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.