|PUBLIC HEALTH EDUCATION
|Year : 2014 | Volume
| Issue : 1 | Page : 34-39
Engagement of national board of examinations in strengthening public health education in India: Present landscape, opportunities and future directions
Anjali Sharma1, Sanjay Zodpey2, Bipin Batra3
1 Program Officer-Academics, Public Health Education, Public Health Foundation of India, New Delhi, India
2 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
3 Executive Director, National Board of Examinations, New Delhi, India
|Date of Web Publication||5-Mar-2014|
Director, Public Health Education, Public Health Foundation of India, ISID, 4, Institutional Area, Vasant Kunj, New Delhi - 110 070
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A trained and adequate heath workforce forms the crux in designing, implementing and monitoring health programs and delivering quality health services. Education is recognized as a critical instrument for creating such trained health professionals who can effectively address the 21 st century health challenges. At present, the Public Health Education in India is offered through medical colleges and also outside the corridors of medical colleges which was not the scenario earlier. Traditionally, Public Health Education has been a domain of medical colleges and was open for medical graduates only. In order to standardize the Postgraduate Medical Education in India, the National Board of Examinations (NBE) was set up as an independent autonomous body of its kind in the country in the field of medical sciences with the prime objective of improving the quality of the medical education. NBE has also played a significant role in enhancing Public Health Education in India through its Diplomat of National Board (DNB) Programs in Social and Preventive Medicine, Health and Hospital Administration, Maternal and Child Health, Family Medicine and Field Epidemiology. It envisions creating a cadre of skilled and motivated public health professionals and also developing a roadmap for postgraduate career pathways. However, there still exists gamut of opportunities for it to engage in expanding the scope of Public Health Education. It can play a key role in accreditation of public health programs and institutions which can transform the present landscape of education of health professionals. It also needs to revisit and re-initiate programs like DNB in Tropical Medicine and Occupational Health which were discontinued. The time is imperative for NBE to seize these opportunities and take necessary actions in strengthening and expanding the scope of Public Health Education in India.
Keywords: Education of health professionals, India, National Board of Examinations, Public Health Education, Public health workforce
|How to cite this article:|
Sharma A, Zodpey S, Batra B. Engagement of national board of examinations in strengthening public health education in India: Present landscape, opportunities and future directions. Indian J Public Health 2014;58:34-9
|How to cite this URL:|
Sharma A, Zodpey S, Batra B. Engagement of national board of examinations in strengthening public health education in India: Present landscape, opportunities and future directions. Indian J Public Health [serial online] 2014 [cited 2019 Jul 20];58:34-9. Available from: http://www.ijph.in/text.asp?2014/58/1/34/128163
| Introduction|| |
Jean Piaget has stated that "the principle of good education is to create men who are capable of doing new things, not simply of repeating what other generations have done - men who are creative, inventive and discoverers."  This statement is as much pertinent for the education of public health professionals as that of any other sphere. A well-educated workforce is essential for a strong public health system which forms the crux in designing, implementing and monitoring health programs and delivering quality health services. The World Health Organization (WHO) has developed a framework in 2007 entitled "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes." The framework has six building blocks, namely, financing, health workforce, information, medical products and technologies, service delivery and leadership/governance, leading to specific goals and outcomes such as improved health, responsiveness, social and financial risk protection and improved efficiency and builds on previous WHO work.  A critical mass of trained health professionals is necessary to manage a health system and is often a crucial limiting factor in the delivery of quality health services. The health workforce is characterized by its diversity and its complexity and includes people from a wide range of occupational backgrounds, e.g., doctors, nurses, public health professionals, dentists, paramedical workers, grass root workers and other health support staff. Public health professionals, one of important constituents of health workforce, are the key stakeholders for advancing the agenda of Universal Health Coverage and can thus serve as means for tackling global public health challenges.
