India’s healthcare sector has made significant strides in the last couple of decades. Yet, progress in terms of access, affordability, and quality of healthcare remains variable across states. There are many factors that affect the status of health in a national/sub-national geography, with the political economy of healthcare being a key driver of health outcomes. This case study interrogates the socio-political factors that have impacted the status of health in Tamil Nadu.
I. Introduction
| Demographic Indicator | Tamil Nadu |
| Population | 7.21 crores |
| Share of urban population | 48.5% |
| Literacy rate | 80.09% |
| All-India rank by size of GSDP | 2nd |
| Sex ratio | 996 females per 1000 males |
In 2019, the NITI Aayog published the second round of its Health Index,[1] – a composite marker on indicators of ‘health outcomes, governance and information, and key inputs and processes. Similar to the first round published in 2017, states were assigned a score based on their performance on these markers. Although Tamil Nadu registered a change of -2.97 in its score from the previous round, it was nonetheless ranked 9th among 21 large states in India, indicating a relatively better performance in comparison to other states.[2]
For its population of roughly 7.2 crore people,[3] the state has consistently allocated about 5% of its total expenditure to the Department of Health and Family Welfare in the past decade. A dip was noticed in 2016-17, when the allocation dropped to 4.05%. The department has received a fillip in the past two Budgets, with allocations touching 6% of the total expenditure.[4]
As per the National Health Accounts 2017-18, Tamil Nadu’s Total Health Expenditure (THE)[5] was 2% of its Gross State Domestic Product, while the THE at an all-India level was 3.3% of the Gross Domestic Product. Nearly 46% of THE in Tamil Nadu is Out of Pocket Expenditure (OOPE), in contrast with about 48.8% at the national level. Further, that state government’s per capita health expenditure, at Rs. 1,621, is marginally lower than the central government’s per capita expenditure, at Rs. 1,753 per capita. Despite this, the per capita OOPE in Tamil Nadu was about 13% lower than the national per capita OOPE of Rs. 2,097.
The high burden of OOPE is traditionally complemented with low insurance coverage. Tamil Nadu introduced the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) in 2009,[6] which provides a cover of Rs. 5 lakh per family per year to government employees and pensioners, and to families earning below Rs. 72,000/- per annum. This scheme was merged with the national level insurance scheme – the Pradhan Mantri Jan Arogya Yojana (PM-JAY), in 2018. PM-JAY benefits are available to beneficiaries as per the Socio-Economic Caste Census and beneficiary lists provided by the Civil Supplies Departments. As of November 2021, 1.47 crore families are eligible under both these schemes combined.[7] It is notable that there was only a marginal increase in insurance coverage after PM-JAY was introduced, as gleaned from the National Family Health Surveys-4 (2015-16) and 5 (2019-21). At least one member in 64% of surveyed households had insurance as per NFHS-4, compared to 67% in NFHS-5. Further, the National Health Profile 2020[8] reveals that in Tamil Nadu, a mere 0.8% people in rural areas, and 1.8% people in urban areas had signed up for private voluntary health insurance. This points to low levels of insurance coverage for the non-poor in the state, and also for outpatient care for chronic non-communicable diseases which require regular treatment but are not covered by the government-sponsored insurance schemes.
In terms of health-related infrastructure and resource personnel, there are 2.6 functioning Primary Health Centres (PHCs) per 1 lakh population in Tamil Nadu.[9] This is slightly higher than the national figure, which is 2.5.[10] Under the Ayushman Bharat Yojana, states were exhorted to upgrade existing PHCs into Health and Wellness Centres (HWCs). The latter are envisaged to deliver an expanded range of services that go beyond those provided at PHCs. As of May 2021, Tamil Nadu had 5.8 HWCs per 1 lakh people, compared to 6.3 HWCs at the national level.[11]
There are varying accounts on the availability of allopathic doctors and other medical personnel in Tamil Nadu. The National Health Profile 2020 estimates that the state has the second highest number of doctors in India, after Maharashtra. As per the National Health Workforce Account 2018 (NHWA), there are 1.35 lakh allopathic doctors in Tamil Nadu, which is 12.2% of all such doctors in India. On the other hand, researchers estimate that as per the Periodic Labour Force Survey 2017-18 (PLFS), there are 54,000 allopathic doctors in Tamil Nadu, which is 6.7% of the total number of such doctors available in India.[12] This disparity between NHWA and PLFS data may occur as doctors may register with more than one state Medical Council, but not be active in the workforce, emigrate, etc.[13] Further, it is estimated that the combined density of doctors (allopathic and AYUSH affiliated) and nurses/midwives in Tamil Nadu is 32 per 10,000 people.[14] Although this figure is less than the WHO prescribed density of 44.5 doctors, nurses and midwives per 10,000 population, this compares favourably with the average all-India figure which is around 23.[15] Only Uttarakhand (33), Delhi (41) and Kerala (65) have a better density than Tamil Nadu.
With the available network of primary health institutions and health personnel, Tamil Nadu has managed to perform better than many states in India on key health outcomes, especially those relating to child and maternal health. While it may be difficult to establish direct causal relations, certain factors point towards a consistently high priority given to health issues and policy by the state. These include Tamil Nadu’s decision to retain a dedicated public health cadre since independence, a maternity benefits scheme in operation since 1987, pioneering a state-led drug distribution system in 1994, and so on, some of which are discussed in the following sections.
