scheme to regular ante-natal check-ups and immunisation for infants. The success of the Child Marriage Prevention programme ensured gains for teenage girls, who were otherwise yoked into child marriages and early sexual contact. 

Smart cards for the Chief Minister’s Comprehensive Health Insurance Scheme.
| Photo Credit:
B. Jothi Ramalingam

As Parthasarathi and Sinha reiterate, the importance of good political commitment and leadership in the health gains of the State warrants special mention. Without the political will that has clearly guided Tamil Nadu, it is indeed inconceivable that such outcomes would have been realised or retained.  

Burgeoning private sector care

The growth of the private healthcare sector was also, in some ways, heralded by the State. Leading the trend was Apollo Hospitals in Chennai, the first corporate hospital in the country. After liberalisation in the early 1990s opened up the economy, many more private individuals started venturing into the healthcare business. Over the years, the setting up of high-quality private hospitals with state-of-the-art diagnostics, equipment, research centres, and employing medical specialists as good as any in the world, soon brought huge benefits to Tamil Nadu, turning Chennai into the medical tourism capital of India.  

This, however, has not been without a flipside: costs. Costs in the private sector are naturally much higher, and while services are available now, more than ever before, round-the-clock, out-of-pocket expenditure has begun to soar. Medical insurance as a concept is only picking up in the country, unlike its more popular cousin, life insurance. More awareness needs to be generated to ensure every individual is insured for health emergencies, and efforts need to be made to make insurance schemes affordable.   

Challenges ahead

Among the grim realities of today, Tamil Nadu struggles with vacancies that exist across the spectrum of health services. Over the years, the State’s health infrastructure has grown to over 11,000 government health facilities, including 2,336 PHCs, 8,713 health sub-centres (HSCs), 372 government hospitals, and 36 government medical college hospitals. Further, new multi- and super-specialty hospitals and numerous health schemes have been rolled out in order to improve public access to healthcare. But has the government paid as much attention to recruitment over the years? While the government and the current Health Minister maintain that the goal is to reach a zero-vacancy position, the reality is far from ideal. Requests for better pay and work hours notwithstanding, here is a serious malaise that threatens to collapse the health system in the State.  

J. Amalorpavanathan, member, State Planning Commission, highlighted four key aspects that have to be dealt with urgently. Among them are persistent anaemia among adolescent and pregnant women, despite interventions, and stunting and wasting among children.  

According to NFHS 5 data, Tamil Nadu shows mixed trends in child nutrition, with stunting levels declining, but persistently high wasting, including severe wasting that affects children in the State, heavily influenced by factors including low socio-economic status, gender, delayed breastfeeding initiation, and parental education. As per the NFHS data, over 7,60,000 wasted children under five years of age (2019-2021) were identified, and the high-burden districts included Chennai, Kancheepuram, and Tiruppur.  

Polio vaccine being administered to a child.
| Photo Credit:
C. Venkatachalapathy

Dr. Amalorpavanathan also flagged a possible, though marginal, increase in teen pregnancies as an area of concern. He listed increasing chemical dependence among schoolgoing children as a cause for worry. These issues will have to be addressed by the government sooner rather than later in order to keep the health gains on track, he said.  

Challenges will also be thrown in the State’s path by non-communicable diseases; the full complement of their complications will deeply impact the health of the community. The ideal approach would be to be aggressive on prevention strategies — primordial (addressing the infant in the womb) and primary, to prevent the onset of diseases, followed by secondary prevention, and finally adopting a lifestyle that would prevent individuals who have developed these conditions from lapsing into debilitating complications. 

In addition to this, Tamil Nadu will also have to negotiate the demographic transition with a new set of skills, and a reorientation towards the needs of the elderly. While it retains its demographic dividend with the youth for now, the future promises to scarcely be anything but grey. The State needs to plan for, and accommodate in its health agenda, a plan that will ensure physical and mental healthcare, and emotional support for the elderly, while working on schemes to assist the elderly to remain financially independent as they age.  

While the inequities between urban centres and rural areas are not as pronounced as in some other States, Tamil Nadu will have to work on easing access to care along its entire length and breadth. As urban tertiary centres remain crowded, many peripheral centres do not have diagnostic tools, specialists, or experts to do the job effectively.  

Additionally, the debate now broaches areas that have not been of concern in the past. Is there an increasing centralisation in decision-making in the healthcare sector? If there is, will it dull the ability of the State to be nimble and responsive, to strike at crises before they blow up?

The challenge for Tamil Nadu is now to protect its gains — strong primary care, good maternal and child health care, innovative outreach, and a socially conscious development approach. At the same time, it clearly needs to invest in staff and in quality, and ensure accountability so that every single citizen can continue to be able to tap into a system that will remain responsive to them.  

This article is part of The Hindu e-book. Tamil Nadu’s progress: economic growth through social equality