Tamil Nadu has performed extremely well in most health indicators because creative technical intervention in the state has been coupled with social mobilization. The National Eligibility cum Entrance Test (NEET) has the potential to reverse all past achievements—the innovative reservation policies and the incentive structure which ensured a seamless flow of health personnel in rural areas.
The NEET is ostensibly meant to curb corruption in admission to medical colleges in India. The Medical Council of India (MCI) has been attempting to standardise this entrance criterion across the country. However, the exam has come under severe criticism for being detrimental for education and social justice as a whole (Kumar 2017). Tamil Nadu (TN) has especially a lot to lose with NEET, for it attacks the very foundation upon which the efficient public health system—with innovative reservation policies and incentive structure—was built in the state.
As per the Constitution, health is a state subject. State leadership can make or break health systems. The public health act in place in TN is one which lays out and specifies all legal and administrative structures for the public health system, providing a framework of well-defined responsibilities to different government agencies within the structure, with corresponding budget allocations. Moreover, all this is implemented rigorously. The NEET contradicts the spirit of this act.
The success story of the public health administration in TN is usually attributed to the coordination among the public health managers and the technical staff. However,apart from this, there are other significant factors at play. Santosh Mehrotra (2006) argues that the real explanation for TN’s performance has to be located in the social movements that it has witnessed in the last century. As a result, the state has mobilised health personnel across caste groups to operate the vast network of primary health centres (PHCs), community health centres (CHCs) and district health centres (DHCs). The state is thus able to achieve better health outcomes with less per capita health expenditure as compared to other states in India. As Jean Dreze and Amartya Sen write (2011),
Less well known, but no less significant, is the gradual emergence and consolidation of universalistic social policies in Tamil Nadu… Tamil Nadu, unlike most other states, also has an extensive network of lively and effective healthcare centres, where people from all social backgrounds can get reasonably good healthcare, free of cost. (Dreze and Sen 2011)
In one fell swoop, the NEET has the potential to reverse these painstaking achievements of the state which took decades.
TN has performed extremely well in most health indicators because creative technical intervention was coupled with social mobilisation. The evidence from the latest SRS statistical report (2015) suggests that the infant mortality rate (IMR) is the lowest in the country, second only to Kerala, standing at 19 deaths per 1,000 live births (Figure 1).
The corresponding all-India figure is 37 deaths per 1,000 live births. Similarly, TN’s maternal mortality rate (MMR) annually per-100,000 live births due to any cause related to or aggravated by pregnancy is also the lowest, and nearly half of the all-India average (Figure 2).
The state has one of the best reproductive health and childcare systems in the country. The percentage of pregnant women who deliver their babies at a health facility is 99% in Tamil Nadu, the highest in the country. These outcomes are socially inclusive; perhaps the most inclusive across India.
Through its innovative incentive structures and reservation policies, TN has ensured a vibrant cadre of medical personnel represented from across caste groups, and from small towns who are willing to work in primary health centres in villages (Mehrotra 2006; Sinha 2013). As a result, in many health indicators, deprived caste groups in TN have performed better than upper caste groups in the North.
For instance, as per the National Family Health Survey–3 (2005-06) survey available on caste-wise health indicators, the IMR for the Scheduled Castes (SCs) in TN is 37 deaths per 1,000 live births, while it is 66 for India as a whole. If one compares this with Uttar Pradesh, the IMR among the SCs is 90.7. The IMR among the upper castes (non-SC/OBC) in Tamil Nadu is 38.2 while it is 71 in UP. Thus the IMR for the SCs in Tamil Nadu is lower than even the upper castes in UP, who have an IMR of 71.
Even in the case of indicators such as child immunisation and mother’s antenatal care, deprived caste groups in TN have performed better than the upper castes in UP. The coverage of child immunisation in TN is 81% as compared to UP’s paltry 23%. Similarly, about 88% of pregnant women in TN deliver their babies at health facilities while only 21% of women use such facilities in UP. Generally, women from the SCs in TN have better healthcare facilities (80%) than women from the SCs (15%) and upper castes (21%) in UP.
Another indicator of the health of women and children is the proportion of births that are assisted by a health professional (that is, a doctor, nurse, or midwife). The delivery assistance provided to pregnant women by such health personnel is about 91% in TN while it is just 27% in UP. And such assistance for SC women in TN is 82% while it is just 40% even for upper caste women in and much lower (20%) for SC women in UP. In all such indicators, TN has been doing extremely well across caste groups. All of this is a result of creative incentive structures and social justice policies of the state which have ensured relative equitable developmental outcomes in TN.
