|Year : 2013 | Volume
| Issue : 4 | Page : 219-224
Developing a public health cadre in 21 st century India: Addressing gaps in technical, administrative and social dimensions of public health services
Ritu Priya1, Anjali Chikersal2
1 Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
2 Research Scholar, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Web Publication||18-Dec-2013|
Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This paper presents a possible framework for designing a public health cadre in the present context, with lessons from health services development of the last six decades. Three major gaps that the public health cadre is meant to bridge have been identified. These are capacities within the system to address the technical requirements (epidemiological and health systems analysis); administrative/managerial dimensions; and the social determinants of health. Therefore, it argues that the cadre must not only have a techno-managerial structure, but also create a specific sub-cadre for the social determinants of health.
Keywords: Multi-disciplinary teams, Public health cadre, Social determinants cadre, Sub-cadres
|How to cite this article:|
Priya R, Chikersal A. Developing a public health cadre in 21 st century India: Addressing gaps in technical, administrative and social dimensions of public health services. Indian J Public Health 2013;57:219-24
|How to cite this URL:|
Priya R, Chikersal A. Developing a public health cadre in 21 st century India: Addressing gaps in technical, administrative and social dimensions of public health services. Indian J Public Health [serial online] 2013 [cited 2020 Sep 29];57:219-24. Available from: http://www.ijph.in/text.asp?2013/57/4/219/123247
| Introduction|| |
Universal access to health-care requires a strengthening of the public health capacities for systems development and functioning, both in quantitative and qualitative terms. Increasing public health trained personnel in the public system and even a separate public health cadre has been proposed as a necessity for reversing the decline of public health systems, at least since the 1980s. ,,, However, it has not come into being for several reasons, namely the lack of appreciation of the need by the health bureaucracy and the lack of a strong "public health lobby" to provide the pressure that could overcome the power of the "medical lobby." The third could be the inadequacy of credible public health courses and public health specialists. At the present juncture, all three seem to have changed to a more favorable situation. This paper outlines the systemic need for public health capacities in the context of how the content of public health services, their governance and relationship with the community are being envisaged. A brief historical review traces how gaps in public health capacities have developed. The paper then leads to the proposed structure of a three-pronged cadre to fill the gaps.
| The Public Health System and its Workforce|| |
The public health system can be envisaged to have three major task components. Delivery of public services is the largest sub-system with the biggest workforce and its three tier institutional structure at primary, secondary and tertiary levels. The institutional structure for education, training and research constitutes a second sub-system. This is essential to produce the required public health personnel, to provide evidence for health systems evaluation and action research, for strengthening implementation, as well as to introduce new knowledge, technologies, processes and perspectives for continual renewal and up-gradation of the system. Finally, there is the small but vital segment of the system that deals with policy formulation and planning at national and state levels. Although the first large segment primarily requires clinical, community interaction and administrative skills, the latter two require contributions from a variety of fields such as epidemiology, sociology, anthropology, economics, philosophy and ethics, law, engineering, communications, pharmaceuticals industry; all that contribute to developing the relevant perspectives and tools for public health.
The public health workforce can be depicted as in [Figure 1]. (i) The service providers up to district level who need public health knowledge and skills. Among these are; Auxiliary Nurse Midwife and Multipurpose Worker (M) at the sub-center level; the MO, nursing staff and health supervisors at the Primary Health Centre and Community Health Centre levels; and the CMO and program officers at the district level. (ii) Public health educators and researchers; in Preventive and Social Medicine Departments in medical colleges and community nursing teachers in nursing colleges; faculty and researchers in the Centers/Schools/Institutes of public health; Indian Council of Medical Research and its network of research institutions, the National Center for Disease Control, National Institute of Health and Family Welfare and other such institutes of research and training. (iii) Policy and planning officials at the state and national levels; as in Department of Health and Family Welfare, Department of Ayurveda Yoga-naturopathy Unani Siddha and Homoeopathy (AYUSH), Directorate of Health Services and Health System Resource Centers.
It has to be recognized that service providers from the most peripheral to the center, require to do planning and management, data analysis, research, training and supervisory activities as well as inter-sectoral coordination for delivering comprehensive services effectively.
