The people of Thally must pray for good health with extra fervour.

Not because this block along Tamil Nadu’s north-western flank is uniquely disease-prone. But because medical care is implausibly hard to find here.

Going by the state government’s blueprint, this forested, hilly part of Tamil Nadu’s Krishnagiri district should be thickly dotted with health workers.

For every 500 people, there should be a government-run anganwadi providing children with a nutritious meal each day, and for every 1,000 people, an ASHA or community health worker acting as link to the state government’s health centres. A qualified nurse must be available at the health sub-centre, serving 5,000 people. A primary health centre, staffed with doctors and nurses, should cover 35,000-50,000 people. In addition, there should be well-functioning hospitals at the block and district levels.

Travel around and you see something very different.

Several villages do not have ASHA workers. A nurse said 20 of the 36 health sub-centres in the block have nursing vacancies. At least two of the five public health centres do not have a single functioning health sub-centre. Even the primary health centres are not working as projected.

In Urigam, one of the larger villages in the block, this reporter found the public health centre closed in the afternoon, even though it is supposed to be open between 9 am and 4 pm. Villagers said the doctor sits at the clinic only between 9 am and 2 pm.

The shuttered public health centre in Urigam.

A month later, on another visit, the centre was open but only a nurse and a compounder were in attendance. There was no doctor, even though smaller public health centres like this one are supposed to have two doctors and three staff nurses.

With medical care not available locally, the people of Thally have no choice but to travel to the taluka hospital at Denkanikottai. The hospital serves a population of 1.64 lakh people and gets about 200-300 patients every day. But it is understaffed, with just one doctor of medicine, three pediatricians, a gynaecologist, an orthopaedician, two ENT specialists, a dermatologist, but no anesthetist. “We contract one for surgeries but he comes in only on Saturdays,” said a pediatrician at the hospital. This means the hospital cannot tackle emergencies.

The hospital’s medical staff, said the pediatrician, reaches at 9 am and leaves at 1 pm. In the afternoon, there is only one doctor on duty. “Most of our patients come in the morning. But about 50-80 patients come after 1 pm. The doctor on duty sees them between 3 pm and 5 pm.” Which works out to 25-40 patients per hour.

What Krishnagiri tells us

This understaffing is useful for understanding a recent, baffling trend in Tamil Nadu’s health statistics.

In India’s development circles, Tamil Nadu is viewed as one of the best performing states in the delivery of public welfare like education and healthcare.

But, as the first part of this story reported, the state is improving on some public health indices (institutional deliveries), plateauing in others (infant and maternal mortality), and slipping backwards elsewhere (vaccinations, awareness about HIV/AIDS).

Why is it yielding such contradictory outcomes? Part of the answer lies in the weakening of its public health system.

Making sense of understaffing

From his modest office in Denkanikottai, a small town in Krishnagiri, S Josephstalin has watched the district become a revolving door for health workers.

In recent years, said the programme officer of Rural Development Council, a local NGO which works on healthcare, a growing number of health workers are getting themselves transferred closer home, away from relatively remote and backward locations like Thally. “New VHNs (village health nurses) are appointed to Urigam,” said Josephstalin. “Within three days, they pay a bribe and get a transfer.”

A senior official in the Tamil Nadu administration, who used to work in the state health department, concurred. Doctors and nurses rarely stayed at their posts and officials who tried to ensure attendance were shunted out, he said.

He attributed this to a rise in the power of employee unions of doctors, VHNs and others. The employee unions control transfers, and even trade in them. They are mostly made up of people from dominant communities, said Josephstalin, and political parties need their support during elections.

Their rise has fed into another, older shift in the state’s health department.

Tamil Nadu’s health department has three directorates – medical education, public health and health services. The directors running these institutions are doctors drawn from the state cadre who report to the health secretary.

Over the years, said a United Nations consultant who works closely with the state government, these directors have become more powerful than the state health secretary. They have a greater familiarity with politicians as they have risen through the ranks at the same time. They also know district and block level functionaries well. “In the 1980s, the system worked well. Karunanidhi and others trusted the IAS. Since then, the IAS gets lip-service. And the politicians trust the people they grew up with,” said the consultant.

The former health official explained: “In the past, when the unions put pressure on the health minister – sometimes seeking an intervention in individual cases, or when the mandarins cracked down – we could tell the ministers what was non-negotiable. That is not the case right now.”

The rise of this triad – unions, directors and politicians – appears to have resulted in the junior bureaucracy becoming less answerable to the senior bureaucracy.