Why it Works in Tamil Nadu
TN’s success in public health mainly lies in the efficiency gains rather than the quantum of expenditure by the state. It is true that the state has been consistently spending on health for a long time, and the average per capita health expenditure in Tamil Nadu is indeed higher than that of India as a whole. For instance, the recent Tamil Nadu Health Account reports it as Rs 1,254 during 2013-14 while the corresponding expenditure in India was Rs 1,042. However, as Sen and Dreze (2013) have argued, while other states such as Haryana spend more money on health, TN outperforms the former in health outcomes. The logic lies in translating health services into health outcomes. Both, utilisation pattern and better access to government health services play a significant role in deciding outcomes.
In the case of rural TN, an additional explanation for this is the reservation policy in professional education in operation, which made the flow of doctors possible from across caste groups—a key for ensuring socially inclusive access to health services. Simultaneously, the state has built health infrastructure and crafted policies which prioritise planning for the provision of primary and tertiary healthcare to all. As Sarah Hodges (2013: 245) says,
The government of Tamil Nadu was the first to constitute a state planning commission with a task force on health … presided over by Malcolm Adiseshiah… [It] divided itself into working parties to consider in depth the problems of health services, medical education, family planning, nutrition, sanitation, the role of voluntary organisations and indigenous medicines, including homeopathy.
Further, the state has built 22 government medical colleges, which form 11.9% of the total medical colleges in the country, the most by any state, followed by Maharashtra at 10.8%. Even in intake of total government medical seats in India, TN has the highest share in the country (11.1%) (Choudhury 2016).
NEET against Public Health
TN has also built an innovative incentive structure to retain doctors in the rural health system. One crucial result of this is the diverse social composition of medical officers willing to work in PHCs in villages. These PHCs are well-equipped and function far better compared to other states.
Another important incentive is the “in-service” quota for doctors who complete a minimum of two years of service in the PHCs or district hospitals. The state has a 50% in-service quota for post-graduate programmes in all medical colleges run by the government, including super-specialty courses. Certain seats are reserved by the government even in private colleges for those “in-service”.2
Such incentive systems in the admission process for education in medicine have ensured the retention of doctors within the state health system, who are specialists and yet willing to work in rural areas. For instance, in 2015=16 (pre-NEET), at least about 300 doctors (50% of the state quota) who completed their MD/MS through in-service quota in government colleges went to work in the rural health system; now they need not. If we add the share of government seats in private colleges, this number will increase. There are similar incentive structures in all super specialty DM/MCh courses. The NEET will bypass all these incentive structures which have worked efficiently to produce socially inclusive health outcomes.
The NEET is also a prelude to corporatisation of health system. Despite its effective public health system, the state has seen a tilt towards privatisation in recent times. The corporate has made major inroads into the health system. For instance, Hodges (2013) argues that Apollo, India’s first private limited hospital, has built an aura of ”successful” private healthcare system by “myths and myth-making”. It provided a template for how a multispeciality medical centre can be run on corporate lines. The NEET is an additional weapon for the corporatisation of healthcare in the state.
As the dreams of NEET aspirants who had to spend a lot of money and resources in coaching centres in metropolitan cities converge with the dreams of world-class corporate hospitals like Apollo, dreams of students like Anitha, a daughter of a Dalit labourer who committed suicide on not being able to clear NEET, would continue to be pushed out of the system.
In sum, the NEET holds the potential to reverse all the achievements made by the state of TN in the health sector. The incentive structure that the state has built over years and which ensured a seamless flow of health personnel is under attack. The health supply system which is responsive to its citizens because of institutional commitments can soon disappear. Institutions are defunct without people; public investment in health does little if it is not supported by both competent and socially committed health personnel. The NEET is an attack on this very social commitment.
