Note: In their 2013 book, An Uncertain Glory: India and its Contradictions, economists Amartya Sen and Jean Dreze devote a number of pages to Tamil Nadu’s progress over the past 30 to 40 years in terms of social development. The authors place much emphasis on how Tamil Nadu, along with Kerala and Himachal Pradesh, has achieved some of the best public services among most of India’s states as a result of constructive state policies.

While Sen and Dreze do not specifically name or credit any politician or leader for this, Jayalalithaa – as the 11th, 14th, 16th, 18th and 19th chief minister of the state spread out over 15 years – played an important part in Tamil Nadu’s development, as did others.

The following excerpts from the book on Tamil Nadu’s development trajectory are reproduced here with the permission of the authors.

Tamil Nadu is another interesting case of a state achieving rapid progress over a relatively short period, though it started from appalling levels of poverty, deprivation and inequality. Throughout the 1970s and 1980s official poverty estimates for Tamil Nadu were higher than the corresponding all-India figures, for both rural and urban areas (about half of the population was below the Planning Commission’s measly poverty line).

Much as in Kerala earlier, social relations were also extremely oppressive, with Dalits (scheduled castes) parked in separate hamlets (known as ‘colonies’), generally deprived of social amenities, and often prevented from asserting themselves even in simple ways like wearing a shirt or riding a bicycle.

It is during that period that Tamil Nadu, much to the consternation of many economists, initiated bold social programmes such as universal midday meals in primary schools and started putting in place an extensive social infrastructure – schools, health centres, roads, public transport, water supply, electricity connections, and much more. This was not just a reflection of kind-heartedness on the part of the ruling elite, but an outcome of democratic politics, including organized public pressure. Disadvantaged groups, particularly Dalits, had to fight for their share at every step.

Today, Tamil Nadu has some of the best public services among all Indian states, and many of them are accessible to all on a nondiscriminatory basis. Tamil Nadu’s experience will be discussed again in Chapter 6, with special reference to health and nutrition. While each of these experiences tends to be seen, on its own, as some sort of confined ‘special case’, it is worth noting that the combined population of these three states is well above 100 million. Tamil Nadu alone had a population of 72 million in 2011, larger than most countries in the world.

Further, the notion that these states are just ‘outliers’ overlooks the fact that their respective development trajectories, despite many differences, have shared features of much interest. First, active social policies constitute an important aspect of this shared experience. This is particularly striking in the vigour of public education, but it also extends to other domains, such as health care, social security and public amenities. Second, these states have typically followed universalistic principles in the provision of essential public services. This is especially noticeable in the case of Tamil Nadu, as will be further discussed in Chapter 6, but the point also applies to Himachal Pradesh and Kerala. The basic principle is that facilities such as school education, primary health care, midday meals, electricity connections, ration cards and drinking water should as far as possible be made effectively available to all on a non-discriminatory basis, instead of being ‘targeted’ to specific sections of the population. In fact, in many cases the provision of essential services and amenities has not only been universal but also free.

Third, these efforts have been greatly facilitated by a functioning and comparatively efficient administration. The governments involved have delivered their services in traditional lines, and there has been little use of recently favoured short-cuts such as the use of parateachers (rather than regular teachers), making conditional cash transfers, or reliance on school vouchers for private schools (rather than building government schools). The heroes in these successful efforts have been ‘old-fashioned’ public institutions – functioning schools, health centres, government offices, Gram Panchayats (village councils) and cooperatives. These traditional public institutions have left much room for private initiatives at a later stage of development, but they have laid the foundations of rapid progress in each of these cases.

Fourth, dealing with social inequality has also been an important part of these shared experiences. In each case, the historical burden of social inequality has been significantly reduced in one way or another. In Kerala and Tamil Nadu, principles of equal citizenship and universal entitlements were forged through sustained social reform movements as well as fierce struggles for equality on the part of underprivileged groups – especially Dalits, who used to receive abominable treatment and have to continue their battle to reverse the old handicaps altogether. Himachal Pradesh benefited from a more favourable social environment, including relatively egalitarian social norms and a strong tradition of cooperative action. While substantial inequalities of class, caste and gender remain in each case, the underprivileged have at least secured an active – and expanding – role in public life and democratic institutions.

Fifth, these experiences of rapid social progress are not just a reflection of constructive state policies but also of people’s active involvement in democratic politics. The social movements that fought traditional inequalities (particularly caste inequalities) are part of this larger pattern. These social advances, the spread of education, and the operation of democratic institutions (with all their imperfections) enabled people – men and women – to have a say in public policy and social arrangements, in a way that has yet to happen in many other states.

Last but not least, there is no evidence that the cultivation of human capability has been at the cost of conventional economic success, such as fast economic growth. On the contrary, these states have all achieved fast rates of expansion, as indeed one would expect, both on grounds of causal economic relations and on the basis of international experience (including the ‘east Asian’ success story). While many of their big social initiatives and achievements go back to earlier times, when these states were not particularly well-off, today Kerala, Himachal Pradesh and (to a lesser extent) Tamil Nadu have some of the highest per capita incomes and lowest poverty rates among all Indian states. Economic growth, in turn, has enabled these states to sustain and consolidate active social policies. This is an important example of the complementarity between economic growth and public support, discussed earlier.

