Why Public Health Is India’s Best Investment: Insights from Tamil Nadu and Sri Lanka

Monica Das Gupta’s paper argues that India can drastically improve health outcomes and economic productivity by prioritizing low-cost, preventive public health services using existing resources. Drawing lessons from Tamil Nadu and Sri Lanka, she advocates structural reforms, grassroots workforce revitalization, and better public health governance.

In her incisive World Bank Discussion Paper Improving Public Health Services: India’s Best Investment, Monica Das Gupta makes a persuasive case for why India must urgently revamp its public health system. Drawing on research supported by institutions including the Maryland Population Research Center, the National Centre for Disease Control, the Institute for Health Policy in Colombo, and the College of Community Physicians of Sri Lanka, the paper argues that India’s failure to invest in preventive health has resulted in vast and avoidable economic losses. Despite having the administrative infrastructure and national technical institutions in place, India continues to prioritize curative healthcare over preventive public health services. The result is a country grappling with high child stunting rates, recurring outbreaks of communicable diseases, and a reactive health system that scrambles during emergencies but fails to prevent them.

The paper reveals that India’s health strategy has long focused on expanding hospitals and clinical services while neglecting the services that prevent diseases in the first place, such as sanitation, vector control, food safety, and public hygiene. This oversight has led to persistent disease burdens even among wealthy populations. Das Gupta highlights the paradox that affluent Indian children, though surviving illnesses due to access to treatment, still suffer from stunting and long-term cognitive disadvantages due to repeated infections from poor environmental conditions. The paper argues that public health services, which deal with the environment rather than individuals, have remained invisible and politically unattractive because their successes are measured in absences, no typhoid, no dengue, no outbreak.

Why Curative Services Overshadow Prevention

The root of India’s neglect of public health lies in the invisibility of its outcomes. Das Gupta cites former New York Mayor Michael Bloomberg’s observation that hospital patients can name who saved their lives, while people protected by public health interventions often don’t realize they've been helped. Political leaders are less inclined to champion services that do not yield visible wins. The result is a skewed allocation of funds and attention. In India, disease control efforts tend to be reactive, driven by emergencies or international campaigns like polio eradication. These short-term successes often fade without sustained follow-up, as seen in the resurgence of malaria after its near-elimination in the 1950s.

The central government’s financial transfers to states are frequently tied to narrow health targets, pressuring states to focus on specific diseases instead of comprehensive, locally tailored public health strategies. National institutions like the National Centre for Disease Control are poorly resourced and lack autonomy, their activities micromanaged by ministry officials who often lack public health backgrounds. This has diluted technical training and overlooked the need for medical professionals in public health leadership roles. Moreover, the 1993 constitutional amendment that decentralized key responsibilities to local bodies did so without training or accountability mechanisms, severely weakening sanitation and hygiene services.

Tamil Nadu: A Quiet Champion of Public Health

Against this national backdrop of neglect, Tamil Nadu stands out as a beacon of success. It is one of the few states to have retained a clear institutional distinction between medical and public health services. Its separate Directorate of Public Health has its own budget, staffing, and authority, unlike other states where public health has been subsumed under broader medical services. Tamil Nadu’s model ensures that public health professionals have the autonomy and support to plan long-term strategies and respond proactively to threats.

The state’s investments are not unusually high, but they are far more effective. For instance, Tamil Nadu employs over 100 entomologists for vector surveillance, while other states struggle with just a handful. Its annual disaster planning exercises ensure preparedness. During the 2004 tsunami, the state swiftly deployed chlorination, sanitation, and fly control teams, and successfully prevented any major outbreaks. The Tamil Nadu Medical Services Corporation further ensures a reliable supply chain for public health materials. The state also maintains plague surveillance units to monitor rodent activity, underscoring its commitment to anticipating rather than reacting to health threats.

Sri Lanka’s Ground-Level Blueprint for India

At the grassroots level, Sri Lanka offers a powerful example of what India could achieve with focused training and respect for its male health workers. Sri Lanka’s Public Health Inspectors (PHIs) serve as the country’s frontline defenders against disease. Each PHI is responsible for a clearly defined area and has authority over sanitation, water testing, food inspection, school health, and outbreak response. Their training is comprehensive and practical, enabling them to guide everything from toilet construction based on groundwater levels to emergency health interventions during epidemics. Importantly, PHIs are treated with respect within the health system and among citizens.

In contrast, India’s male health workers, originally conceived for a similar role, have been diverted into implementing national health programs. Their training, autonomy, and visibility have eroded, diminishing their impact. Das Gupta emphasizes that revitalizing this cadre using Sri Lanka’s training curriculum and manuals could dramatically improve India’s environmental health conditions.

The Road Ahead: Reform Within Reach

The paper concludes with a call for action that is both simple and achievable. Rather than requiring large new investments, Das Gupta proposes reconfiguring existing health budgets to prioritize prevention. She urges the central government to incentivize states by linking funding to key reforms: establishing separate public health directorates, adopting modern public health legislation, revitalizing the male health worker cadre, and replicating Tamil Nadu’s supply chain model. These actions would empower states to respond not just to current disease burdens but also to future threats such as climate-driven health shocks.

India has before it two proven models, Tamil Nadu and Sri Lanka, that show what’s possible with the right focus and organization. If adopted widely, these approaches could transform India’s public health outcomes, saving lives, improving productivity, and placing the nation on firmer footing for sustainable development. It is a rare opportunity to invest smartly, not spend more, and to bring health prevention into the center of national strategy.