Dr. Amalorpavanathan is one of the leading vascular surgeons in Tamilnadu. He was a Professor and Director of the Department of Vascular surgery in Madras Medical College and retired now. He pioneered Organ Transplantation movement in Tamilnadu and was the founder Secretary of Transplantation Organisation of Tamilnadu (TRANSTAN). Tamilnadu leads organ Transplantation in India
Q: Greetings sir. What are your thoughts on NEET? A: I am against this examination system of NEET. The elected state government should decide what kind of education system should be given to its people. A government which is far away and does not have any direct connectivity to people, cannot claim that they are the custodians of the education system and hence will conduct this examination. Second, a change is needed, only when the existing system has gone bad. The present system has its positives and negatives. In the existing system, we are not able to get a proper representation from Government schools. This led to Namakkal type schools have come up in large numbers. Third is the admission criteria and capitation fee of the Private Medical colleges. Out of this, The Tamilnadu Government has clearly spelt out that, it does not object to NEET exams for Private medical Colleges for their Management Quota. That is my stand as well. So, let’s look at the other two negatives. The students from government schools should get more seats. We should have done that in the last ten years which has not been done. Both the education department and their policies have missed this. Secondly, we should have curbed the growth of Namakkal type schools by proper policies. That has been missed out as well. The Medical colleges should be represented by the entire cross section of the society – Students from Government schools, More women, widows, children of Intercaste marriages, sports persons, people who had excelled in extracurricular activities etc. Tamilnadu is fortunate to have hundreds of educationists like me to get all this implemented. NEET examination did not solve any of these issues. After, the implementation of NEET did government school students get maximum admissions? NO!! After the implementation of NEET, has the fees in private medical colleges reduced? NO!! After implementation of NEET, we now have Kota (Rajasthan) broiler models and Trichur Broiler models instead of namakkal broiler schools. Why do we need this NEET exam which does not solve any of our problems? Our state government should take medical education in its hands. With the help of genuine educationalists who truly have a stake in the welfare of the state, there are hundreds of them; we should design our own education system. And as I had mentioned earlier, it should be representing the entire cross section of the society – girls, widows, students from rural area, sportsmen, first generation graduate etc. This is not difficult. You just need will power to do it. You need an organization and a government which encourages all this. The first two are there whereas the third one is missing now. We should work towards that.
Q: You have studied in Madras Medical College. You have passed the AIMS examination. Is there any difference in the standards of AIIMS and Madras medical college? What are your views? A: I wrote the AIIMS exam in 1986. After that, I have worked as a professor in Madras medical college. As assistant professor, professor and then director. I have visited AIIMS many a times on work. Students studying in AIIMS are very intelligent. You call them as ‘cream’. But our students are no lesser than them. One thing missing in our students is exposure, if we give our students exposure like students of Delhi, and then there will be no difference. Apart from this if you compare the quality of medical care, I will not say that AIIMS is better than any of the medical colleges in Tamilnadu. Infact, TN colleges are pioneers in many areas. For example, there is no Vascular Surgery Department in AIIMS. Madras Medical College has vascular department for the past 40years. Tamilnadu was the pioneer in producing vascular surgery graduates in India. Till date, AIIMS does not have a vascular surgery department.
Q: An argument which is placed in the public for a – that Tamilnadu Medical Council is older than Medical Council of India… A: True. We should say this loudly. Tamilnadu Medical council is not a branch of Indian Medical council. It is another Institution. The sad part is, neither the members of the Tamilnadu Medical Council nor the government realize this. Medical colleges in Tamilnadu can very well be controlled by the Tamilnadu Medical Council. We can frame our own policies to regulate the colleges of Tamilnadu. MCI inspection format has many good features, we can adopt them. We can recognize our own colleges. We can take action on deviants. We can debar them…
Q: Net-Net, can we say that Tamilnadu is a pioneer in Medical education and Healthcare. There is not great value addition from the centre? A: We can say that. We do not get much value addition from Delhi. Tamilnadu Public Healthcare department is a complete one. It is a 4 tier structure comprising of Medical colleges, District Hospitals, Taluk Hospitals, Primary healthcare Centres and Sub Centres. All of this are properly structured and administered. There might be some deficits in the system but they are minor and can be easily resolved. Since, other states do not have such well-knit system, you see them having very poor scores in public healthcare like infant mortality rate, maternity mortality rate, anemia etc. we have developed this system in the last 40-50 years. NEET exam will destroy this system.
Q: AIIMS and JIPMER have been exempted from NEET exams. But Christian Medical College has not been. CMC vellore is considered as one of the best Medical Colleges and Hospitals in the world – won’t they know how to select students for their college? A: It is a political intervention. NEET will destroy this. Hope NEET supporters realise this.
