Kerala and Tamil Nadu have outstanding outcomes on health and social indicators. They are beacons in India’s public health landscape. According to the latest data, maternal deaths per 100,000 live births is 61 in Kerala, and 79 in Tamil Nadu, while the all-India average is 167. Both have achieved 99% institutionally delivered births. Kerala’s neonatal mortality rate is 6, which falls in the same bracket as the US at 4 and UK at 3. These two states, comparative laggards in economic growth, emerged as leaders in public health for three reasons—genuine universal health access, innovations in front-line health delivery and political will.

Kerala and Tamil Nadu have taken an enlightened, integrative view of health. They focus on access not only to basic health services, but also related services such as education, sanitation, food and clean water. The concept of equity has also played a decisive role. The two states have appreciated that large populations above the poverty line are also in need of good health services. They have not taken the route of focusing expediently on below-poverty-line populations. For example, the public distribution system in both Tamil Nadu and Kerala provided food rations to all households in their respective states, instead of targeting a select few, considered the neediest. Other examples include provision of well-staffed and equipped primary health centres (PHC) availed by all that offer 24x7 medical facilities and ready availability of free medicines.

Novel approaches have been adopted. In Tamil Nadu, a separate cadre of medical officers is dedicated to PHCs and they are offered incentives to work in the most remote, underserved areas. Consequently, only 7.6% of medical officers’ posts at PHCs are vacant in Tamil Nadu, while in a state like Bihar the corresponding figure is as high as 63%. The pain and palliative programme in Kerala is a community-led initiative, with students volunteering to provide home-based care to people in need and a mobile medical van available for technical support.

In Tamil Nadu, the multipurpose workers’ scheme was launched in 1980, in which women with at least 10 years of schooling trained for 18 months to become village health nurses. Front-line workers were enrolled in refresher courses and taken on inter-district exposure tours, as part of their training. In Kerala, devolution of powers to ensure that panchayats decided on health-related matters means decision-making involves village communities, which are the ones most acutely aware of their own healthcare needs.

In both states, these and other measures have been implemented under the protective umbrella of a strong political will. Political parties come and go but each one, when in power, has sustained a commitment to provide basic healthcare services, especially for women and children. In Kerala, the emphasis on literacy and healthcare services was laid as long back as the reign of the erstwhile states of Cochin and Travancore. Post independence, the Communist government under E.M.S. Namboodiripad continued this emphasis. The literacy movement, combined with healthcare reforms, played a major role in creating demand for these services. In Tamil Nadu, too, successive DMK and AIADMK regimes have built on each other’s work, at least in healthcare services. The political leadership in both states has also had the savvy to realize that provision of basic healthcare services is a sure way to garner political support.

Political will goes a long way in ensuring public health. It was the concerted political will of several states that led to the defeat of polio in mothers and children, and HIV in India. Working in Rajasthan today I see the same commitment towards mother and child health. Sustaining it is the key.

Learnings from Kerala and Tamil Nadu make for a compelling argument: when political will is combined with demand from the community, innovative practices are bound to follow.

Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok

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