The recently articulated vision of Tamil Nadu Chief Minister M.K. Stalin, for decentralised district level health management, is very timely in the post-pandemic era. Tamil Nadu is ahead of most other States in socio-economic development, thanks to the high priority given to health and education, by successive governments.
During the British Raj, doctors were mandated to report every case of 24 “notified communicable diseases” to health officers, enabling the Public Health Department to detect, count and counter specific diseases, control outbreaks and document all data. During major epidemics, public health assumed extraordinary powers through the 1897 Epidemic Diseases Control Act, recently invoked in 2020 to face the COVID-19 pandemic.
Independent India assigned public health to the Ministry of Health, and disease surveillance fell by the wayside. India became notorious for not collecting or verifying data on diseases or causes of death. For want of functional public health infrastructure, the National Disaster Management Agency (NDMA) acted after the disaster struck; public health would have forecast the emergency and intervened pro-actively.
Health must be managed like an asset. What is health? The best definition has two parts — subjective: physical, mental and social well-being, and objective: absence of disease, validated with evidence. Many people conflate public sector healthcare with public health, two systems for the common goal of keeping citizens healthy and improving health indicators. Public health has disease prevention through interventions targeted at social and environmental disease determinants, as its primary purpose.
Functional epidemiology
Epidemiology is the foundation science of public health. Disease surveillance and epidemiology are two sides of the same coin; the former provides real-time information for action and the latter analyses data and facilitates planning. During the COVID-19 pandemic, lack of functional epidemiology led to inadequate forward planning. India has good epidemiologists, but they use their expertise predominantly for research and teaching — it is high time they used this discipline for managing public health.
Among British India’s presidencies, Madras alone retained the legacy of the Public Health Act — the Department of Public Health and Preventive Medicine (DPHPM) continues since 1930 — unique among Indian States. After State reorganisation, Tamil Nadu assigned primary healthcare to DPHPM, secondary healthcare to the Department of Health Services and tertiary healthcare to the Department of Medical Education, each with its directorate within the Health Ministry.
After achieving population stabilisation by planned activities, Tamil Nadu is moving forward for greater investment in health and education, with assured, perpetual, high-order returns.
The 2017 National Health Policy (NHP) recognises “the emergence of a robust healthcare industry estimated to be growing at double digit”. Medical professionals in private tertiary care facilities make us proud, providing world class surgical and medical interventions and attract healthcare seekers even from developed countries. Paradoxically, our own citizens are forced to pay for services that are due to them as legitimate human right.
Surveillance model
Tamil Nadu was the first to eliminate smallpox, guinea worm, polio and measles mortality and the first to document Japanese encephalitis, dengue virus types 1 to 4, HIV and hepatitis B infections, in India. North Arcot District had a District Level Disease Surveillance model that pioneered pulse polio immunisation. Its monthly health information bulletin (called NADHI), widely appreciated globally, was undervalued nationally. Given the wide penetration of mobile phones, the State can easily revive and revise it — utilising electronic data collection and communication, up-scaled to every district in Tamil Nadu — to become a potential national leader in systematic data collection, analysis, disease prevention, outbreak control and credible recording of causes of death.
Tamil Nadu must also design a just system of universal healthcare, maximising public-private partnership. We now need to design an equitable health delivery system for everyone, with seamless referral from primary to tertiary care.
It is now for the administrative machinery to put in place a health management programme consisting of public health and universal healthcare in Tamil Nadu.
T. Jacob John and M.S. Seshadri are retired Professors of Clinical Virology and Endocrinology, respectively, at Christian Medical College, Vellore