This is in addition to the staff specifically mandated for these tasks at the block, district, state and national levels.
This means that those placed in leadership roles at any of the tiers of the services need to be able to guide and manage multi-tasked public health teams. They have also to interact with various department officials, workers, community leaders and members. In addition, at least those at the periphery must continue their clinical role as well. This is a daunting array of tasks, and repeated evaluations have found that the medical officers are not adequately equipped to perform them, both because they have inadequate training and because they have not honed these skills while practicing clinical roles. Some exceptional doctors and nurses are able to pick up many of these competencies while on the job, but the majority remain steeped in the clinical paradigm and just manage to cope when required to perform non-clinical tasks. This is why various analysts recommend going back to the development of a separate career path that constitutes a Public Health Cadre, with its members having received specialized education in public health.
| The Public Health Leadership Gap|| |
Integration of preventive and curative services has been a key concept in health services development in independent India and it was operationalized by reversing the earlier divide between the Indian Medical Service (IMS) and the curative service providers of the colonial period.  The IMS and the posts of public health commissioners were abolished. Instead, an integrated Directorate of Health Services was to provide the technical leadership at the central and state levels, with chief medical/health officers at district levels. Though extremely important for establishing the link between the curative and preventive dimensions, this integration proved detrimental in dealing with the health services from a population and systems perspective. It also failed to address the social determinants of health or provide an efficient administrative structure for the health system. Even on the technical content of the services, because we have not provided for specific institutional structures and human resources for critical examination of technologies and system designs, we seem to have left the space vacant for international trends and expertise to guide us.
The Bhore committee that provided the blueprint for the post-independence development of health services had recommended that doctors should provide medical relief, health workers in the field should carry out public health preventive activities and the linking of preventive and curative activities was to be provided by social workers. Furthermore, "the technical advisor to the minister should be the Directorate General of Health Services (DGHS), supported by the deputy DGHSs, all with experience in state administration and public health supervision."  Although the recommendations for medical officers and health workers were followed, the social worker's role has not been adequately assigned. Nor have the administrative and supervisory skills been adequate. The Mudaliar committee of 1962, noted that "although abolition of the post of public health commissioner and the complete merger of his organization with the DGHS at the time of independence was a move in the right direction, it has resulted in weakening of the epidemiological, statistical and other aspects of public health activity."  An all-India cadre recruited from within State Health Cadres, was recommended. Unfortunately, the Central Health Service, including the faculty of central government medical colleges, is for clinicians and it is from among them that the doctors, by seniority, move into positions of administration, planning and policy making at the highest levels, with or without, any public health education. Bhore committee's social worker also remained restricted to hospitals and primarily supported the curative activities for "needy" patients.
The Mukherjee committee of 1966 was seized of the administrative limitations and therefore recommended for the head of the district Health Organization "a whole time non-practicing medical officer with training and experience in community organization, in health administration, planning and preferably also in hospital administration."  The committee also emphasized that he should not be given any clinical responsibility. Even though, committees have recognized the need for public health/administrative training and capacity building, all committees from Bhore to Shrivastava have in their recommendations suggested an integrated approach to the services. It was the Bajaj Committee, 1996 that recommended "appropriate qualified public health professionals" for public health tasks, but still shied away from actually recommending a separate cadre. 
By the 1980s analysts did begin to recommend a separate Public Health Cadre  and the necessity of increasing public health capacities in the system has been reiterated by several committees and consultations since then. ,,, The most recent is the Planning Commission's High Level Expert Group (HLEG) on universal health coverage that has even suggested a structure for the cadre.  This structure is what needs to be seriously thought out, now that the Prime Minister's Office has committed to the setting up of the cadre  and the Steering Committee for Health in the 12 th Plan has endorsed it. 