| Public Health Education in India|| |
Education is recognized as a critical instrument for creating trained health professionals who can effectively address the 21 st century health challenges. Conventionally, Public Health Education in India has been offered through medical colleges as part of undergraduate (MBBS) curriculum and hands on experience is provided during internship. Currently, there are 381 medical colleges in India which produce 49918 medical graduates every year.  The Departments of Preventive and Social Medicine/Community Medicine (PSM/CM) in medical colleges also provide postgraduate education in public health in the form of MD (PSM/CM), Diploma in Public Health (DPH) and Diploma in Community Medicine (DCM). There are a total of 218 medical colleges which offer MD (PSM/CM) with an annual intake capacity of 740. Likewise, 39 medical institutions offer DPH to a batch size of 140 students  and 6 colleges run DCM with annual intake capacity of 11 students.  In addition to these traditional programs, some of the medical colleges/institutions run following specialized courses for medical graduates with limited annual intake capacity: MD (Community Health Administration), MD (Hospital Administration), Masters in Hospital Administration, MD (Tropical Medicine), MD (Maternity and Child Health) and PhD (Hospital Administration), Diploma in Hospital Administration, Diploma in Health Education and Diploma in Industrial Health.  However looking beyond the statistics, these postgraduate courses are available only for medical graduates.
Currently, Public Health Education in India is at a critical juncture with a conscious shift at establishing public health schools outside the realm of medical colleges. Taking cognizance of the fact that public health is a multidisciplinary science, Public Health Education in India is being offered in few institutions for both medical and nonmedical graduates in the last two decades. Some of them offer core public health programs (General Masters in Public Health [MPH]) and some of them offer specialized courses (MPH with tracks/specialization)  . At present, a total of 31 institutions offer MPH programs in India with annual intake capacity of 806 candidates. In the recent past, some institutions have launched specialized courses in public health-related disciplines. These courses include masters and diploma programs in health and hospital management/administration, epidemiology, health economics, health care financing and policy, bio-statistics and data management, occupational and environmental health, public health nutrition, etc.  [Table 1]. In addition to these, National Board of Examinations (NBE) has been offering Diplomat of National Board (DNB) in Social and Preventive Medicine, Health Administration, Field Epidemiology, Family Medicine and Maternal and Child Health.
| National Board of Examinations|| |
In order to standardize the Postgraduate Medical Education in India, the NBE was established in 1975 on the basis of the Report of a Working Group set up by the then Prime Minister , Smt. Indira Gandhi. The NBE functioned as a wing of the National Academy of Medical Sciences from 1975 to 1982 and the Government of India, after review, took a policy decision to make it an independent autonomous body with effect from March 1, 1982 of the Ministry of Health and Family Welfare. Since 1982, the NBE has been functioning as an independent autonomous body of its kind in the country in the field of medical sciences with the prime objective of improving the quality of the Medical Education by elevating the level and establishing standards of post graduate examinations in modern medicine on an all India basis. 
NBE conducts examinations in 65 specialties and has accredited 485 institutions/hospitals in public and private sector hospitals all over the country for the purpose of training of candidates in various specialties, in various disciplines of modern medicine. At present, NBE conducts postgraduate and postdoctoral examinations in approved specialties leading to the award of DNB providing a common national standard for assessment of postgraduate and postdoctoral training. NBE grants accreditation for DNB courses to hospitals in various broad and super specialties and has laid down norms for recognition of hospitals/institutions, which seek to train candidates. The board conducts postgraduate and postdoctoral examinations in 65 disciplines approved by the board for the award of DNB. The Medical Council of India (MCI) has laid down standards for Postgraduate Examinations conducted by various medical colleges and affiliated to concerned universities and other institutions, yet the levels of proficiency and standards of evaluation vary considerably in these institutions. The setting up of a national body to conduct Postgraduate Medical Examination was intended to provide a common standard and mechanism of evaluation of the minimum level of attainment of the objective for which post graduate courses were started in medical institutions.  This brief review highlights the contributions of NBE in enhancing the agenda of Public Health Education in India and thereby contributing in building a strong health workforce.