These initiatives have possibly contributed to the performance on key health outcomes. As per the National Family Health Survey-5 (2019-21) and Sample Registration System (2016-18), the infant mortality rate (IMR), under-5 mortality rate (U5MR) and maternal mortality ratio (MMR) in Tamil Nadu (at 18, 22, and 60 respectively) are well below the national average of 35, 42, and 113.[16] Likewise, nearly all childbirths in the state are done in institutional facilities (98.9%), higher than the all-India figure (78.9%). The state’s performance on maternal and child health is also reflected in better provision of antenatal care and immunisation services.
II. Factors Affecting Health as a Political Priority in TN
Tamil Nadu performs better on maternal and child health outcomes and on infectious diseases, than many other states in the country. With over 54% of all ailments being treated in government health institutions, the Government of Tamil Nadu believes that the people show ‘tremendous faith’ in publicly provided services. [17] Notwithstanding the state’s performance on non-communicable diseases such as those related to the heart, lifestyle-related diseases such as diabetes, etc.,[18] citizens seem to receive certain quality of primary healthcare that was made possible by various enabling policy decisions on infrastructure, human resources for health, drug procurement systems, etc. For example, Tamil Nadu’s Public Health Act, which came into effect in 1939 facilitates several healthcare related functions even today. It provided the legislative basis for strategy and execution of the work of the Public Health Directorate. Therefore, it is useful and relevant to study the evolution of publicly delivered health services in Tamil Nadu and examine how it captured the attention of the policy makers among other competing priorities.
To understand the political economy of health in Tamil Nadu, we spoke with prominent stakeholders who witnessed, researched or were part of the process of health services delivery in Tamil Nadu. These stakeholders included former bureaucrats, research scholars, politicians, and journalists. The list of stakeholders consulted for Tamil Nadu can be found in Annexure-I.
To gather their view, a specific set of questions on the political economy of healthcare in Tamil Nadu was prepared for each stakeholder, keeping in view his/her background. Our discussions were based on these questions. This exercise was further supplemented by an extensive review of the literature and secondary research by our team. Through this exercise, we learnt that the following factors had a significant role to play in health becoming an important agenda for policymakers in the state:
1. Dravidian Movement and its Political Legacy
Sunil Amrith, while analysing health care in India since independence, notes the following about Tamil Nadu:[19]
Amongst the explanations for Tamil Nadu’s relative commitment to public health (its ‘political will’ in the language of policy) are its long tradition of social reform, manifested in the rise of the radical anti-caste Self Respect movement in the 1920s, and the translation of this movement into a powerful regional political force after independence. Tamil Nadu’s unusually competitive political system –the Congress has not ruled in the state since 1967 – allowed for the politicization of issues of public health. Described by some commentators as a form of ‘populism’ (Subramanian 1999, Harriss 2001), the competition between rival factions of the Dravidian movement in Tamil Nadu have made public health a subject of political competition in a way that it has not been elsewhere in India (Visaria 2000). The history of anti-Brahmin activism in Tamil Nadu translated into a widely implemented program of affirmative action (‘reservations’) in the health sector, with the result that the ‘social distance’ between medical workers and patients is perhaps smaller in Tamil Nadu than elsewhere (Visaria 2000).
Health, arguably, became a prominent political issue in Tamil Nadu about a century ago. The South Indian Liberal Federation, or the Justice Party, made a poll promise to promote health for all in the 1920 Madras Legislative Council elections.[20] After setting up the Directorate of Public Health and Preventive Medicine in 1923, the Party introduced a rural healthcare scheme in 1924.[21]
In the late 1940s, the Justice Party was subsumed under the Self-Respect Movement led by Periyar E.V. Ramaswamy, who coalesced non-Brahmin, pro-poor interests under the banner of the Dravida Kazhagam (DK). The DK managed to mobilise lower castes and classes under a Dravidian Tamil non-Brahmin identity. It aimed to upend caste-based division of labour to ensure social justice for previously marginalised communities. Over the past 70 years, the political outlook of the Dravidian Movement has shaped the development trajectory of Tamil Nadu and has been an influential factor in the provisioning of publicly delivered healthcare.[22]
The Dravida Munnetra Kazhagam (DMK), which came to power in 1967, was the first non-Congress party to form a government in Tamil Nadu. Owing possibly to the influence of the Dravidian Movement, the DMK government set up the first State Planning Commission in India in May 1971.[23] The Commission had as its Vice-President Malcolm Adiseshiah, who headed the task force set up for health issues.[24] This task force considered problems relating to health services, medical education, family planning, etc. and laid the groundwork for setting up a network of Primary Health Centres across Tamil Nadu.[25]
This DMK government also set up the Backward Classes Commission, to ensure adequate representation for marginalised communities in the bureaucracy. On its recommendations, Tamil Nadu adopted an affirmative action policy to address caste-based inequalities.[26] The broad basing of access to healthcare has been credited with creating networks that enabled better information dissemination and generated better health outputs.[27]
For instance, owing to the policy of 69 percent reservation in education, the social composition of healthcare professionals is socially representative. In 2015-16, out of the total MBBS/BDS seats on offer, about 68 percent were filled by Other Backward Classes and 26 percent by Scheduled Castes – more than the 50 percent and 16 percent seats reserved for these communities.[28] This suggests a diffusion of aspirations among marginalised youth, who are also likely to appreciate the importance of delivering healthcare to marginalised communities.[29] The reservation policy has broad-based access to medical education and ensured the supply of a cadre of health professionals with roots in towns and villages who are willing to work in primary health centres in such areas.[30]
Amartya Sen and Jean Dreze have also written that mobilising these communities in Tamil Nadu has lent voice to the beneficiaries of publicly provided healthcare, who use collective action to demand accountability from the State.[31] The nature of competitive politics in the state also makes the primary political parties alive to the negative publicity brought about by protests such as road blockades, hunger strikes, etc. Vivek Srinivasan has documented the impact of such collective action by a few Dalit groups, for better public provisioning of not just healthcare, but also in areas such as food distribution, infrastructure like roads, water supply, etc.[32] This is corroborated by S Narayan, a former bureaucrat from the Tamil Nadu cadre, who says that the mediation of Dravidian party cadres, who are eager to retain their voter bases from marginalised communities played a role in making parties responsive to citizens’ demands and contributed to better delivery of public services.[33]
This mobilisation has borne fruit particularly in the context of the health status of marginalised communities. Data from the National Family Health Survey-4 (2015-16) suggests that deprived caste groups in Tamil Nadu enjoyed better health status than even dominant caste groups in other states, especially in north India. For instance, Tamil Nadu and Uttar Pradesh have a similar proportion of Scheduled Castes (SCs) as part of the population, and over half of their population as Other Backward Classes (OBCs).[34] Nonetheless, the infant mortality rate for dominant castes (non-SC/ST/OBC) in Uttar Pradesh was 60.2, compared to 23.6 for SCs and 18.4 for OBCs in Tamil Nadu.