On Tamil Nadu’s Health Services

Unlike most other Indian states, Tamil Nadu has a clear commitment to free and universal health care – not extending to every aspect of health care by any means, but covering a wide range of facilities and services. As discussed in our previous book, this commitment is evident in relatively good health services, and also translates into better health achievements than most other states. 31 Recent studies suggest not only that Tamil Nadu has made further rapid progress in this field during the last ten years or so, but also that these achievements fit into a larger pattern of comparatively active, creative and inclusive social policies. In our earlier work, Tamil Nadu’s lead in terms of health outcomes was brought out by comparing them with those of other states (e.g. the ‘large north Indian states’) that had similar levels of per capita income or per capita expenditure at that time. Tamil Nadu is now significantly better-off, economically, than most of those states, because of its relatively high rate of economic growth in recent years. In terms of per capita expenditure, it is now in the same league as states like Gujarat, though still significantly poorer than, say, Haryana. As Table 6.7 illustrates, however, Tamil Nadu’s health-related indicators are enormously better than those of both Gujarat and Haryana (for instance, its infant mortality rate and maternal mortality ratio are about half as high as the corresponding figures for those states). In fact, Gujarat and Haryana’s health indicators are not very different from the all-India averages in most cases, while Tamil Nadu is much closer to Kerala in this respect – and getting closer year after year.

Tamil Nadu has also been able to concentrate on many of the health ‘basics’ that have been so neglected in much of India, as discussed in Chapter 3 (and also in this chapter). For instance, there has been a sustained focus on ‘public health’, in the technical sense of public activities that are aimed at preventing illness rather than curing it. Among other results of this focus on the basics are high child immunisation rates – the highest among all major Indian states, with more than 80 per cent of children fully immunised in 2005–6. Similarly, to ensure timely supply of free medicines in government-run health centres, the state has set up a pharmaceutical corporation and developed a sophisticated supply chain with computerised records. This, again, is in sharp contrast with the situation prevailing in many other states, where patients in government health centres are typically given a prescription and told to buy their own drugs in the market – often from a nearby chemist (the charge that these chemists share their profits with the prescribing doctors is unfortunately quite common). In Tamil Nadu’s health centres, the provision of free medicines is compulsory and doctors are not allowed to send patients away with a paper prescription.

The creative activism of Tamil Nadu’s welfare delivery

Tamil Nadu was the first state to introduce free and universal midday meals in primary schools. This initiative, much derided at that time as a ‘populist’ programme, later became a model for India’s national midday meal scheme. Today, school children in Tamil Nadu (more precisely, those enrolled in government schools) get not only free midday meals but also free uniforms, textbooks, stationery and health check-ups. Creativity and initiative have also been observed, more recently, in other major social programmes, such as the Public Distribution System (PDS) and the National Rural Employment Guarantee Act (both programmes are discussed in more detail in the next chapter).

Tamil Nadu’s PDS, like its midday meal scheme and anganwadis, has become a model for the country, with regular distribution, relatively little corruption, and a major impact on rural poverty. The standards of implementation of the National Rural Employment Guarantee Act in Tamil Nadu are also among the best in the country. Tamil Nadu’s capacity for innovation and creative thinking in matters of public administration is an important example for the entire country. Some of the initiatives that have been taken there to improve the functioning of anganwadis, or to plug leakages in the Public Distribution System, or to ensure timely supply of drugs in health centres, are truly impressive. It is not an accident that Tamil Nadu has been ranked first among India’s major states in terms of the overall quality of public services. Another noteworthy feature of Tamil Nadu’s experience, already mentioned in Chapter 3, is the commitment to comprehensive and universalistic social policies. The most striking example is Tamil Nadu’s PDS: every household is entitled to a minimum quota (currently 20 kgs) of subsidized rice every month, aside from other essential commodities. When an attempt was made to ‘target’ the PDS in 1997, in pursuance of national policy, targeting had to be rolled back within a week ‘following a spate of protests’. The principle of universalism in Tamil Nadu also applies to public health, midday meals (and other school incentives), childcare, employment guarantee, public transport, and also basic infrastructure such as water and electricity.As a result, the incidence of deprivation of some of the basic necessities of life is remarkably low in Tamil Nadu, as Table 6.9 elucidates. .

The question arises as to how and when Tamil Nadu developed this commitment to universal and well-functioning public services. Various interpretations have been proposed, focusing for instance on early social reforms (including the ‘self-respect movement’ founded by Periyar in the 1920s), the political empowerment of disadvantaged castes, the hold of populist politics, and the constructive agency of women in Tamil society. These and other aspects of the social history of Tamil Nadu, and their relevance to the state’s contemporary achievements, remain a lively subject of research. What is interesting is that these different interpretations point, in one way or another, to the power of democratic action.

This includes the power of public reasoning and social action in elevating the visibility of health issues and opening new horizons. Visionary figures such as Dr K. S. Sanjivi, a pioneering proponent of social health insurance in Tamil Nadu, argued for public support for health care a long time before this became a more discussed issue in the country.* Tamil Nadu has had a major role, in general, in initiating public discussion of social issues. Health-related programmes, such as the provision of midday meals in schools, became subjects of lively public discussion quite early and were often implemented first in Tamil Nadu. These issues have continued to play an important role in election campaigns in the state, much in contrast with the rest of the country, particularly north India, where health (or other basic needs such as elementary education or child nutrition) does not seem to figure much on the political agenda.