In 1985, the Rockefeller Foundation published a report titled Good Health at Low Cost to discuss why some countries or regions achieve better health and social outcomes than others at a similar level of income and to show the role of political will and socially progressive policies. Twenty-five years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and Tamil Nadu in India, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours.
A series of comparative case studies (2009–11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations.
Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part.
These experiences showed that improvement in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations. A Lancet report on ‘Good Health at low cost: Lessons for the future of health systems strengthening’, in which two professors from Indian Institute of Technology, Madras — Prof Muraleedharan and Prof Umakanth Dash — have also contributed, says that the Rockefeller Foundation had considered experiences of four countries or regions seen as success stories: China, Costa Rica, Sri Lanka, and Kerala in India. All had achieved substantially better health outcomes than other nations at similar levels of development.
Twenty-five years later, the threats to health and the scope to respond are much more complex. Do the lessons of 25 years ago still apply? The Lancet paper sought to study this. In 2011, the authors revisited the original countries and regions and looked at the five different places to reflect on lessons they offer.
The results showed that strategic investment in health systems remains key to accelerate and sustain the achievements in health and access to essential services. Continued health system development will allow countries to move beyond picking the low-hanging fruit that make up the common causes of childhood death, onto tackling chronic diseases that are accelerated by growing urbanisation and changing lifestyles.
The report highlights the importance of individuals in creating ideas and generating political momentum. But community matters too, as the relation between education and fertility transition in Tamil Nadu shows. In all countries and regions, good governance and leadership were important for determining whether the health systems operated effectively.
Tamil Nadu is the seventh most populous State in India. Despite spending only about one per cent of its GDP on health, it has made great progress in improving population health. Between 1980 and 2005, infant mortality fell in Tamil Nadu by 60 per cent, compared to 45 per cent nationally, with the greatest gains in rural areas. In 2006, Tamil Nadu had the third lowest rate of under-five mortality in India, at 35.5 deaths per 1,000 live births, compared to 74.3 deaths per 1,000 live births for India as a whole.
However, the greatest achievement in Tamil Nadu has been reduction of maternal mortality, from 319 deaths per 1,00,000 live births in the early 1980s to 111 deaths per 1,00,000 live births in 2004–06, the second lowest of any State. This decline was much faster than in India overall. By 2006, fertility was below the replacement rate.
A characteristic of Tamil Nadu’s success is the high healthcare coverage: 90 per cent of deliveries are attended by a skilled birth attendant, almost 25 per cent of deliveries take place in primary health-care facilities, and 81 per cent of infants are fully immunised.
It was one of the first States to implement in large scale a multipurpose worker scheme in 1980. Women with at least 10 years of schooling were trained for 18 months to become village health nurses. Existing maternity assistants were retrained and new training facilities were built. Second, an initiative was proposed by the Centre to build a network of primary healthcare centres; Tamil Nadu was one of the first states to build a vast network of these facilities.
Third, immunisation schedules were scaled up rapidly. By the early 1990s, Tamil Nadu had achieved the highest immunisation coverage in India, with the narrowest gap between the richest and poorest quintiles and between rural and urban areas.
Finally, a reliable supply of essential drugs was established with the setting up of the autonomous Tamil Nadu Medical Services Corporation in 1995 to purchase and distribute pharmaceuticals to public health facilities. The new system, providing about 250 generic essential drugs, is credited with substantial improvements in drug supply and transparency. It has also contributed somewhat to driving down the cost of drugs supplied in the private sector.