|PUBLIC HEALTH EDUCATION
|Year : 2012 | Volume
| Issue : 2 | Page : 110-115
An innovative National Rural Health Mission capacity development initiative for improving public health practice in India
Preeti Negandhi1, Kavya Sharma2, Sanjay Zodpey3
1 Assistant Professor, Indian Institute of Public Health, New Delhi, India
2 Manager- Academic Programs and Adjunct Lecturer, Public Health Foundation of India, New Delhi, India
3 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
|Date of Web Publication||21-Aug-2012|
Director, Public Health Education, Public Health Foundation of India, ISID Campus, 4 Institutional Area, Vasant Kunj, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
National Rural Health Mission (NRHM) foresaw improved health management in India through sustained capacity development of in-service health personnel and their post-training duties in the public health system. Acknowledging the urgency of addressing this issue, the Indian Government, under the NRHM, launched a 1-year Post Graduate Diploma in Public Health Management (PGDPHM) to impart public health management knowledge and skills to these professionals in the state health services. Four institutes partnered this program in 2008, its first year. Between 2008 and 2011, this expanded to 10 institutes and 386 students have graduated the program. The program offered across all these institutes is uniquely identified as against other Health Management courses being offered across the country. The NRHM context in its content and pedagogy is its prime feature. The program offers multiple opportunities to encourage states and the central government to clearly delineate a much needed specialized public health cadre in India. The efforts of this program emphasize on improved public health practice and are a unique pathway to a better health system. Its multidisciplinary facets are aimed at addressing the mismatch of demand and supply of health professionals who could contribute effectively to strengthening the public health system in India through proficient public health practice.
Keywords: Partnership, Public Health Management, Public Health Practice
|How to cite this article:|
Negandhi P, Sharma K, Zodpey S. An innovative National Rural Health Mission capacity development initiative for improving public health practice in India. Indian J Public Health 2012;56:110-5
|How to cite this URL:|
Negandhi P, Sharma K, Zodpey S. An innovative National Rural Health Mission capacity development initiative for improving public health practice in India. Indian J Public Health [serial online] 2012 [cited 2020 Jan 19];56:110-5. Available from: http://www.ijph.in/text.asp?2012/56/2/110/99900
| Introduction|| |
India is an emerging economy with rapid development in several sectors. Adequate and quality health care can be a vital driver of this economic success. In the field of health care, one of the various challenges India faces currently is the shortage of qualified public health professionals across all levels of the health system. The delivery of good health care is dependent on the knowledge and skills of such public health personnel.  There is evidence that despite strong political commitment and availability of ample funds, public health lacks in advocacy due to poor resources in the fields of infrastructure and human resource capacity.  This lack of and need for professional health care providers has been an area of discussion for the past many decades; the launch of the National Rural Health Mission (NRHM) in 2005 was a turning point for health planning in India.  As part of this initiative, human resource recruitments under the NRHM at various levels have increased over the years,  albeit with questionable quality of health care delivery. The NRHM 'Framework for Implementation' report  discusses detailed strategies to be employed to achieve good health care practices. The idea is to improve the architecture of the health system for improved service delivery.
As part of the guiding principles and policy recommendations of NRHM and Indian Public Health Standards (IPHS), the central as well as state-level governments expressed a pressing need for adequate public health management training of in-service professionals who would return to the health system  and would be expected to design, implement, monitor, and evaluate health programs, supervise the public health workforce, assess the dynamics of and develop appropriate mechanisms to address various public health challenges. The larger goal was an improvement in the quality of health care practice through the development of a sustainable health care system, vital for achieving the Millennium Development Goals.
The current medical education system in India focuses minimally on the development of managerial competencies to address public health needs of the population,  resulting in medical graduates with poor public health management skills. Ironically, the job profile of such doctors subsequently joining the health system demands knowledge and skills related to public health management. NRHM, having recognized this gap, has been providing valuable support to initiatives for motivating and empowering health personnel within the government health system as well as civil society, to meaningfully participate in and strengthen decentralized planning processes and outcomes. 