Based on the legacy of the Dravidian movement, both the primary Dravidian parties – the DMK and the All India Anna Dravida Munnetra Kazhagam (AIADMK), owe their electoral success to their ability to mobilise subaltern communities on the plan of dignity and social justice.[35] These two parties have alternated in power since 1967 and, as described earlier, ensured broad-based access to healthcare through their interventions. They tend to continue health-related initiatives, even if initiated by the other party.[36] Thus, we have the example of the Tamil Nadu Medical Services Corporation (TNMSC), set up in 1994 to procure and distribute drugs, which remains central to the operations of public health institutions in the state till date. Similarly, the contemporary relevance of the Dr. Muthulakshmi Reddy Maternity Benefit Scheme, launched in 1987, and the Chief Minister’s Comprehensive Health Insurance Scheme, launched in 2009, highlights the parties’ tendency to continue health schemes even if initiated by the other party.
The competitive nature of politics in Tamil Nadu also led to a clamour for setting up medical colleges across the state. Stakeholder conversations suggest that politicians were often eager to set up medical colleges in their own constituencies, for politically expedient reasons. Today, the state ranks first in terms of the number of Government medical colleges across the country (56) – a feat it shares with Maharashtra and Uttar Pradesh, which have 1.5 times and 3 times the population of Tamil Nadu, respectively.[37]
While Tamil Nadu does benefit from a historical context few other states can share, its performance on health is owed to certain institutional factors. The political will to act on health resulted in separation of the public health and medical functions of the state with a separate public health cadre, setting up of functional entities like the TNMSC, etc. Each of these decisions has influenced health outcomes substantially and could serve as examples other states could follow.
2. Impact of Women’s Political Participation and Female Literacy
Women have comprised a substantial voting group in Tamil Nadu since independence. Our stakeholder conversations suggest that high turnouts by women voters, with high levels of female literacy, created a political impetus for measures around maternal and reproductive health in the decades after independence.
The ‘silent revolution’ of increasing turnout of women voters, as christened by Shamika Ravi and Mudit Kapoor, has been observed in Tamil Nadu, since the 1960s.[38] For instance, the average sex ratio of voters in the state assembly elections, per 1000 men, in the 1960s was 949.[39] This was higher than other large states, barring Kerala where it was 981. For comparison, in Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, this figure was 567, 558, 603 and 614 respectively. The average sex ratio of voters marginally dropped in Tamil Nadu in succeeding decades, before bouncing back to 961 by the 2000s. In fact, in the most recent Tamil Nadu assembly elections held in April 2021,1022 women cast their vote for every 1000 men.[40]
Women voters may have played an instrumental role in driving action on health, particularly around maternal and children’s health, as suggested by a former state Health Secretary during consultations. The former bureaucrat said that while the Dravidian Movement did not particularly focus on women and children, this changed when M.G. Ramachandran, or MGR, became Chief Minister in 1977.
Pradeep Gupta, psephologist and chief of Axis My India, notes how women had a decisive role in ensuring long stints for former Chief Ministers M.G. Ramachandran, and later for J. Jayalalithaa.[41] In fact, the former received particular acclaim for his efforts toward family planning, spearheaded by former Chief Secretary T.V. Antony.[42] This is said to have cemented his popularity among women voters, who welcomed measures on reproductive, maternal and child health. While scholars have noted protests by women’s rights groups against compulsory family planning in many parts of India,[43] it seems to have become popular in Tamil Nadu. A former bureaucrat pointed to an awareness among women of the benefits of family planning – e.g., to avoid succession battles in their family. As per NFHS-2 (1999), 100% of surveyed women in TN had knowledge of different methods of contraception. Similarly, Jayalalitha’s sway over women voters is credited to have helped her party beat anti-incumbency in the 2016 assembly elections and defy a 25-year trend of alternating between the two primary parties in the state.[44]
While scholars have noted the ‘silent feminisation’ of electoral politics in India,[45] pointing to the surge in women voters across the country, research on the impact of women voters on parties’ agendas has been scarce. In a 2009 paper, Grant Miller wrote how granting suffrage rights for women in the United States resulted in greater attention towards women’s preferences by politicians.[46] The underlying logic may be true in Tamil Nadu as well, where political parties have clamoured to cater to women, especially after MGR’s tenure. The state has seen schemes for the distribution of free washing machines, mixer-grinders and other household appliances, cash assistance for women homemakers, subsidies for housing owned by women, and so on.[47] In our consultations, a Member of Parliament from the state recounted how women in their constituency tended to raise issues relating to healthcare and maintenance of local health sub-centres far more than men did.
