A combination of factors led by state policy has enabled the southern State to become a notable achiever with respect to some key indicators of development.
In 2001, Nobel Laureate Amartya Sen recorded an eyebrow-raising fact in his book, “Development as Freedom”, that Tamil Nadu and Kerala had both achieved much faster rates of decline in fertility than China had achieved since it introduced its one-child policy.
That same year, the international community signed a historic, unprecedented accord — an eight-fold road map to eliminate poverty and hunger, preventable disease and death, and to protect the earth's environment. These are the Millennium Development Goals. Two of the goals, No. 4 and No. 5, concerned reducing infant and maternal mortality rates, respectively. Again, Kerala and Tamil Nadu defied national trends.
Kerala today has among the lowest infant mortality rates in India (12 per 1,000 live births: SRS data, 2008), and Tamil Nadu, among the lowest maternal mortality rates, with an impressive 70 per cent reduction over the last 20 years (380 in 1993 to 111 in 2008 per 100,000 live births: National Family Health Survey (NFHS) and Sample Registration System (SRS) data). “Back then, it was a very male-dominated government and bureaucracy,” said Sheila Rani Chunkath, a senior Tamil Nadu-cadre Indian Administrative Service officer who was instrumental in jump-starting the State government's policies on women and child welfare. “But we thought it was a scandal for a woman to die in this day and age and this cannot be tolerated. We also believed that government could work.”
Maternal mortality
Tamil Nadu's experience in reducing maternal mortality is particularly instructive because even more than in the case of infant mortality, India is way off-track with respect to reducing maternal mortality. Every year, approximately 80,000 mothers die in India at childbirth. The media have often termed the startling trend as “silent genocide.” The MDG 2015 target is 100 per 100,000 live births, while India's projected rate for 2010 is 220 per 100,000 live births, according toThe Lancet, a global medical journal.
The inevitable question that arises, then, is: what did Tamil Nadu do differently? What were the enabling factors?
Inevitably, some of them are the same factors that Professor Sen cited 10 years ago in his book to explain Tamil Nadu's reduced fertility rates — a combination of “an active, but cooperative” family planning programme, high literacy rates and high female employment in gainful employment.
Widely understood by public health professionals but not necessarily by the public at large, though, is that many of Tamil Nadu's achievements in human development are the result of a conscious and deliberately crafted state policy. “Ultimately, it all boils down to an issue of management and logistics,” said Ms. Chunkath. “We found, for instance, that many deaths occur because in the crucial hours, pregnant women were running about trying to access too many different places that simply didn't have the necessary care.”
One-stop centres, assistance
Ms. Chunkath was part of government efforts to establish and eventually improve a network of one-stop emergency centres, known as CEmONC (Comprehensive Emergency Obstetric and Newborn Care), across Tamil Nadu. Equipped with operation theatres and blood storage units and staffed by obstetricians, paediatricians, anaesthetists and other specialists, these are intended to be available round the clock. Since 2004, when the centres were introduced at the district and sub-district levels, news reports have recorded a sharp increase in the number of complicated cases being registered across the network, underscoring their crucial role.
Over the years, a slew of ambitious and targeted, if populist, schemes have been introduced in Tamil Nadu. On closer scrutiny, these may not bear the true imprint of a social welfare state, but the schemes have nevertheless proved to be effective, heightened consciousness and led to many desirable public policy outcomes. The best-known and widely studied initiative for reducing maternal mortality is the Dr. Muthulakshmi Reddy Maternity Assistance Scheme, under which pregnant mothers are entitled to financial support of Rs. 6,000 each time, for up to two children. The State's main marriage assistance scheme (the official name is Moovalur Ramamirtham Ammaiyar Ninaivu Marriage Assistance Scheme) complements this effort by providing Rs. 20,000 to young women for marriage, provided they have studied up to at least Class 10. The amount has now been increased to Rs. 24,000.
Dhatchayani, who lives in a thatched-roof hut in Kovathoor village in Kanchipuram district, 70 km from Chennai, is a beneficiary of both schemes. She belongs to a Scheduled Caste, below poverty line household. Her husband is a dye-worker and earns Rs. 6,000 to Rs. 7,000 a month. When she got married, Ms. Dhatchayani, educated up to Class 12, received Rs. 20,000 under the marriage assistance scheme. The mother of a two-year-old son, she is now seven months pregnant with her second child, and has applied for the Dr. Muthulakshmi Reddy Scheme. It delivers half the money to the mother a few months before delivery and the rest in the months following it. Asked whether she wants more children or if there was a preference for boys in her village, she said: “Male or female, a child is a child; and two are enough.”