Acknowledging the urgent need to address this issue, the Government of India, under the aegis of the NRHM, proposed the launch of a Post Graduate Diploma program to impart public health management knowledge and skills to working health professionals in the state health services. A group was created for developing and delivering a full-fledged program, which would satisfy the short-term as well as the long-term needs of the public health system. The conceptualization, designing, and implementation of this program were entrusted to various public health institutes across the country as a partnership under NRHM. The Public Health Foundation of India (PHFI) was one such institution under this partnership.
| Post Graduate Diploma in Public Health Management (PGDPHM) Program|| |
The PGDPHM program was launched under the sponsorship of the Ministry of Health and Family Welfare, Govt. of India on July 31, 2008. As part of an interinstitutional partnership program, PHFI, through its institute, Indian Institute of Public Health, Gandhinagar, joined hands with three other institutes, namely, National Institute of Health and Family Welfare (NIHFW), New Delhi, All India Institute of Hygiene and Public Health (AIIH and PH), Kolkata, and Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram, Wardha, in the first year. Leading public health academicians and practitioners of all the partner institutes developed innovative, comprehensive, need-based, and context-specific modular program content, based on a review of the existing programs in the country and the gaps in ongoing public health management training. A common structure of program modules, shared teaching resources such as e-modules and evaluation modalities were shaped for this flagship program by experts of the partner institutions.
Structure and Execution
The program is designed as a 1-year residential diploma program. Enrollment of potential in-service health care professionals is based on nominations from state governments. Self-sponsored students with a suitable medical or other health-related qualification can also apply for a nominal fee. The program includes 8.5 months of institution-based teaching followed by 2.5 months of field-based project work and 1 month of project writing and final evaluation. It is organized around a multidisciplinary curriculum, focusing on broad areas like public health, management, and analytical skills [Table 1]. At the outset, students are given an orientation of their respective institute and the PGDPHM program and computers as well as language skills. They are taught for 35 total credits (23 credits for taught modules, 12 credits for project work). The curriculum is, thus, based on core competencies and skill-sets expected from a public health manager. The project work is the applied research component of the program, aimed at exposing the students to 'real world' public health problems and their possible solutions by applying their knowledge and analytical skills to the community setting.
In the first batch (2008-09), 72 students graduated the program across all four partner institutes. Over the next two batches, the partnership extended to five more institutes across the country [Table 2]. The number of graduates in 2009-10 increased to 144 and 170 in 2010-11. Three years of operations have been completed. The fourth batch commenced in August 2011. In the batch of 2011-12, 158 students have enrolled in the program across all 10 partner institutes. The increasing number of students with each passing year is testimony to the positive response to the program.
|Table 2: Partner institutes offering the PGDPHM program and year-wise number of participants|
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The commencement of the program at State Institute of Health Management and Communications (SIHMC), Gwalior in 2010-11 was an initiative supported by Government of Madhya Pradesh (GoMP). The GoMP had expressed a felt-need to develop a sustainable, robust, and dynamic public health cadre that is adequately equipped to address the state's public health challenges. Aimed at improvising the efficiency of in-service health personnel for better health care delivery by empowering them with managerial competencies, the GoMP initiated an agreement with PHFI in 2010 to launch the PGDPHM program at SIHMC in Gwalior. SIHMC is an apex training and research institute for health personnel in Madhya Pradesh. The GoMP also endeavors to facilitate the initiative to establish a public health cadre in the state thereby creating a favorable environment for future enrollment into public health courses. Inspired by the success of GoMP's efforts, other states such as Bihar, Chhattisgarh, and Jharkhand have also expressed keen interest in this enterprise.
The network of academic institutions across the country has put in place quality assurance mechanisms to ensure smooth delivery of the program. A unique and varied pedagogy including seminars, journal clubs, collaborative learning, group discussions, case studies, lecture discussions, participant assignments, hands-on training on computers, visits to organizations of public health interest, field work, practicum, and field projects are highlights of the program. Examinations are held at the end of each term and a common final exam is held at the end of the year at all partner institutes; students are evaluated by two internal and two external examiners. Examination results and feedback of examiners from all the partner institutes are compiled, analyzed, and an overall report is prepared and shared with the concerned stakeholders. Since inception, all partner institutes have been meeting regularly every year to review the program's technical and administrative advancement and amend the strategies for the forthcoming batches accordingly. Thus, this 1-year PGDPHM program has been developed as a complete and concrete academic program with interinstitutional uniformity. All these measures together ensure an unbiased, standard, and reliable output in terms of enhancement of knowledge and skills of the public health professionals who are expected to bring about a visible improvement in the public health system in the long run.
| PGDPHM in the Context of Public Health Practice|| |
Public health management has been defined as 'the optimal use of the resources of society and its health services towards the improvement of the health experience of the population'.  Public health practitioners and managers of health care systems occupy two distinct and significant portfolios in the health care delivery systems of the country. Public health cannot be bound to any one group of health personnel. Understanding and sharing the strengths and complementing the limitations between the two groups can be useful for initiating and escalating appropriate public health action at all levels of the health system.