Along with political participation, an increase in the education levels of women could also be a potential contributor to creating demand for maternal and reproductive health services in Tamil Nadu. The improvement in female literacy in Tamil Nadu over the past few decades has coincided with its performance on key maternal and child health indicators. The female literacy rate was around 21 per cent in 1961 and improved to about 74 per cent by 2011.[48] Notably, Tamil Nadu also has the highest Gross Enrolment Ratio among females aged 18-23 in higher education, at 51 per cent.[49] This is the highest across all large states in India. The state also initiated measures to delay the age at marriage, through the Moovalur Ramamirtham Marriage Assistance Scheme, where women are paid cash and gold if they have completed 10 years of schooling at marriage. This amount is doubled if they have completed a bachelor’s degree or a diploma. Though this scheme was introduced only a decade ago, the scheme is said to have already had an effect on the age of marriage among women.[50]
Educational attainment, complemented by a higher age at marriage, may have led to better appreciation of the need for maternal and child health services, especially to promote the health of the baby. A former bureaucrat shed some light on this – even while the women may not demand healthcare for themselves, such as for breast or cervical cancer, there is an expectation that children will be taken care of well by the state. In a paper from 2010, Monica Das Gupta and others wrote how awareness and knowledge are requisites for building political demand for public health services.[51] This demand helps to sustain political commitment towards these services, which in turn leads to better management, monitoring and accountability from the system.[52]
3. Role of High State Capacity in Health Policy Formulation and Implementation
Stakeholders interviewed largely agreed that high state capacity has acted as an enabler of public provision of health services in Tamil Nadu. The term state capacity generally refers to the willingness and capability of the state apparatus to carry out government policy.[53] The level of high state capacity in TN has helped achieve desirable health outcomes while leaving the potential for further improvement. High state capacity (enabling confidence in the effective delivery of services) could have contributed to the prioritisation of publicly delivered health services in the state. The political leaders may have been more confident of promising, launching and funding health initiatives in the state knowing that the Government is indeed capable of delivering on their promises.
Academic research corroborates this view. Tamil Nadu’s better performance with respect to public health indicators has been attributed to the efficiency gains accrued on account of a separate public health cadre.[54] The Health Department in Tamil Nadu has three key directorates – Directorates of Public Health, of Medical Services, and of Medical Education. They have their own dedicated budget and workforce. Each of them offers its own career progression and incentives for its employees, allowing them to rise up to the same level in the health department. This also ensures continuity of officials in the directorates, resulting in a deeper understanding of health issues. Finally, all three directorates are staffed with people who possess extensive knowledge, skills and experience in the area of healthcare management. In addition, significant investments since the 1980s have markedly enhanced the health infrastructure in Tamil Nadu, such as the large-scale expansion of the public health centres (PHCs).[55] Such structures enable a robust public health system in Tamil Nadu, which makes it possible to manage health services effectively in the state.
Owing to the high state capacity built early on in the state, a plausible reason for continued pressure on policymakers in Tamil Nadu to deliver on health could be the loss aversion displayed by the electorate. Once the electorate in the state was used to a certain level of health services, stakeholders interviewed felt, political parties would have found it detrimental for their future prospects to under-provide or de-prioritise those services. While studying the elections to the US state legislatures, researchers found that voter loss-aversion leads to policy rigidity.[56] Some stakeholders interviewed pointed out that it may not hurt a political party in the state if it does not provide new health services in its tenure in the Government, but discontinuation or under-provision of certain health benefits will likely lead to adverse electoral implications in the next election. One such scheme pointed out by a stakeholder is the Dr. Muthulakshmi Reddy Maternity Benefit Scheme, launched in the year 1987 in Tamil Nadu. This scheme currently provides financial assistance of Rs. 18,000 to poor pregnant mothers, in five installments (conditional on aspects like Measles Rubella vaccination post delivery).[57] The scheme also offers a Nutrition Kit consisting of health supplements to reduce MMR and IMR. In a 2019 survey, it was found that 95.3% of the women respondents were aware of this scheme and 76% of them utilised its benefits.[58] It has been emphasised by the discussant that owing to the popularity of the scheme, the successive Governments have found it imprudent for their political benefit to discontinue this scheme.
Bureaucracy in Tamil Nadu
The Tamil Nadu bureaucracy is known for its relative effectiveness; the reasons cited for which include a strong `work culture’ or `work ethic’.[59] Beyond reasons of ethics, there are political factors that contribute to the bureaucracy being welfare-oriented in the state. During the terms of the first Chief Minister from the DMK and party co-founder Annadurai and later Karunanidhi in the 1960s and 1970s, the state Government strived to recruit from the backward classes.[60] Many of these new recruits came from rural areas. They were better able to understand the needs of those areas and the local people, being more attuned with their issues and demands. These state government employees became a bridge between the welfare-oriented Dravidian parties in power and the people who were the recipients of the welfare policies of the state.[61] This was a crucial step in Tamil Nadu which not only resulted in social balance in the state administration but also enabled better design and delivery of social welfare services to the targeted population.
Strong state capacity is an imperative for ensuring adequate health services in a state. It not only ensures that the existing health programs are satisfactorily implemented but also increases the probability that new health schemes are introduced because policymakers are confident of proper execution of these programs. In this regard, one of the stakeholders remarked that successive governments in Tamil Nadu are fairly sure about continuing funding to various schemes and programs because they know that state capacity exists to utilise the funds well.