Accountability and incentives
Compared to other Indian States, Tamil Nadu has also been better able to implement governmental schemes by instituting strong accountability measures and incentives at the grassroot level. The public health centre (PHC) network is well established: there are about 1,700 of them here, each serving a population of 30,000 to 40,000. “The main difference I have seen is that our PHCs function, whereas they don't in other States,” said Sharda Suresh, a Chennai-based paediatrician and public health expert who advised the Tamil Nadu government and now works for a research-based non-governmental organisation, Samarth. “The credit goes to the Public Health Department for ensuring that PHCs function with spot checks, taking action and making local administration accountable.”
The PHC that Ms. Dhatchayani goes to for regular check-ups is a 10-minute walk from her home and provides a ready example. Located in Luthoor block, most of the 10-member-strong medical and support staff seemed to be in attendance on a government holiday for Onam, the popular festival of Kerala celebrated widely across South India. This PHC functions six days a week, except on Sundays, but staff nurses are on call round-the clock, including on Sundays. Serving a population of about 35,000 covering 30 villages, the Koovathur PHC has an estimated daily footprint covering 160 to 260 patients, a majority of them from the Dalit community. About 20 new cases of pregnancies are registered each month, according to the PHC health staff nurse. She is 47-year-old Tamil Selvi, who has studied up to Class 12. In the past four years, there have been two maternal deaths. There have been four to five infant deaths annually at the PHC level, and since 2007, when the Dr. Muthulakshmi Reddy Scheme was introduced, there have been almost no home deliveries in the entire Kanchipuram district, Ms. Selvi claimed.
The Tamil Nadu Government has tried to fill the gaps at the PHC level with supporting schemes. For instance, PHCs can only assist in natural births and not caesarean sections, which are referred to CEmONCs or district and other hospitals. As part of the GVK Emergency Management and Research Institute's ‘108' ambulance services, Tamil Nadu has at least 385 ambulances, one for each of its 385 community development blocks. Following a public-private partnership model, its services are free to users such as pregnant mothers. They generally ensure that anyone in need of emergency care would not have to wait for more than 20 minutes for transport to reach them. Finally, under the Chief Minister Kalaignar's Insurance Scheme for Life Saving Treatments, families earning less than Rs. 72,000 annually can be insured for up to Rs. 1 lakh each, for up to four years. For maternal care, coverage includes being able to access a private nursing home or hospital for “major operations.”
Resource staff
No well-thought-out public policy initiative is bereft of in-built incentives, and so it is the case for Tamil Nadu's health care service delivery system. Public health experts working closely with infant and maternal mortality issues found that making a medical officer available within a five-kilometre range of a PHC and accessible 24/7 a day is crucial. They also concluded that nurses are “better bets for the government because they are cheaper, also more reliable,” as Dr. Suresh put it. “We looked into their problems and enabling conditions such as safety, living quarters and covering their rent.” Ms. Selvi, who works at the Koovathur PHC, has a monthly salary of Rs. 11,500, in addition to medical, housing, travel and “washing” allowance. She avails of comprehensive health insurance and will get a pension provided by the State government.
Even with Central government-initiated schemes such as Integrated Child Development Services (ICDS), the incentives in Tamil Nadu are more visible than elsewhere even during a casual visit. At an Anganwadi in Thirukazukundran village, an hour's drive from Chennai and off the East Coast Road, the helper was in the midst of cooking the prescribed mid-day meal for the 25 children who come there. Her salary is Rs. 2,300 a month, while the main caretaker makes Rs. 4,000. An Anganwadi teacher from a neighbouring village, who dropped by, has a salary of Rs. 5,000. All these incentives underscore something vital for effective public policy implementation. “You are not only creating a health structure but you are creating trust in the government,” as Dr. Suresh put it.
Discrimination and corruption
In spite of Tamil Nadu's visible success in health care and health service delivery, as elsewhere in India issues of neglect, accessibility and corruption plague it too.
Child Rights and You (CRY), a national child rights advocacy organisation, has been working closely with the State's under-served communities such as Dalit people, who comprise 38 per cent of the population. “They still face strong social discrimination and children are disproportionately affected,” said P. Krishnamoorthy, a Chennai-based manager with CRY. “The conditions of women and children among the few tribal pockets are still abysmal. But comparatively, the overall picture is still better than many other States.”
Last but not least, some public health experts link Tamil Nadu's relative success in overall human development to a heightened awareness among the common person of his or her rights as distinct from high literacy rates in the State. Dr. Suresh attributes it partially to the language and the Dravidian movement in Tamil Nadu. “One thing it did was help develop a strong sense of self-identity even among the common person,” she said. “The common Tamilian felt he can make a difference, that he has the right to protest and his voice will be heard.”
(Divya Gupta is an independent journalist supported by Save the Children to raise awareness about issues around child mortality ahead of the UN Millennium Development Goals summit scheduled to be held in New York from September 20 to 22.)