| Endeavour of NBE in Advancing Public Health Education Agenda in India: Present Landscape|| |
NBE was set up with the mandate to standardize the postgraduate medical education. However through few of its programs, NBE also played an important role in enhancing Public Health Education. NBE offers DNB Programs in Social and Preventive Medicine, Health and Hospital Administration, Maternal and Child Health, Family Medicine and Field Epidemiology  [Table 2]. Through these disciplines, NBE has been contributory in improving the scope and reach of education in public health. As an academic discipline, the Family Medicine program includes comprehensive health care services, education and research. A family doctor is the first contact physician and provides primary and continuing care to the entire family within the communities; addresses physical, psychological and social problems; and coordinates comprehensive health care services with other specialists, as needed. The practitioners in family medicine can play an important role in providing health care services to the suffering humanity. Since this specialty is broad, a single postgraduate in Family Medicine can meet the requirement of a Surgeon, Obstetrician and Gynecologist, Physician and a Pediatrician in a Community Health Center, besides taking care of public health needs of the community. In a country with a large population spread over to the rural sector, the need for adequately trained, properly qualified, competent general practitioners is acutely felt. And therefore, family physicians are in an ideal position to drive changes in the public health and health care service delivery.
|Table 2: Public health related academic programs currently being offered by NBE|
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Likewise, the program DNB in Health Administration including Hospital Administration has also played a significant role in building a cadre of professionally trained and competent personnel in the field of health and hospital administration who can ensure quality, improvement and better productivity in the delivery of health care services. The overall goal of the program is to train the candidate to carry out the job functions of an expert consultant in the specialty. This intensive program with a practical focus is designed to develop a cadre of professionals competent enough to take up key managerial and research positions in health and hospital settings. It helps the medical graduates in understanding health administration, planning and hospital administration, administration of clinical and non-clinical services and the overall health care delivery system, in the country. It also promotes research and training in the field of health and hospital administration.
DNB program in PSM aims to prepare CM specialists of the highest caliber who have a basic understanding of clinical practice, a thorough knowledge of epidemiological principles and methods and epidemiology of communicable and non-communicable diseases, a familiarity with statistical methods, the relevant aspects of the social sciences and the principles of administration and management and the ability to apply this knowledge to the management of health services and the study of diseases.
The DNB Field Epidemiology Program is structured to impart hands on training and competencies to public health graduates on disease surveillance and disease response in public health systems. This program helps in developing sustainable capacity for detecting and responding to health threats; further disease outbreaks can be detected locally at early stages and prevented from spreading. The DNB Maternal and Child Health is a post graduate program aimed at capacity building and certification of skills in the continuum of services across maternal and child health, this integrated program besides focusing on preventive, promotive and curative health has strong components of health management, health systems and health workforce management for setting up and improvising MCH services through community participation and health systems strengthening and elements of research.
| Opportunities for NBE in Expanding the Scope of Its Engagement in Public Health Education|| |
NBE has also been actively involved in advancing the implementation of various other public health workforce development initiatives. With an endeavor to advance public health at the grassroots level including ambulatory care for common conditions and to give impetus to public health action in rural areas and take the core healthcare closer to people under the NRHM, the Government of India has decided to create a new group of middle level health professionals to be deployed at the sub-centers. For this, a course known as Bachelor of Science (Community Health) would be started which is a step toward the creation of public health cadre in the states as recommended by expert committees and the Planning Commission. This 3½ years course includes 6 months of internship and the medium of instruction is decided by the State Governments (which could be any national language). The graduates of BSc (CH) program would be known as Community Health Officers (CHO). They are not entitled as doctors and hence are not eligible to write a prescription for drugs/medicines or to provide private clinical services to any individual outside the government health system under any circumstance. They would however authorized to dispense and administer designated/notified set of drugs and medications, many of them as part of the various National Health Programs. Auxiliary Nurse Midwife (ANMs) and male health workers would report to these CHOs and CHOs in turn report to the Medical Officer of the area PHC. Both public health and clinical competencies would be inculcated in these BSc (CH) graduates. These CHOs would not only assist in implementing national programs on the ground with ANMs, male health workers, Accredited Social Health Activists and others but also work closely with other development teams (agriculture, Integrated Child Development Services, water and sanitation) at the village level. CHOs would also work closely with women's groups, Panchayati Raj Institutions, Non-government Organizations and others.  NBE shall be the principal institution entrusted with regulating the program through accreditation of district hospitals, affiliation of the graduate programs, faculty development and recognition of the graduate and post graduate qualifications besides advisory role to the government.