Center-State Relationship
Soon after independence, Tamil Nadu, and the erstwhile Madras State, engaged in a pitched battle with the Central Government over demands for greater autonomy.[62] Demands for state autonomy have been a recurrent theme of the state’s politics. These were first championed by the DMK, which came to power in 1967 dislodging the Indian National Congress government. Karunanidhi, who became Chief Minister in 1969, advocated for greater devolution of powers to the states – to set up industries, collect taxes, pass welfare measures, and so on. He set up the Rajamannar Committee in the same year, which even suggested that several items be moved from the Union and Concurrent Lists to the State List in the Constitution.[63] In 1974, the Tamil Nadu Assembly urged the Central Government to adopt the Committee’s report, resolving that this be done “in order to secure the integrity of India with people of different languages, civilisation and culture, to promote economic development and to enable the State Government…to function without restraints, and in order to establish a truly federal set up with full State Autonomy”.[64]
A former state Health Secretary suggested that the desire for autonomy extended to health policy as well; a desire traced to the Dravidian Movement, which started in the 1920s. As described earlier, in attempting to broadbase access to health care, the state adopted measures much before they were taken up at the Central level.[65] These included, as per Kalaiyarasan A from the Brown University, and M Vijaybhaskar from the Madras Institute of Development Studies, “investments in public health infrastructure, democratisation of the social profile of health personnel, innovative public drug procurement policies, and policies to retain professionals in the public health system ensured more inclusive access to healthcare.”[66] These authors in fact credit the prevalent demand for autonomy as an important factor in the setting up of the State Planning Commission in 1972, the first such body across any state in India.[67]
Since health is a subject in the State List of the Seventh Schedule of the Constitution, Tamil Nadu could legitimately differ from the prescriptions of the Central Government. It did so when it chose to retain separate cadres for public health and medical services – even as these merged in the rest of India in the 1950s.[68] Notably, the latest National Health Policy, 2017 iterates that all states should aspire to set up a Public Health Management Cadre, seemingly following the example created by Tamil Nadu by having separate cadres.[69]
Conversations with stakeholders suggest that Tamil Nadu did not hesitate to follow the Centre’s guidance where it felt appropriate. Thus, in 1973, the Kartar Singh Committee’s recommendations to position health personnel in Primary Health Centres as ‘Multipurpose Workers’ were accepted,[70] although the state continued to retain the nomenclature of ‘Village Health Nurses’.[71] Similarly, another former state Health Secretary revealed that the state received considerable flexibility and support from the central government in implementing the National Health Mission, launched in 2013.[72]
These sentiments are reflected in the Tamil Nadu Human Development Report published by the State Development Policy Council (formerly the State Planning Commission) in 2017:[73]
In India, although several major national programmes financed by the Government of India (GoI) (such as national blindness control programme, national malaria control programme, national HIV/AIDS control programme), have played and continue to play a significant role in building healthcare systems across States, State governments have a greater role and responsibility in building a sustainable delivery system in the long run. Over the years, Tamil Nadu has acquired the distinction of having implemented various national and State-level health programmes more effectively than most other States. The people of Tamil Nadu also enjoy a far better health status than those in most parts of India.
In today’s context, the desire for autonomy is manifested in the opposition to the National Eligibility cum Entrance Test (NEET), for admission to undergraduate medical (MBBS), dental (BDS), and alternative medicine (BAMS, BUMS, BHMS, etc.) courses. Both major parties, the DMK[74] and the AIADMK,[75] have publicly opposed conducting the NEET in Tamil Nadu, stating that it disadvantages backward classes and poorer sections of the society who cannot access expensive exam coaching. Another concern is that the NEET will potentially disturb the cadre system in place, which ensures that health workers are incentivised to serve in rural areas after graduation, as they have a high tendency to practice in their home districts, if they get trained at a local medical college. This sentiment was echoed by a Tamil Nadu Member of Parliament from the Indian National Congress, as well as by senior journalists from the state.
4. Mixed Impact of Media and Other Actors
The role of independent media is well recognized for promoting good governance in a democracy.[76] Media, through its reporting and criticism, can influence the views of the people and spur the Government into action. It acts as a watchdog that promotes the accountability of a government to its citizens. This can result in, among other things, better government service delivery and state responsiveness. A free and independent media also aids in informing the citizens of government actions and societal issues, leading to better electorate decision-making in a democratic society. Finally, the media acts as a channel through which citizens can convey their demand for public services (like security, public infrastructure, or health services) to the government.
Besley and Burgess (2000) analyzed data for Indian states for the period 1958-1992, to map the factors that influence Government responsiveness in the states. They found that states with greater newspaper circulation, literacy and turnout also have the most responsive Government.[77] It should be noted here that there is an extensive media presence in Tamil Nadu, with Tamil Nadu ranking 9th compared to other states (6th among larger states) in terms of the number of registered newspapers per million population.[78] It also ranks 2nd, after Delhi, in terms of the number of languages in which publications are published in the state.[79] In addition, Tamil Nadu has a high literacy rate – 80.33% based on Census 2011. Combined together, these factors indicate that media may have a considerable influence on the Tami Nadu Government’s responsiveness and its developmental activities.