A concentration of power

Even as staff were vying for transfers closer home, the state government itself was pulling health staff out of the field.

Over the last decade, Tamil Nadu has concentrated healthcare services at the public health centres. Fieldworkers have been redeployed as helpers at the centres. Several tasks have been taken away from village health nurses and handed over to the centres. After three children died in 2008-‘09 from measles contracted at the time of immunisation, the state decided to move the service to the public health centres. That decision alone, said the official, “almost dismantled the system”. The village health nurses began to make fewer visits to the villages, and the immunisation numbers fell.

A similar process took place with institutional deliveries. Earlier, women fell back on health sub-centres where nurses were trained in mid-wifery. Subsequently, the government decided to encourage child birth in public health centres, contending they were better equipped. In this, the government “missed the simple fact that the woman may go into labour at any time of night,” said PV Srividya, a journalist in Krishnagiri. It would have made more sense to improve infrastructure in the health sub-centres.

A shuttered health sub-centre in Krishnagiri.

Why is this happening? According to T Sundararaman, the former head of the National State Health Resource Centre, an advisory arm to the National Rural Health Mission, this is because Tamil Nadu’s healthcare system is run by medical professionals. In most other states, the health department is run by IAS officials.

The result? The state was very proud of the professional healthcare system it created. But the flip side to this attitude, he said, is that “it also pushed out other skills, especially at the lower end of the spectrum like ASHAs [community health workers].”

A misplaced focus

At the same time, the state’s health department has narrowed the services it provides.

Till 2005, Tamil Nadu’s primary health centres worked as all-purpose clinics, treating a cross-section of ailments. But the state’s public health system, said Sundararaman, now focuses mostly on reproductive and child health.

It is unclear what led to the singular attention on reproductive and child health. Sundararaman said it was the result of the World Bank advising the state that the “government cannot focus on everything”.

According to Rakhal Gaitonde, a Chennai-based healthcare researcher, the state government wanted to bring down infant and maternal mortality ratios in order to claim larger improvements in the socio-economic characteristics of poor households. Both the ratios are seen as good barometers of community health and nutritional well-being.

What is more incontrovertible is this: this focus on reproductive and child health has dramatically reshaped the lower reaches of Tamil Nadu’s health architecture.

This becomes evident in the allocation of duties. In rural Tamil Nadu, healthcare is delivered through a three tiered structure.

  • Accredited Social Health Activist: A village woman trained in basic healthcare who escorts pregnant women to the primary health centre, reports births and deaths, provides nutritional supplements to children and sanitary pads to adolescent girls.
  • Village Health Nurse: A qualified nurse stationed at the health sub-centre who maintains a registry of pregnancies, handles immunisation and tracks adolescent girls’ development till 19. 
  • Primary Health Centre: Three doctors, nurses and a compounder provide first aid, conduct family planning surgeries, maintain local health records like Mother and Child Protection cards. 

Between them, these three trends – understaffing due to weakening discipline, consolidating staff and services at the public health centres, and a focus on reproductive and child health – have created something very suboptimal.

Take the village nurse at Thally. Vacancies do not get filled up fast, she said. “If someone is transferred and goes away within one year, the gap before another person gets appointed can run up to an year. Nobody comes willingly and if when they do, they do not stay very long.”

Given the understaffing, the government has put her in charge of two health sub-centres. At one time, she said, she was looking after as many as ten. As the chart above shows, she has several responsibilities. But there is particular pressure on her to focus on reproductive and child health.

As the previous story reported, the state relied on institutional deliveries to bring down infant and maternal mortality rates. To boost institutional deliveries, Tamil Nadu runs schemes like Muthulakshmi Reddy Maternity Benefit Scheme which pays Rs 12,000 to poor women who give birth in a clinic. The ASHA and village nurse involved in the delivery get financial incentives as well. In addition, the state has an health management software called PICME (Pregnancy Infant Cohort Monitoring and Evaluation) which collates realtime information about pregnant mothers and newborns across the state.

The village nurse spends a lot of time updating the PICME database. “If there is no light, we have to go to Denkanikottai 25 km away for the data entry,” she said.

Said Sundaraman, “The focus on RCH [reproductive and child health] is so strong that a large part of the population now considers the PHCs as maternity centres.” Patients with other ailments have to go elsewhere, he said. “Just 10% of the morbidity is seen by the [village level] government setup. All others are turned away.”

Agreed the former health official. “Are other parts of healthcare getting equal attention? Are cataract surgeries working? What about other eye diseases? Other ailments?”

