TAMIL NADU HEALTH SECTOR 1980s2005

VR Muraleedharan Umakant Dash Lucy Gilson

.,,/ Presented at IIM, Bangalore 28 December 2011

Public Private and Expenditure Health major in by States (200405) States Expenditure in Percentage (in Rs.) Per Capita Per Capita Public Exp. Public as Exp. Share as Public Private Share GSDP of of State Expenditure Andhra Pradesh 191 870 0.72 3.22 Assam 162 612 0.86 3.08 Bihar 93 420 1.12 4.12 Gujarat 198 755 0.57 3.06 Haryana 203 875 0.49 3.19 Himachal Pradesh 630 881 1.74 4.98 Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal All India 233 287 145 204 183 247 186 223 128 173 242 597 2663 644 1008 719 1112 575 1033 846 1086 959 0.87 0.88 0.87 0.55 0.98 0.65 0.98 0.71 0.92 0.69 0.84 3.77 4.65 3.19 2.88 4.41 3.01 3.90 3.43 3.86 4.32 ----

Infant mortality rate per 1000 live Total fertility births (2007) Life expectancy at birth rate % (years)* (2009)# (2006)$ (20022006) States/India Male Female 62.9 65.5 1. Andhra Pradesh 3197 2 54 58.6 59.3 2. Assam 1875 2.7 66 62.2 60.4 3. Bihar 1068 4.2 58 62.9 65.2 4. Gujarat 3849 2.7 52 65.9 66.3 5. Haryana 5386 2.7 55 63.6 67.1 6. Karnataka 3244 2.1 47 71.4 76.3 7. Kerala 3854 1.7 13 58.1 57.9 8. Madhya Pradesh 1692 3.5 72 66 68.4 9. Maharashtra 4288 2.1 34 59.5 59.6 10. Orissa 2303 2.5 71 68.4 70.4 11. Punjab 4133 2.1 43 61.5 62.3 12. Rajasthan 2110 3.5 65 65 67.4 13. Tamil Nadu 3522 1.7 35 60.3 59.5 14. Uttar Pradesh 1462 4.2 69 64.1 65.8 15. West Bengal 2839 2 37 62.6 64.2 India 2930 2.8 55 GDP PPP per capita in USD

Maternal mortality Under-5 rate 2004 mortality 2007@ rate per Full 1000 live immunizatio births** n (2002 (2006) 2004)^ 87.7 85 84.8 60.9 52.3 54.7 16.3 94.2 46.7 90.6 52 85.4 35.5 96.4 59.6 74.3 154 480 312 160 186 213 95 130 335 303 192 388 111 440 141 254 62.9 19.3 24.4 57.7 62.9 74.1 81.2 32.5 74.3 55.1 75.3 25.4 92.1 28.1 54.4 47.6

MCH Indicators

Assam UP Rajasthan MP Bihar Orissa 254 INDIA Karnataka Other Punjab Haryana Haryana Gujarat Gujarat AP

MMR Major States (2004-06)

IMR_2006
80 70 60 50 40 30 20 10 0

480

111

Tamil Nadu Tamil Nadu Kerala Kerala

600

500

400

300

200

100 MMR

Key Question
TN spends not more than 1% of SGDP, as most other states; About 4% of expenditure is from private sources! The challenge is to maximise the health gains from the scarce government funding for healthcare; TNs experience highlights where and how this scarce public funds could bring about greater health gains than is achieved in other states/countries.

Good Health at Low Cost 25 years on. What makes an effective

health system?
Dina Balabanova & GHLC project team

New countries:
Bangladesh, Ethiopia, K yrgyzstan, Tamil Nadu, India, Thailand

Original countries reviewed:

China, Costa Rica, Kerala, Sri Lanka

Objectives
Question: how certain factors, individually and combined, contributed to improvements in health and access to key services (beyond what could be expected at their income level):
Factors related to the health system; Factors related to living conditions and public services (policies in other sectors); Factors related to the institutional environment (political, economic, social); Factors related to the context (geography, climate etc.)

Conceptual framework: Good health at low cost 2011

Historical approach
Historical approach chosen aiming to:
construct rich analytical case studies tracing pathways to good health, by which good health at low cost is achieved over long periods of time analysis reflecting interplay of different factors recognise path dependency of health systems development establish temporal and plausible relationships pattern recognition within and between countries

Methods
Historical case studies mix of quantitative and qualitative methods:
Secondary analyses/synthesis of existing data Analysis of documents Semi-structured interviews (policy-makers, providers, managers etc.)
Qualitative survey
25 in-depth interviews and 2 focus groups
National/State level: MOHFW, MOH (Tamil Nadu), NGOs etc. District level: health facilities, Social Departments under local authorities
(Dharmapuri, Madurai, Salem, Coimbatore)

Experts from International organizations: WHO, WB, UNICEF

Cumulative reduction of IMR since 1971

Utilization of public In-patient, out-patient and maternal delivery services: Quintile wise analysis
50 45 40 35