A former bureaucrat also highlighted that courts, through their decisions in Public Interest Litigations (PILs), have often taken up questions of health care. For example, since the outbreak of the COVID-19 pandemic in early 2020, the Madras High Court has issued multiple directions to the Tamil Nadu government regarding the management of the pandemic. In May 2021, the High Court directed the state government to formulate a standard operating procedure for vaccination of people who are homebound or suffer from serious disabilities.[80] Similarly, while responding to a PIL filed by a non-governmental organization, the Madras High Court in June 2021 instructed the state government to clarify its stand on implementing the State-level Mental Health Policy.[81] The Court noted that clarity on this policy is needed so that “the mentally challenged are accorded the basic human dignity to which they are entitled to and the larger society begins to take care of such vulnerable sections”. The Court ordered that just like differently-abled people, a comparable vaccination drive must be implemented for the mentally challenged and a standing report needs to be filed within the court docket by the Tamil Nadu Health Department.
Such decisions and directions by the High Court not only result in immediate action by the State Government but also likely create an incentive mechanism where Government authorities factor in the Court’s reaction to their actions in their decision making. However, as per the discussant mentioned before, the role of the courts has only begun to take shape from year 2000 onwards.
III. Conclusion
Tamil Nadu has performed well on several health indicators, in part driven by enabling policies, well-performing services and adequate infrastructure. The underlying hypothesis that health has been a political priority in the state has rung true, as the state’s journey of the last several decades reflects. There are several motivations and drivers for this prioritisation, the most prominent being the nature of politics witnessed in the state, emerging from the Dravidian movement and its continuing legacy. The Dravidian movement created and embedded a mandate of social justice and welfare, targeted at marginalised groups, resulting in what became a part of the ideology of the competing political parties on the state. Not only did the focus on health equity emerge from this, but the significant representation of marginalised communities within the bureaucracy ensured effective and sustained attention to health and other social issues from an equity lens. So strong was the legacy of this movement for the state’s politics, that it continued across different political parties, and became an issue for competitive politics.
This core was surrounded by other driving factors. An increasing number of women voters with relatively higher levels of education became a key electoral constituency, for whom health services (largely focused on maternal and child health) were key. Beyond citizens, the bureaucracy and a relatively higher state capacity were key contributors to the prioritisation of health and other social issues. The effectiveness of the bureaucracy and its orientation to welfare policies on the one hand and the confidence in the state being able to design and deliver social polies effectively, enabled leaders to commit to and introduce reforms. Well implemented policy in turn led to continued expectations from citizens, further reinforcing the electorate as a driver.
The prioritization of publicly delivered health services in Tamil Nadu has thus been an outcome of many factors; historical politics of caste and welfare, higher levels of education and agency for women, focus on building state capacity and a resultant state less dependent on the centre. The foundation of the state’s distinct political journey and legacy, contributed to and was supported by other factors.
Annexure I
| Sr. No. | Indicator/State | Tamil Nadu | India |
| 1 | Infant mortality rate (per 1000 live births)[82] | 18.6 | 40.7 |
| 2 | Under-five mortality rate (per 1000 live births)[83] | 22.3 | 49.7 |
| 3 | Maternal Mortality Ratio[84] | 60 | 113 |
| 4 | Total Fertility Rate[85] | 1.8 | 2.2 |
| 5 | Mothers who had at least 4 antenatal care visits (%)[86] | 89.9 | 58.1 |
| 6 | Mothers who received postnatal care from a doctor/ nurse/ LHV/ ANM/ midwife/ other health personnel within 2 days of delivery (%)[87] | 93.2 | 78 |
| 7 | Institutional births (%)[88] | 99.6 | 88.6 |
| 8 | Institutional births in public facility (%)[89] | 66.9 | 61.9 |
| 9 | Children aged 12-23 months fully immunized (BCG, measles, and 3 doses each of polio and DPT) (%)[90] | 89.2 | 76.4 |
| 10 | Out of Pocket Expenditure as % of Total Health Expenditure[91] | 45.9 | 48.8 |
| 11 | Number of Primary Health Centres per 1 lakh people[92] | 2.6 | 2.5 |
| 12 | Number of functional Health and Wellness Centres per 1 lakh people[93] | 5.8 | 6.3 |
| 12 | Number of Allopathic Doctors per 1000 people[94] | 2 | 1 |
[1] NITI Aayog, Health Index: Healthy States Progressive India (June 2019).
[2] The Health Index has been hotly debated by Tamil Nadu. In 2019, the then Health Minister of Tamil Nadu wrote to the Union Health Minister disputing the methodology used by the NITI Aayog and the rank assigned to Tamil Nadu. See https://tinyurl.com/yxc3jjn8.
[3] 7.21 crore as per Census 2011.
[4]See Annexure I.
[5] Total Health Expenditure is made up of current and capital expenditure incurred by Government and Private Sources including external/donor funds, as per National Health Accounts 2017-18.
[6] Originally known as the
[7] https://tinyurl.com/yckjwptx
[8] Relying on data from NSS 75th Round – Health in India (2018).
[9] Population as per Census 2011; Data on PHCs from Answer in Lok Sabha dated 18 Sept. 2020, available at http://loksabhaph.nic.in/Questions/QResult15.aspx?qref=17064&lsno=17.
[10] Author calculations.
[11] Author calculations.
[12] Anup Karan et al., Size, Composition and Distribution of Health Workforce in India, Human Resources for Health, 19:39 (2021), available at https://human-resources-health.biomedcentral.com/track/pdf/10.1186/s12960-021-00575-2.pdf.
[13] Anup Karan et al., Size, Composition and Distribution of Health Workforce in India, Human Resources for Health, 19:39 (2021), available at https://human-resources-health.biomedcentral.com/track/pdf/10.1186/s12960-021-00575-2.pdf.
[14] Economic Survey 2020-21.
[15] Ibid.
[16] See Annexure I.