The WHO Health Report 2006 discusses the importance of health workforce and highlights human resources for health as a high priority area for upgrading health care services. It further elaborates that strategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers. Substantial improvements in the availability, competence, responsiveness, and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments. 
The Lancet report on Health Professions for the 21 st Century  emphasizes the three generations of educational reforms. These reforms characterize progress during the past century. The first generation, launched at the beginning of the 20 th century, taught a science-based curriculum. Around the mid-century, the second generation introduced problem-based instructional innovations. It discusses the glaring gaps and inequities in health, which persist both within and between countries. The report acknowledges that the professional education offered in various countries has not kept pace with these challenges, largely because of fragmented, outdated and static curricula that produce ill-equipped graduates. A third generation is, therefore, needed that should be systems-based to improve the performance of health systems by adapting core professional competencies to specific contexts while drawing on global knowledge.
Currently, the Indian public health system lacks a strong and dedicated public health cadre. The existing health structure has seen revolutionary changes over the past few decades. India's Health Ministry and states' health departments have done much to improve health services, building an enormous infrastructure of publicly funded medical services, medical education facilities, high-quality laboratories, and research institutions. However, central public health interventions are focused largely on single-issue programs for controlling specific diseases, delivering maternal and child health services, disease surveillance, etc. 
Post the launch of NRHM, the IPHS revamped and redesigned the requirements for minimal functional grades of the health facilities. The launch of NRHM created various state and district level positions for program managers. Currently these positions are being occupied by general MBA and MSW qualified candidates who have limited knowledge of health systems.
The PGDPHM program aims to address the gaps in the health system in the context of above mentioned issues. The candidates enrolled for this innovative program come from within the health systems, bringing with them huge experience from the field. They are directly responsible for implementing the various reforms and programs formulated and initiated at the central and state government levels. Coming from a medical background and getting into clinical practice following their medical education, these candidates have limited knowledge of the new health policy reforms and initiatives undertaken by the government. Moreover, they lack the technical know-how for implementation of these reforms and appropriate action plans. The PGDPHM program offers enough perspectives relevant to public health management and justifies their specific roles and responsibilities in these endeavors.
The PGDPHM program offered across all these partner institutes is differently placed and uniquely identified as compared with the other Health Management courses being offered through various institutes in the country. The prime feature remains the NRHM context it brings in the course content and pedagogy. The various partner institutes are very important and major stakeholders as they represent elite national institutes of the country. These institutes are pioneers in public health with richly experienced and varied faculty pool. The end user of the program is the government itself, since the candidates after their training resume their respective positions within the state health systems. This brings out strong academia and state health systems interface, where classroom teaching can be brought into practical applications at the field. The program is multidisciplinary and focuses on the various parameters of public health teaching and practice. The syllabus is competency-based and meets the 21 st century reforms, which talks of systems strengthening through a competency based curriculum. It offers a window of opportunities to encourage states and the centre to move in the direction of a clear delineation of a specialized public health cadre, which is being increasingly recognized as an essential need all over the country. The program also serves as a strategy for career advancement of the graduates. Of the 386 graduates over the last three batches, almost 90% were nominated. While some government-nominated graduates might have been promoted to higher positions and/or have received incentives on returning to their workplaces after completion of the program, this diploma serves as a stepping stone toward an organized career in public health management for the 36 self-sponsored graduates. The efforts generated through this program emphasize on health systems strengthening and is a unique pathway to the health systems.
Various state governments have commenced trainings of nursing professionals in health management. GoMP began the initiative by nominating the nursing staff to the PGDPHM program and assuring suitable placement opportunities for them in the health systems after the completion of their trainings.
The other public health management programs available in the country are usually of 2 years duration, regular on-campus programs.  It is difficult to get candidates working in the health systems to join a public health management program for 2 years since it bears impact on the public health practice in their respective facilities and districts. Therefore this 1-year diploma program was designed specifically to address the needs of the government health facilities. There is a huge demand of public health specialists trained in the multidisciplinary facets to meet the mismatch of demand and supply of such professionals. There is a felt need for leaders trained in health, administration, planning, economics, and management who could design and run the health programs. The focus of this program has based itself around the limitations in the appropriate functioning of health care delivery systems. Thus it is expected to contribute towards strengthening the capacity of health professionals in public health management thereby improving the functioning of public health system in India.
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[Table 1], [Table 2]
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