Given the workload, trickier cases get referred up. The village nurse refers them to the public health centre which sends them to the taluka hospital which, burdened under its own understaffing, tells people to go elsewhere.

Said Josephstalin, “If a pregnant woman comes to the PHC with high anaemia and low blood level, they say go to Krishnagiri. The proper way of doing this is to get an ambulance and have a staff nurse accompany the patient to the general hospital. But all that gets told here is: go elsewhere.” In several cases, he said, the patient went back and gave birth at home, followed by the death of the child.

The question of data

The focus on reproductive and child health has also created a misleading image of health problems in the state.

The healthcare in Krishnagiri might be in free fall, but in Chennai, a senior official in the state health mission claimed great success in bringing the district at par with others. The department runs three mobile clinics that travel to dispersed hamlets. The death of every mother and child is audited. “So we know if the doctor is working or not,” he said, adding that the department had thrown “the kitchen sink at the problem”.

As a result, he said, the infant and maternal mortality ratios in the district were close to the state average.

While he is right about the health data showing no difference between Krishnagiri and other districts, the reasons for this are possibly not what he claimed.

Health researchers and activists point out that the state has incomplete data on the general health of its population. Said Gaitonde, “Most of the focus is on immunisation, deliveries and antenatal care. On diseases like Chikangunya and Dengue, there is a complete breakdown of surveillance.”

Even in infant and maternal mortality ratios, the state’s data is incomplete, even though officials claim it is close to perfect. In the Adivasi basti at Mallhalli, for instance, several women do not have the Mother Child Protection cards that are meant to be filled out at the time a woman is registered as pregnant.

Said the former health official: “We are not good at capturing deaths during early pregnancies due to complications, women who are not in the Mother Child Protection cards due to carelessness or the data collection being weak. Some of these deaths are migrants without ration cards, gypsy mothers, unmarried women who were trying to keep the pregnancy a secret, botched abortions. Some are women in their 40s who are pregnant again, which is seen as a stigma. Your daughter is 15 and you are still having babies. Such women do not dare to go to the VHN.”

Infant mortality data is even harder to capture. Some private hospitals in the state, said another official in the state health department, report infant mortalities as stillborns in order to escape government scrutiny. “The norm is that stillborns are half of IMR. But our numbers say that stillborns are equal to IMR.”

The fallout of this is a misleading health information system. A part of the morbidity does not get captured given the focus on reproductive and child health. Within this narrow field, there is a concern that the most vulnerable are slipping out. Agreed the former health official, “Only those who enter the database are visible.”

The state government is trying to fix this by merging its health database with census records. But for this to happen, said the official, there needs to be more than one village nurse in a sub-centre. One to run health services, the other to collect data.

There is a focus on infant and maternal mortality numbers, but not on the nutrition of families.

What complicates matters is that unlike other states where the health department works with a network of non-profits, in Tamil Nadu, it works mostly in isolation. Rival datasets are not created.

While carrying out surveys as part of a project aimed at making people aware of their rights, Gaitonde’s organisation found 40% of the people in the state were not getting health services. The state government stopped the project’s funding, which suggests vindictiveness on its part. emailed questions to Dr J Radhakrishnan, principal secretary to the state government for health, and sent him text messages about the queries. He was asked about the recent trends and changes in the state’s healthcare delivery. He did not respond. This article will be updated when he does.

What it all means

Put the two parts of this story together and you see why institutional deliveries are rising, why infant and maternal mortality ratios are plateauing and why the state is slipping backwards on other fronts like immunisation.

It also becomes evident that even as the healthcare problems of Tamil Nadu become more complex, the state’s ability to address them is eroding.

This is a complex problem that cannot be solved by the health department alone. Both the public distribution system and anganwaadis need to work better at bolstering the nutrition levels of people. Even that is not enough. The state needs to start fighting caste, gender and poverty.

Instead, the state government is focusing on a handful of metrics – like infant and maternal mortality ratios – to prove its healthcare delivery is improving. It is also increasingly turning towards what the former health official calls “decorative programmes”, or schemes that generate good optics, like Amma Canteens that serves subsidised meals and Amma Baby Care Kits that contain a blanket and a dress. “System correction work has taken a backseat to decorative programmes,” said the former official.

Put it all together and you get a better sense of why Soumya Ramakrishnan, a young woman profiled in the first part of this series, lost her baby. She was anaemic, the public health centre near her village did not function well, and her sickly infant was referred to successive hospitals that failed to save it.

Read the first article in this two-part series here.