[17] Department of Health and Family Welfare, Government of Tamil Nadu, Policy Note 2021-22, https://tinyurl.com/2p86rprv
[18] Dandona, L., Dandona, R., Kumar, G. A., Shukla, D. K., Paul, V. K., Balakrishnan, K., Prabhakaran, D., Tandon, N., Salvi, S., Dash, A. P., Nandakumar, A., Patel, V., Agarwal, S. K., Gupta, P. C., Dhaliwal, R. S., Mathur, P., Laxmaiah, A., Dhillon, P. K., Dey, S., … Swaminathan, S. (2017). Nations within a nation: variations in epidemiological transition across the states of India, 1990- 2016 in the Global Burden of Disease Study. The Lancet, 390(10111), 2437–2460. https://tinyurl.com/6cu6hjwp
[19] Sunil Amrith, 2009, “Health in India since independence”, Available at: https://tinyurl.com/yz3b8knf
[20] Kalaiyarasan A. & Vijayabaskar M., The Dravidian Model: Interpreting the Political Economy of Tamil Nadu, Cambridge University Press, 2020.
[21] Muraleedharan, V. R., 1992, ‘Professionalising Medical Practice in Colonial South-India’, Economic & Political Weekly 27(4).
[22] Sunil Amrith, 2009, “Health in India since independence”, Available at: https://tinyurl.com/yz3b8knf
[23] M. Karunanidhi, Foreword, State Planning Commission Report, 2008, available at https://tinyurl.com/k5cvfazh
[24] Kalaiyarasan A. & Vijayabaskar M., The Dravidian Model: Interpreting the Political Economy of Tamil Nadu, Cambridge University Press, 2020.
[25] Ibid.
[26] Pandian M.S.S., 2012, ‘Being “Hindu” and Being “Secular”: Tamil “Secularism” and Caste Politics’, Economic & Political Weekly 47(31): 61–67.
[27] Kalaiyarasan A. & Vijayabaskar M., The Dravidian Model: Interpreting the Political Economy of Tamil Nadu, Cambridge University Press, 2020.
[28] Ibid.
[29] Mehrotra, S. 2006. ‘Well-being and Caste in Uttar Pradesh: Why UP Is Not Like Tamil Nadu’. Economic & Political Weekly 41(40): 4261–71.
[30] Ibid.
[31] Jean Drèze & Amartya Sen, 2013. An Uncertain Glory: India and Its Contradictions, Princeton University Press.
[32] Srinivasan, V. 2010. ‘Understanding Public Services in Tamil Nadu: An Institutional Perspective’. Unpublished doctoral dissertation, University of Syracuse, New York, available at https://tinyurl.com/2v9t7ubs
[33] Narayan, S. 2018. The Dravidian Years: Politics and Welfare in Tamil Nadu. New Delhi: Oxford University Press.
[34] In Tamil Nadu, SCs and OBCs make up 28% and 69% of the population respectively. In UP, the corresponding figures are 24% and 53%.
[35] M Vijayabhaskar & V. Karthik, A Crucible of Tamil Nadu’s Sociopolitical Ethos, Economic and Political Weekly, Vol. 56 No. 11 (2021), available at https://tinyurl.com/cywezprr
[36] Stakeholder consultation with Dr. Girija Vaidyanathan.
[37] National Health Profile, 2020.
[38] Kapoor et al. 2014, “Women Voters in Indian Democracy”, Available at: https://tinyurl.com/8aw6j5s
[39] Kapoor et al. 2014, “Women Voters in Indian Democracy”, Available at: https://tinyurl.com/8aw6j5s
[40] Tamil Nadu Elections: More Women Voted This Time Than Men, The New Indian Express, 10 April 2021, available at https://tinyurl.com/2mkumfx2
[41] Nistula Hebbar, Women’s Vote a Key Factor in Recent Polls, The Hindu, 27 April 2021, available at https://tinyurl.com/y3trtkex
[42] Raj Chengappa, Tamil Nadu: The New Star in India’s Population Scenario, India Today, 30 Sept 1994, available at https://tinyurl.com/aysm3shs
[43] https://www.jstor.org/stable/2991871?seq=2#metadata_info_tab_contents
[44] Aravind Kumar, A Victory Built on Welfare Schemes, The Hindu, 20 Mar 2016, available at https://tinyurl.com/3s9k3pbz
[45] Praveen Rai, Women’s Participation in Electoral Politics in India: Silent Feminisation, South Asia Research, Vol. 37 No. 1, 2017, available at https://tinyurl.com/zmusxcrn
[46] Grant Miller, Women’s Suffrage, Political Responsiveness, and Child Survival in American History, Quarterly Journal of Economics, Vol. 123 No. 3, 2008, available at https://tinyurl.com/4mue7zmp
[47] Bharathi SP, AIADMK’s Social Welfare Promises, The News Minute, 15 March 2021, available at https://tinyurl.com/kknafwr3
[48] Overview of Tamil Nadu, India Census 2011, available at https://tinyurl.com/4xk3fsv7
[49] All India Survey of Higher Education 2019-20.