Q: People, who oppose NEET, present another argument – Tamilnadu had earmarked 50% of the seats for its Post Graduate Medical courses for Doctors who work in Government Hospitals and rural health centres. Now, this service quota has been abolished. People say that hereafter, doctors will not have any incentives to work in government hospitals. This will adversely impact the availability of doctors for Government service. A: Definitely, first of all we must have some clarity, why do we produce doctors? To send them to England or America? No, we produce them to send them serve our villages, if we are clear about this, then we can be clear about the criteria for admission. We don’t want doctors who want to go to America, let them study in AIIMS or Private Medical Colleges. Our doctors must go to primary healthcare centers and government hospitals. Doctors who are ready to go there should be given reservation. Only then they will be ready to go there. I won’t even call it as an incentive. It is a good economic concept. Only then can we give high end healthcare to all sections of people at very minimal cost. There is nothing wrong in giving 50% reservation for our students who are ready to work in taluk or district hospitals. NEET exams are breaking this good system. This will be catastrophic to our healthcare system. For example, take my department of Vascular Surgery – Doctors through service quota, studied vascular surgery and went back and created Vascular surgery department in Madurai, Kilpauk and Thanjavur Medical colleges. Now, all the seats are given up to All India Quota. Some Chatterjee, Mukerjee all will come, study in our Medical Colleges and will get back to their states. There is no use in conducting the course for them. But what do they say in NEET is, to get a bond for 10 years and 20 years but it is unfair for both the parties. Just because a person to came to study in our land we cannot arrest him for 10 years. Let him do service in his land, that is fair. Our point is, we did not build colleges for other state people to come and study and go back. We should use our infra structure for the development and healthcare of our people.
Q: They say this bond system is impossible to implement? A: Even if it possible, it is not fair. Students coming to study from north, should work here for 10years is not right.
Q: We are told that Super specialty courses after post graduation, almost 170 seats in Tamilnadu have been given up to All India Quota? A: yes! I just mentioned about the MCh – all these are super specialty courses. All these will completely come under All India quota.
Q: is this not justified? A: Definitely not .. we created the course through hardwork. We trained professors for this, selected students and created this higher course , not fair in giving to someone else. If we ask this, they are saying go to Delhi and study M.C.H. When we have sufficient seats here itself, why should our students go to Delhi and study? In U.P where the population is 20 crores, they have 8 seats for nephrology. In Tamilnadu, which has a population of 7 crores has 16 seats… Every year we create 16 kidney specialists. Why should we go and study there when we have seats in Tamilnadu?
Q: Are there not stringent criteria for creating a super specialty courses sir… like hospitals with so many beds, professors etc.? All this was created after so many years of work by us. How can it be fair to give it away to All India Quota? A: Not fair at all to give it away.
Q: Education was a state subject but during emergency it was added to concurrent list… and specifically, union central government seems to have got a strong hold over it. A: Not just Medical Education. Technical studies are not different from other academic studies. First we should remove such classification from our mind. There is no difference between disciplines. You can’t say let the State look after some and the central look after others. Education is the same. Saying, studying history is of lesser importance, let the state look after it and Medical and engineering Education are of greater importance let the union government look after it, is wrong. Education is something which will uplift man, discriminating one against the other is wrong.
Q: Rather than looking at India an a single nation, it should be seen as a coalition of many different nations is a debate on the table now, earlier it was addressed as the Indian sub-continent… A: Yes, the more the powers are decentralized, the deeper you take it to the villages, the better and stronger will the federal structure become. It will not become weak. The people in Delhi refuse to understand this basic truth.
Q: The Tamilnadu Medicine Procurement Organisation is said to be an unique creation in Public Healthcare. It is said that it is very successful that WHO and many countries have studied and adopted this system? What are your views on it? A: I was involved in it from the time it was started. I know completely about it. Earlier, every hospital would buy their requirements on tender basis. Lot of issues were there in that system. You will know- what kind of problems will arise in it . During the tenure of a Health Secretary called, Poornalingam, this was started. The medicine needs of all the hospitals were collated and were sourced centrally at the state level through a transparent system. This gave lot of advantages – The collation led to procurement of a large volume which led to great reduction in procurement costs. We had centralized labs in one place and the procured medicines were tested and the qualities of medicines were ensured. We then went on to create district warehouses and from there the required medicines were sent to all the hospitals in a transparent manner. This is a very good system.
Q: This system was the first of its kind in India, I suppose? A: As far as I know this was the first of its kind. Afterwards many states and countries have studied this system and adopted
Q: It is said that all the Heads of Government, irrespective of political affiliation, have continuously focused and supported Health care initiatives in Tamilnadu. What are your views? A: Yes. When it comes to healthcare, we cannot differentiate between parties. Mostly, this depart was governed by officers. Political interference was minimal. Maybe in a few places. But largely supportive. But for the support and focus, we would not achieved so much.