Public health and medicine have been mutually dependent and interact with each other, in the past as well as in modern times. And considering the fact that NBE has been striving for excellence in Postgraduate Medical Education and Examinations, its full potential is yet to be tapped in public health domain. Governance and accreditation issues are one of the major roadblocks in channelizing and improving Public Health Education in India. The MCI is a statutory body charged with the responsibility of establishing and maintaining uniform standards of medical education and recognition of medical qualifications and it also ensures the ethical practice of medicine by all registered medical practitioners.  It is important to note that its mandate covers only medical education across the country. Therefore, only the public health degrees granted by medical colleges (MD, DPH/DCM, PhD) come under the purview of MCI. The public health courses for non-medical professionals are not overseen by MCI and are either registered under the All India Council for Technical Education or the University Grants Commission. This raises a situation where there is no single uniform central body or council responsible for Public Health Education in the country. In the absence of such an overarching body responsible for the accreditation of Public Health Programs and Institutions, NBE's capacity and ability can be utilized in this regard and it can be an impetus in improving and standardizing Public Health Education in India.
It is evident that public health is a discovered discipline and is inherently multi-disciplinary which requires multi-sectoral collaboration and integration. Having said this, need of the hour is to train and educate professionals beyond the medical discipline as well, assisting them in gaining insights in various complexities, allowing them to shape new ideas and explore the wide range of possibilities and confront the most pressing health challenges of our times. NBE can be a forerunner in this front and take up additional responsibilities such as further engagement in educational research and training of medical and non-medical professionals. Looking back, NBE had been offering other specialized programs in public health related courses-Tropical Medicine and Occupational Health. However, they have been discontinued due to low enrolments in these disciplines coupled with fewer institutions offering such programs. However, it is the right time to revisit them and re-initiate such programs. Besides this, it can also be a key player in initiating and implementing new specialized programs in the field of public health viz. Health Promotion, Public Health Nutrition, Environmental Health and other core domains of public health.
A CII policy paper points out that "capacity building and training initiatives by the government need sharpened focus not only for quantitative increase in trained manpower but also for improving the effectiveness of existing methods in training."  NBE can be an important agency in steering the agenda of building capacities of health professionals in the country. There is also a need to create synergy between medical education, public health and delivery systems to address the complexities of the existing and emerging health problems. The role of NBE can be redefined and its structure and functions can be expanded and made explicit to carry out these responsibilities. However, there are still many more opportunities for NBE for further involvement in changing the landscape of Public Health Education and to review and standardize medical education keeping it in sync with needs of public health and revisiting career paths and progression for the health professionals.
| Future Directions|| |
For achieving the overall objective of Universal Health Coverage, Health Systems need to be strengthened globally. And this cannot be accomplished without a trained and adequate heath workforce. The NBE has contributed significantly in the development of health workforce with a focus on Public Health Education through its programs in clinical specialties as well as of that for public health. Through its programs in Family Medicine, Social and Preventive Medicine, Maternal and Child Health, Health and Hospital Administration and Field Epidemiology, it envisions to create a cadre of skilled and motivated public health professionals and also developing a roadmap for their postgraduate career pathways. However, it can still play a more significant role in broadening the horizons of Public Health Education through accreditation and initiating new public health programs. Furthermore, the time is opportune for the NBE to revisit and review some crucial programs that were discontinued like DNB in Occupational Health and re-start them in order to build public health workforce in India.
There is a recognized need to introduce a competence driven curriculum and use of new teaching-learning methodologies. This will lead to a new generation of health graduates of global standards. Recognizing the fact that a good education is no longer just a pathway to opportunity - it is a pre-requisite, it is imperative to revitalize our post graduate education architecture and refine it as per the country's public health needs else the "health for all" in India will only remain a mirage.
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[Table 1], [Table 2]