[50] Thanks to Marriage Assistance Schemes, Now More Women Become Graduates, The Times of India, 9 May 2018, available at https://tinyurl.com/2j2rd84d
[51] Monica Dasgupta et al, How Might India’s Public Health System be Strengthened? Lessons from Tamil Nadu, Economic and Political Weekly Vol 45 No 10 (2010), available at https://tinyurl.com/vkrsmz4u
[52] Mukesh Hamal et al, How do Accountability Problems Lead to Public Health Inequities?, Public Health Reviews No. 39 (2018), available at https://tinyurl.com/4af4m74
[53] “State capacity, state failure, and human rights”, Englehart, 2009, Available at: https://tinyurl.com/599vpcx8
[54] “How Might India’s Public Health Systems Be Strengthened? Lessons from Tamil Nadu“, Das Gupta et al., 2010, Available at: https://tinyurl.com/r4uj6h95
[55] “Inclusive growth in Tamil Nadu: The role of political leadership and governance”, Akileswaran et al., 2020, Available at: https://tinyurl.com/nfjva6w9
[56] “Negative Voters: Electoral Competition with Loss-Aversion”, Lockwood, Rocky, 2015, Available at: https://tinyurl.com/y3y6uww2
[57] “Dr. Muthulakshmi Maternity Benefit Scheme”, https://tinyurl.com/azsrvact
[58] “Knowledge and Utilisation of Various Schemes of RCH Program among Antenatal Women and Mothers Having Less than Five Child in a Semi-Urban Township of Chennai”, Vithya Priya et al., https://tinyurl.com/y4v9nbh7
[59] “The political economy of growth under clientelism: an analysis of Gujarat, Tamil Nadu and Pakistan – PhD thesis”, Roy, 2013, Available at: https://eprints.soas.ac.uk/18261/
[60] “How Tamil Nadu changed after 1967”, Narayan, 2018, Available at: https://tinyurl.com/nfjva6w9
[61] “How Tamil Nadu changed after 1967”, Narayan, 2018, Available at: https://tinyurl.com/nfjva6w9
[62] B Anbuselvan, DMK Picks up its State Autonomy Weapon, The New Indian Express, 18 March 2021, available at https://tinyurl.com/m9x5uvsj
[63] R Kannan, How Karunanidhi Pitched for Greater State Autonomy in the 1970s, The News Minute, 3 July 2021, available at https://tinyurl.com/kass3ttv
[64] Fifth Tamil Nadu Legislative Assembly, Resume, Tenth Session – Second Meeting, March – April 1974, available at https://tinyurl.com/v79w26br
[65] Kalaiyarasan A & Vijaybhaskar M, The Fault Lines in Tamil Nadu that the DMK Now has to Confront, The India Forum, 28 May 2021, available at https://tinyurl.com/ja9kf593
[66] Kalaiyarasan A & Vijaybhaskar M, The Fault Lines in Tamil Nadu that the DMK Now has to Confront, The India Forum, 28 May 2021, available at https://tinyurl.com/ja9kf593
[67] Kalaiyarasan A. & Vijayabaskar M., The Dravidian Model: Interpreting the Political Economy of Tamil Nadu, Cambridge University Press, 2020.
[68] Monica Dasgupta et al, How Might India’s Public Health System be Strengthened? Lessons from Tamil Nadu, Economic and Political Weekly Vol 45 No 10 (2010), available at https://tinyurl.com/vkrsmz4u
[69] Dharmesh Lal, The Case for a Public Health Cadre, The Hindu 15 Oct 2017, available at https://tinyurl.com/93j6hps9
[70] National Health Portal, Kartar Singh Committee, available at https://tinyurl.com/39tdcce2
[71] R Parthasarthi & S.P. Sinha, Towards a Better Health Care Delivery System: The Tamil Nadu Model, International Journal of Community Medicine, Vol 41 No 4 (2016), available at https://tinyurl.com/n8s945jr
[72] Consultation with Dr.. Girija Vaidyanathan.
[73] Tamil Nadu State Development Policy Council, State Human Development Report (2017), available at https://tinyurl.com/2nh5e99t
[74] PTI, Tamil Nadu renews plea to scrap NEET, Centre says more cities from state added for exam, The Economic Times, 15 July 2021, available at https://tinyurl.com/86w5sp34
[75] Saurabh Sharma, AIADMK writes to PM Modi again, urges exemption for Tamil Nadu, says allow admission on Class 12 marks, Livemint, 11 July 2021, available at https://tinyurl.com/2yy3nuxh
[76] “Media and good governance”, UNESCO, Available at: https://tinyurl.com/4yvbp722
[77] “Political agency, government responsiveness and the role of the media”, Besley and Burgess, 2000, Available at: https://tinyurl.com/ys3dbdd6
[78] “Press in states and union territories 2019-20, Chapter 9”, Office of registrar of newspapers for India, Available at: https://tinyurl.com/2tzx3ahz
[79] “Press in states and union territories 2019-20, Chapter 1”, Office of registrar of newspapers for India, Available at: https://tinyurl.com/ynz3nphh
[80] “COVID19: Madras High Court Directs State To Indicate Plan Of Action For Vaccination Of Bed Ridden, Physically Disabled”, LiveLaw, May 2021, Available at: https://tinyurl.com/2pp9a32j
[81] “Spell out stand on implementing State Mental Health Policy, says High Court”, The Greater India, June 2021, Available at: https://tinyurl.com/5b5dnrmf
[82] National Family Health Survey (NFHS)-5 (2019-21).
[83] NFHS-5.
[84] MMR Bulletin, Sample Registration System 2018.
[85] NFHS-5.
[86] NFHS-5.
[87] NFHS-5.
[88] NFHS-5.
[89] NFHS-5.
[90] NFHS-5.
[91] National Health Accounts 2017-18.
[92] Authors calculations based on Lok Sabha Answer dated 21.08.21 and population figures per Census 2011.
[93] Authors calculations based on data from Ayushman Bharat portal on 1.09.21 and population figures per Census 2011.
[94] Authors calculations based on National Health Profile 2020 and population figures per Census 2011.