So far only a few states have developed a separate Public Health Cadre, such as Tamil Nadu and West Bengal. Over the past two decades, some other states have sponsored their in-service doctors for public health courses. Gaining increasingly greater significance has been the non-specialist IAS cadre which has taken over much of the policy making and administrative tasks within the central and state health ministries, the directorates losing their leadership role over the decades. The technical decision-making within policy has thereby gone into the hands of either external consultants (within the central ministry itself, a rough count in 2010 found at least 70 external consultants paid by the related United Nations agencies, bilaterals such as United States Agency for International Development and Department for International Development and others) or followed uncritically the international health prescriptions and fashions.
Thus the Bhore committee's idea of a "social physician" was contradicted by its own emphasis on the newly emerging medical technologies and the "state-of-the-art" doctor. The way preventive and curative integration was undertaken was also not geared to producing the "managerial physician." With poor administration that did not contain adequate public health expertise or the capacity to relate to the community and its needs, even the medical services could not reach their potential. This situation can be addressed now with an adequately designed PHC.
| Public Health Cadre: A Possible Structure|| |
The demands of running a health service system necessitate that doctors trained in the technical, social and managerial public health dimensions provide leadership to the system. However, they need to be supported by a number of other personnel for several reasons:
"A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus."  This would include the doctors, nurses and paramedics as well as health managers and others with specialized education in public health. However, here we are focusing on doctors with public health specializations as the public health leadership. Although increasing their numbers in the system will be useful even without a separate cadre, specific career paths, as designated by a cadre, need to be developed for three reasons: (i) That their education in public health is utilized, (ii) that they gain public health experience, which is optimally utilized as they grow in service and (iii) that they are assured of professional progression and so are attracted and retained in the system.
- Large populations are to be covered at each level and multiple tasks performed.
- The support will partly help in retaining doctors in the public system who otherwise feel overwhelmed by the non-clinical tasks.
- The increasing complexity of administration requires persons with health management expertise.
- The major lag in implementation of inter-sectoral coordination, community processes of participatory monitoring and planning and inclusion of the deprived sections in service provisioning requires special point persons, due to the time-taking nature of these tasks as also the doctors' inability and disinterest in them.
- At the peripheral levels, the support would free their time for clinical roles.
| One Cadre with Three Sub-cadres|| |
Integrated conceptualization and multi-disciplinary implementation teams
Two basic principles underlie the proposed structure: The cadre should be built on the lines of the Indian Administrative Service, with central and state cadres and the possibility of moving between them. Secondly, there should be three separate sub-cadres (i) the clinical and public health stream (medical and nursing), (ii) the management stream and (iii) the social science and social work professionals (see Fig. 2).
Bio-medical public health sub-cadre
Tamil Nadu demonstrates benefits of the medical officers making their choice for the clinical or public health stream at the time of entering state services.  From the entry point onwards, those opting for public health undertake public health courses within a stipulated time if they have not already done so. The system would also benefit by allowing lateral entry into the public health stream to those clinicians who have demonstrated exceptional public health capabilities. Besides, members of the Public Health Cadre and teachers/researchers of public health should be allowed to move between their positions, mutually strengthening both activities.[Figure 2]
|Figure 2: Public health educational qualifi cations linked to cadre structure|
Click here to view
Another issue that needs to be addressed is that AYUSH doctors and dentists are increasingly acquiring post graduate qualifications in public health. Nurses too are getting similar qualifications and the senior ones often perform management roles in any case. Can they not be given leadership roles in the system?
Public health management sub-cadre
Experience of National Rural Health Mission (NRHM) has amply demonstrated that a separate sub-cadre of health management specialists (at the State/District/Block Management Units) is useful for assisting the health officers and increasing administrative efficiency. 
The social determinants sub-cadre
The social determinants of health have been defined in terms of social, economic and political factors that impact on access to basic material needs as well as psychological well-being and thereby influence health status. It includes the factors influencing access to health-care.  Some of the weakest elements of the health service have been its link with the community, the unequal access to services based on social hierarchies and the lack of coordination with other departments relevant for health. Even under NRHM, community processes and convergence have lagged in implementation the most, while management has improved. Clearly, addressing the social determinants of health requires more than management; social sensitivity, a deep understanding of social dimensions and community mobilization competencies. These require a third point person at all levels.
