Ear to the ground

With falling standards in healthcare, education and employment, Tamil Nadu is losing its sheen

And it does not help that the government's response to these crises is largely cosmetic.

How is Tamil Nadu doing?

Ask a layperson this question and, chances are, they will have good things to say. It does have a reputation for being one of the country’s better governed states. A welfarist state where, in marked contrast to large swathes of India, the government provides good healthcare and education to its people.

Between February and August, Scroll.in’s #EarToTheGround project reported from the state. And it found that this perception is no longer true. In both education and healthcare, Tamil Nadu has fallen behind.

Take the case of education. The number of students passing the state boards has risen – in the case of the Class 10 exam, from 85% in 2010 to 95% now. But the quality of school education is facing a serious challenge with the National Council of Educational Research and Training’s National Achievement Surveys flagging a precipitous drop in learning outcomes in the state, as reported by Scroll.in last month.

In the healthcare sector, while Tamil Nadu continues to score high on metrics such as institutional delivery – childbirth in well-equipped health centres – its infant mortality rate and maternal mortality ratio have plateaued. And it has slipped on immunisation coverage. Trying to understand why it does well on some metrics while faltering on others, we reached an important conclusion.

As we reported, Tamil Nadu’s impressive achievements in terms of infant mortality rate and maternal mortality ratio were the result of a push for institutional deliveries. But with institutional deliveries now accounting for 98.9% of all births in the state, the scope for further improvement is limited. Currently, this lack of improvement can be put down to fundamental factors such as poverty, gender and caste discrimination. In other words, the health department has plucked its low-hanging fruits. And the residual problem is more complex.

At the same time, as the second part of our story on healthcare in Tamil Nadu reported, there has been an erosion in the state government’s capacity to address these problems. A combination of factors – understaffing and a reorientation towards reproductive and child health, among others – has blunted what was a well-oiled machine till 10 years ago.

And instead of coming up with sophisticated solutions to these increasingly complex problems, the government has resorted to desperate administrative measures. We found, for instance, data fudging in the case of education and a practice of cherry-picking indices in health.

Multi-layered problems

The problems facing Tamil Nadu are not just limited to education and healthcare. Fisheries and farms, the two biggest providers of traditional livelihoods in the state, have been hit by sliding incomes. Manufacturing clusters, too, are struggling to stay competitive, making employment in these units increasingly insecure.

These are difficult problems to solve. In the case of fishing, the fall in catch is not only because of overfishing or pollution but also a result of climate change. Rising sea temperatures are making fish move further north or into deeper, cooler waters. In farming, changes in rainfall pattern have made the profession even more precarious.

In industry, the need to stay globally competitive has created pressure to keep wages low, leading to a situation where manpower supply companies are tapping cheaper migrant labour. And industries that were once the mainstay of their state’s economy are slowly losing their edge. An example of this in Tamil Nadu is the garment exporting cluster in Tiruppur city, which is struggling to stay competitive amid a fall in cotton production. This, in turn, is because of the change in the economics of agriculture.

On the other hand, the response of successive state governments to these complex problems has been weak. Partly because some of these problems cannot be fixed by the state alone. In the case of climate change, all Tamil Nadu can do is adapt and mitigate. But, as last year’s flood disaster showed, there isn’t much sign of this as well.

Government inaction

But there are problems that can be solved by the state government, and yet have been left to fester.

The rampant over-extraction of groundwater in Tamil Nadu’s Noyyal basin in a case in point. According to residents, the blocking of the river’s tributaries and the mushrooming of mineral water units in its vicinity have sent groundwater levels crashing. The state’s response to this was to revoke its Groundwater Management Act, which spelled out the rules for extraction and guarded against exploitation, in 2013, saying that its implementation would result in unrest.

There there is sand mining, which continues to damage Tamil Nadu’s rivers. But, as Scroll.in found out, the state’s two top parties, the Dravida Munnetra Kazhagam and the All India Anna Dravida Munnetra Kazhagam, gain from the activity. Sand mining is said to contribute to their poll expenditure. As a result, the state’s environmental foundations are being chipped away.

Decorative solutions

In the last six years, instead of resolving, or mitigating, the various crises surrounding the state’s welfare delivery, environment and economy, the government has responded in other ways.

In healthcare, as a senior bureaucrat in the state administration told this reporter, it has chosen to focus on decorative programmes, such as giving away Amma Baby Kits for newborns. In part, because they make for good political communication. And also because the administrative system can deliver on these programmes, as opposed to, say, ensuring health centres are properly staffed.

In the process, the nature of welfarism in the state has changed into something more cosmetic, which meshes into the leadership cult that pervades politics here.

At the same time, as anger over underdevelopment and corruption grows, the state has cracked down on dissent. This is what happened in the case of the folk singer Kovan, who was arrested last year on sedition charges for songs attacking the state’s liquor policy.

According to cultural historian Sadanand Menon, the Tamil Nadu of today is vastly different from how it was in the 1970s. “There was much more dissent, debate and contestation,” he said. “What you see now is a severe crackdown. Tamil Nadu is a permitted democracy.”

In this period, the state has seen democratic checks and balances weaken – for instance, the failure of courts, the media, political parties and communities to rein in sand mining.