40 35 30 Percentage 25 20 15 10 5

Percentage

30 25 20 15 10 5 0 Q1poorest Q2 Q3 Quintile Rural 95-96 Rural 2004 Urban 95-96 Urban 2004 Q4 Q5 least poor

0 Q1 Q2 Q3 Quintile Rural 1995-96 Rural 2004 Urban 1995-96 Urban 2004 Q4 Q5

40 35 30 Percentage 25 20 15 10 5 0 Q1poorest Q2 Q3 Quintile Rural 95-96 Rural 2004 Urban 1995-96 Urban2004 Q4 Q5 least poor

Concentration Curves for Delivery Services in Tamil Nadu Rural and Urban: 1995-2004
Tamil Nadu_R 1995-96 Tamil Nadu_R 2004

Tamil Nadu_U 1995-96

Tamil Nadu_U 2004

Concentration Curves for IP Services in Tamil Nadu Rural and Urban: 1995-2004
TN Urban 1995-96 TN Urban 2004

TN Rural 1995-96

TN Rural 2004

Source: Girija Vaidyanathan, Debashis Acharya et al (2010), Do the Poor Benefit from Public Spending on Healthcare in India?: Results from Benefit (Utilization) Incidence Analysis in Tamilnadu and Orissa

Interventions leading to health gain: Health Systems Related

Rapid Expansion of PHC/HSC network (80s till early 90s) Introduction of Multipurpose Workers (since early 80s) High ANC level (20% in 1990 to 95% in 2006) Expenditure on primary health care About 35% of the budget on primary health care (last 20 years) Pubic Health Cadre/District Public Health Management (1950s) Creation of quasi-government bodies (programme specific): mid 90s Innovative Drug Delivery System (improved quality, reduced costs, etc) mid 90s Vaccination Programme since early 80s and high utilization rate (early 80s) High Institutional Deliveries; Strengthening First Referral Units (mid 90s) Use of Indigenous medicines through PHCs/Secondary Hospitals

A key observation
Greater and rapid Utilization and more efficient utilization of central funds

As a former health sectary (with the Government of India) put it: The TN state had much better combination of managerial skills at various levels, from state secretariat to district health system and even below. In my six years of association with this sector, I would say, no other state could boast of having such a blend of professionals. I would even say that overall the administrative efficiency of the state health system is far higher than that in other states of India
Much of these changes should be attributed to the efforts of VHNs and the overall presence and functioning of the primary health delivery system in the state, as a senior official (now retired) commented.

Key themes emerging from the research

Health Gains: Role of other factors

Low fertility rate (TFR 2.1 by early 90s) Several factors responsible (including Female literacy, female autonomy, higher age at marriage)

Better Infrastructure Higher Industrialisation

Non Health Factors: Infrastructure

Source: B. Ghose, P. De. Investigating the linkage between infrastructure and regional development in India: era of planning to globalisation, Journal of Asian Economics, 15 (2005) 1023-1050

Key points..
In the 1980s, Tamil Nadus elected politicians led and enabled the effective and rapid implementation of national plans to strengthen primary health care services in the public health system emphasis on MCH shown all political parties Stable bureaucracies, an effective management system, and an adequate number of skilled managerial professional staff at state and district levels

Key points..
Innovative approaches have been used at various levels to address the most significant bottlenecks/barriers to the provision of primary health care services in underserved areas rapidly expanding private health sectors in Asia (India) Tamil Nadus achievements in lowering the birth rate, improving gender equality and improving literacy rates, among others

GHLC 1985, 2011: what matters for good health

Political commitment to health as a social goal Strong societal values of equity, political participation and community involvement High-level investment in primary health care and other community based services Widespread education, especially of women Intersectoral linkages for health

Major Challanges:
Make efforts to Integrate complementary programmes (water, sanitation, nutrition, etc) evidence is not robust; (impact of nutrition programme not as positive as expected over the past 20 years) High proportion of neonatal deaths and presence of preventable Maternal deaths Need for better disease surveillance system High Out of Pocket Expenditure Regulatory Issues

Non Health Factors

Tamil Nadu is one of the leading States in the industrial front at the national level.
In terms of number of registered manufacturing factories, the State is placed in the first position for the seventh successive year since 1997-98. (15%-16%) In terms of total number of persons engaged in various activities of production process also, the State ranked first and shared 15.0 per cent at the national level. At the national level, in terms of fixed capital, productive capital, gross value of output and net value added, the State stands next to Maharashtra and Gujarat. High Economic Overhead Capital over the years

Share of manufacturing sector in NSDP

Source: Suresh Babu M. Rajesh Raj S N, Trends in Regional Industrial Growth in India, Manuscript

Share of states in industrial output of India

Source: Suresh Babu M. Rajesh Raj S N, Trends in Regional Industrial Growth in India, Manuscript

Share of states in employment 81-82 to 04-05

Source: Suresh Babu M. Rajesh Raj S N, Trends in Regional Industrial Growth in India, Manuscript