Amma’s legacy inspires ‘Health For All’ momentum

Dr Priya Balasubramaniam, Director, Universal Health for India Initiative, Public Health Foundation of India (PHFI), speaks on the legacy that erstwhile Chief Minister, Late Jayalalithaa Jayaram has left behind in health equity for Tamil Nadu through innovative models and schemes

In the last week, sympathy flooded towards Tamil Nadu from across the country following the demise of the state’s iconic and charismatic Chief Minister, Jayalalithaa Jayaram. As people mourn this loss, it is worth celebrating the solid legacy in health equity, reform and social justice that she leaves behind for the state of Tamil Nadu in the form of innovative models and schemes that are now being replicated across India.

Tamil Nadu has been historically lauded for its well-functioning and relatively equitable health system. A testament to the collective work of government, civil society and a unique cadre of public health workers in providing good quality affordable health services geared towards economically weaker sections of society. The journey to universal health coverage (UHC) is not an easy one. However, the Tamil Nadu model has managed to stand out by consistently making health and social welfare a part of the state’s overall political mandate – where the right to good health is linked to social justice and is fundamental to human productivity and progress.

Jayalalithaa’s own legacy in contributing to developing Tamil Nadu’s health system is significant. She continued and nurtured the innovative school-based Midday Nutritious Meal Scheme, pioneered and universalised by her political mentor, former Chief Minister Dr MG Ramachandran. The scheme addressed the acute problem of hunger and malnutrition in poor children attending government schools and incentivised children to attend school. The success was illustrated by the tremendous increase in school participation and completion rates in the state along with improved health and nutrition outcomes, and is now a nationalised programme.

Jayalalithaa, in her successive tenures as Chief Minister, launched a slew of social welfare schemes, ‘branded’ under her popular moniker ‘Amma’, targetting the urban and rural poor. These schemes helped bridge public health inequities by addressing broader determinants of health. The first in the 1990s – the Cradle Baby Scheme – addressed female foeticide and gender-based abortions, while the more recent, ‘Amma Canteen’ initiative, provides subsidised food to the urban working poor in a hygienic environment for as little as five rupees.

Perhaps her biggest direct intervention in healthcare provision was the initiation of the Chief Minister’s Comprehensive Health Insurance Scheme in 2012, which resulted in a sharp increase in government hospitals’ use. This was followed by the ‘Amma Master Health Plan’ which focusses on preventive care by offering heavily subsidised health check-ups that involved a range of diagnostic tests with subsequent treatment in primary health centres and government hospitals. The ‘Amma Pharmacy’ launched state-wide attempted to address the high cost of medicines through fair price pharmacies that sold both branded and generic drugs, sourced directly from drug companies priced much lower than existing market rates.

Primary healthcare meets 90 per cent of people’s health needs, providing a range of essential health services that people can access in one place at one time and is a key foundational building block for a universal health system. Tamil Nadu was one of the first states in India to build a network of clinics that brought essential health services to those who needed them the most. The state also led immunisation coverage in the 1990s, dramatically reducing child mortality rates resulting from common preventable diseases.

For the poorest and most marginalised communities, many of whom live in remote locations miles away from major health facilities, a resilient primary healthcare system is the most effective way of preventing, monitoring and treating disease. However, health system strengthening is a continuous process which involves good governance, constant surveillance and continuous course correction in complex, ever-changing health and disease environments.

While many of these pro-poor schemes were termed ‘populist’ by critics and as posing undue burden on the exchequer with little evaluation of their sustainability – they have left a lasting impact amongst citizens: of good health being an important social and civil right and that equitable affordable healthcare addressed via various social determinants was an important part of a community’s societal and economic fabric.

To ensure that every man, woman and child across India has access to quality health services, it is important that we adopt an approach that focuses on progressive universalisation. This means prioritising the poor, while not excluding those who are classified as ‘non-poor’ from accessing essential health services that primary healthcare delivers and with which universal health coverage begins.

As Indian states consider the road to universal health coverage, it is important that health services provided to all are explicitly discussed. As resources are added to the health system, the package of essential health services will expand and several indicators should be considered before moving forward. This includes disease burden, potential impact, cost-effectiveness, affordability, financial risk, feasibility, the ability of the health system to implement and scalability potential.

Tamil Nadu’s health system has helped drive progress socially, politically, economically and culturally. It has involved long-term investment in human resources, policy and infrastructure, yet there is still room for further improvement. As India moves towards ensuring quality health for all, Tamil Nadu will always be remembered as a catalyst for the movement. Now is the time to both act and continue to build on a legacy of health and its critical inter-sectoral determinants that Chief Minister Jayalalithaa left behind.

(The opinions expressed in this article are the author’s own)

EH News Bureau

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