In that sense, like Punjab and Odisha, Tamil Nadu has drifted far from the ideals of how a democratic state should function. Among the social fallouts of such governance is reverse migration from the industrial clusters towards the Cauvery delta, a steep rise in caste tensions in the last four years. Another factor the state’s people point to is the lack of economic growth, which has resulted in a spike in household borrowings to meet living expenses.

Now to see how the state’s new chief minister, O Panneerselvam, tackles these problems.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Putting the patient first - insights for hospitals to meet customer service expectations

These emerging solutions are a fine balance between technology and the human touch.

As customers become more vocal and assertive of their needs, their expectations are changing across industries. Consequently, customer service has gone from being a hygiene factor to actively influencing the customer’s choice of product or service. This trend is also being seen in the healthcare segment. Today good healthcare service is no longer defined by just qualified doctors and the quality of medical treatment offered. The overall ambience, convenience, hospitality and the warmth and friendliness of staff is becoming a crucial way for hospitals to differentiate themselves.

A study by the Deloitte Centre for Health Solutions in fact indicates that good patient experience is also excellent from a profitability point of view. The study, conducted in the US, analyzed the impact of hospital ratings by patients on overall margins and return on assets. It revealed that hospitals with high patient-reported experience scores have higher profitability. For instance, hospitals with ‘excellent’ consumer assessment scores between 2008 and 2014 had a net margin of 4.7 percent, on average, as compared to just 1.8 percent for hospitals with ‘low’ scores.

This clearly indicates that good customer service in hospitals boosts loyalty and goodwill as well as financial performance. Many healthcare service providers are thus putting their efforts behind: understanding constantly evolving customer expectations, solving long-standing problems in hospital management (such as long check-out times) and proactively offering a better experience by leveraging technology and human interface.

The evolving patient

Healthcare service customers, who comprise both the patient and his or her family and friends, are more exposed today to high standards of service across industries. As a result, hospitals are putting patient care right on top of their priorities. An example of this in action can be seen in the Sir Ganga Ram Hospital. In July 2015, the hospital launched a ‘Smart OPD’ system — an integrated mobile health system under which the entire medical ecosystem of the hospital was brought together on a digital app. Patients could use the app to book/reschedule doctor’s appointments and doctors could use it to access a patient’s medical history, write prescriptions and schedule appointments. To further aid the process, IT assistants were provided to help those uncomfortable with technology.

The need for such initiatives and the evolving nature of patient care were among the central themes of the recently concluded Abbott Hospital Leadership Summit. The speakers included pundits from marketing and customer relations along with leaders in the healthcare space.

Among them was the illustrious speaker Larry Hochman, a globally recognised name in customer service. According to Mr. Hochman, who has worked with British Airways and Air Miles, patients are rapidly evolving from passive recipients of treatment to active consumers who are evaluating their overall experience with a hospital on social media and creating a ‘word-of-mouth’ economy. He talks about this in the video below.


As the video says, with social media and other public platforms being available today to share experiences, hospitals need to ensure that every customer walks away with a good experience.

The promise gap

In his address, Mr. Hochman also spoke at length about the ‘promise gap’ — the difference between what a company promises to deliver and what it actually delivers. In the video given below, he explains the concept in detail. As the gap grows wider, the potential for customer dissatisfaction increases.


So how do hospitals differentiate themselves with this evolved set of customers? How do they ensure that the promise gap remains small? “You can create a unique value only through relationships, because that is something that is not manufactured. It is about people, it’s a human thing,” says Mr. Hochman in the video below.


As Mr. Hochman and others in the discussion panel point out, the key to delivering a good customer experience is to instil a culture of empathy and hospitality across the organisation. Whether it is small things like smiling at patients, educating them at every step about their illness or listening to them to understand their fears, every action needs to be geared towards making the customer feel that they made the correct decision by getting treated at that hospital. This is also why, Dr. Nandkumar Jairam, Chairman and Group Medical Director, Columbia Asia, talked about the need for hospitals to train and hire people with soft skills and qualities such as empathy and the ability to listen.

Striking the balance

Bridging the promise gap also involves a balance between technology and the human touch. Dr. Robert Pearl, Executive Director and CEO of The Permanente Medical Group, who also spoke at the event, wrote about the example of Dr. Devi Shetty’s Narayana Health Hospitals. He writes that their team of surgeons typically performs about 900 procedures a month which is equivalent to what most U.S. university hospitals do in a year. The hospitals employ cutting edge technology and other simple innovations to improve efficiency and patient care.

The insights gained from Narayana’s model show that while technology increases efficiency of processes, what really makes a difference to customers are the human touch-points. As Mr. Hochman says, “Human touch points matter more because there are less and less of them today and are therefore crucial to the whole customer experience.”


By putting customers at the core of their thinking, many hospitals have been able to apply innovative solutions to solve age old problems. For example, Max Healthcare, introduced paramedics on motorcycles to circumvent heavy traffic and respond faster to critical emergencies. While ambulances reach 30 minutes after a call, the motorcycles reach in just 17 minutes. In the first three months, two lives were saved because of this customer-centric innovation.

Hospitals are also looking at data and consumer research to identify consumer pain points. Rajit Mehta, the MD and CEO of Max Healthcare Institute, who was a panelist at the summit, spoke of the importance of data to understand patient needs. His organisation used consumer research to identify three critical areas that needed work - discharge and admission processes for IPD patients and wait-time for OPD patients. To improve wait-time, they incentivised people to book appointments online. They also installed digital kiosks where customers could punch in their details to get an appointment quickly.

These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.