Social work and development professionals could perform this role in strengthening service delivery. Until now, social workers or counsellors have been appointed in hospitals to provide support to patients with special needs the poor, those requiring follow-up domiciliary services and those needing psycho-social support such as human immunodeficiency virus infected persons. The Panchayati Raj Institutions or Non-governmental Organizations (NGOs) are looked to for the other community activities. However, studies have consistently demonstrated a disinterest within the system and a distrustful passing the buck to the NGOs. In this context, a potential role that is being suggested is the posting of a social/development worker at the PHC level for ensuring access of outreach services to the more vulnerable sections as well as coordinating inter-sectoral convergence from the village end with collaboration of the block development officer.  Functioning of structures of people's participation, community monitoring and people-centered local planning would also be part of their responsibilities, directly or through NGOs where necessary.
Social science contributions are vital for developing a public health perspective that is responsive to the community and the social determinants of health. The role of social scientists, therefore, lies in the spheres of education of the PHC, research in health and health services, planning and policy formulation. This would require social scientists with specialized education/experience in public health and their role could start from the district level and go right up to the state and national levels. Therefore, a combined sub-cadre of social scientists and social workers is proposed with its independent career path.
Multi-disciplinary planning and implementation teams
Personnel of all the three sub-cadres would enter the peripheral level of health service delivery, work as multi-disciplinary teams at each level, but have career paths that lead them up the organizational ladder within their sub-stream, right up to the Department of Human Services (DHS). The DHS could have two wings: A clinician/medical education wing and a public health wing. The public health wing would have the three sub-cadres, working together on programs/problems. The director general could be from the clinical and public health wings by rotation.
Simultaneously, lateral entry into the PH wing may be provided for other specialists such as of health systems research, public health law, engineering and information systems. Thus formed, internal teams of excellence at the central/state ministry/department, using technical, managerial and social knowledge of the three sub-cadres and other disciplines, would then handle public health services and programs with their collective wisdom.
| Public Health Education|| |
Creating sufficient numbers of all the three sub-streams will require public health education for a range of qualifications; doctors, nurses, management, social science and social/development professionals. Several such courses are already being run by an increasing number of institutions in the country. A study mapping courses relevant to building capacities for district health planning found 286 such courses in 15 states, of which 85 covered a course content that qualified them to be called complete public health courses while 201 were of the kind that partially covered minimum public health content, but were relevant and related to public health.  Thus, all the three proposed sub-streams are already being produced in the country. It is the quality of education and the numbers required that needs to be worked out based on the structure adopted for the Public Health Cadre. Otherwise this sorely needed public health capability is going to waste.
| Conclusion|| |
That a Public Health Cadre is an urgent necessity is no longer a matter of debate. ,,,, The challenge is how to design it to serve long-term interests of an efficient, effective and responsive health system as well as to play the visionary role for improving health and wellbeing of all the country's citizenry.
History of health services development teaches us the need for simultaneously developing both conceptual integration of preventive and curative services and organizational structures that can effectively operationalize all elements of the integrated and comprehensive health-care approach, given the ground realities. Within public health, it reiterates the need of conceptual integration of the technical, managerial and social dimensions and therefore inter-disciplinary teaching and skills. While several institutions have public health related courses for social scientists, no significant place or role has been assigned to them in the public system. What has been proposed here is a cadre composed of three sub-cadres providing multi-disciplinary teams: (i) A public health specialized medical sub-cadre, with clinical and public health implementing/teaching/research streams, (ii) a health management sub-cadre and (iii) a social determinants of health sub-cadre. The three would form a team of medical and non-medical persons with public health training at each level, namely block, district, state and national planning and policy formulation. The social scientists are required for infusing knowledge about the social dimensions of health and health-care through research as well as for education and training of all three streams. The HLEG has proposed the first two sub-streams, but not the third.
Despite an urgency to forming the Public Health Cadre, its structure should be well thought out at its very initiation. Systemic needs assessment should be the starting point rather than being constrained by existing structures. A creative, rather than a hide-bound techno-managerial cadre, needs to be envisaged to meet the challenges of the 21 st century and the breadth and diversity of the people of India. Wide discussion on all possible options and innovations will be necessary.
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[Figure 1], [Figure 2]