PUBLIC HEALTH EDUCATION
Year : 2010 | Volume
: 54 | Issue : 3 | Page : 137--144
Public health manpower: An alternative model
Chairman, Indian Academy of Public Health and Principal, KPC Medical College, Kolkata, India
F U Ahmed
Chairman, Indian Academy of Public Health and Principal, KPC Medical College, Kolkata
The Bhore committee observed that «DQ»if nation«SQ»s health is to be built, the health program should be developed on the foundation of preventive health work and that such activities should proceed side by side with the treatment of patients.«DQ» The committee defined two categories of workforce: one for the personal care and the other for the public health namely, public health nurses and sanitary inspectors for public health and nurse, midwife, and pharmacist for personal care. Recommendations of successive health committees lead to amalgamation of personal care services and public health services. Single focus programs and amalgamation of different cadre of Grassroots staff lead to dilution of public health services and more focused on different program-based personal care services. To carry out public health services, we need a sufficiently knowledgeable, well-skilled and competent mid-level supervisory public health workforce who can support and strengthen the performance of the existing multipurpose workers. Increased understanding of the influence of different determinants on health and well-being and also scientific progress to combat the environmental and biological effects on health has widened the gap between the actual need of human resources and expanding public health services needs. Keeping in view of the above and meet the challenges, a 3-year course of Bachelor in Public Health is conceived by the Indian Academy of Public Health. Professional responsibilities expected from this new cadre of workforce are also discussed in this article.
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Ahmed F U. Public health manpower: An alternative model.Indian J Public Health 2010;54:137-144
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Ahmed F U. Public health manpower: An alternative model. Indian J Public Health [serial online] 2010 [cited 2020 May 31 ];54:137-144
Available from: http://www.ijph.in/text.asp?2010/54/3/137/75736
Evolution of public health workforce in India
The type of Human Resources for Health (HRH) engaged in delivery of health services in India have been largely influenced by prevailing health situation and mostly by the recommendation of the "Bhore committee" (1946) and various other committees of the government. The Bhore committee observed that "if nation's health is to be built, the health program should be developed on the foundation of preventive health work and that such activities should proceed side by side with the treatment of patients." The committee visualized the development of primary health center (PHC) and suggested to provide integrated preventive and curative services. In its recommendations, it suggested one PHC for each 40,000 population under a short-term measure and one PHC for 10,000-20,000 populations with 75 beds under long-term measure (also called "3 million plan"). Under the short-term measures, the staffing of each PHC would consist of 2 medical officers of health, 4 public health nurse, 1 nurse, 4 midwives, 4 trained dais, 2 sanitary inspectors, 2 health assistants, 1 pharmacist, and 15 other class IV employees. It is to be noted though he envisaged an integration of preventive and curative services but he defined two specific categories of workforce, one for the delivery of personal care and the other for the public health namely public health nurses and sanitary inspectors. The manpower requirement as per the prevailing health situation was essential, but during that period we did not have the adequate number of human resources in the country. The gap between the actual need of human resources and expanding health services increased in leaps and bounds in the successive years more so after initiation of the massive All India Family Planning Program. Thereafter, the Mudaliar Committee (1962) on future development and expansion of health services recommended that consolidation of advances should be made in the first two five-year plans. He recommended regionalization of health services for providing integrated medical and health services by establishing one PHC for 40,000 population and strengthening the district hospitals with specialists. 
Phase of integration
For making necessary arrangements for the maintenance phase of the National Malaria Eradication Program, the Chadah committee (1963) was constituted. It recommended that the vigilance operation of malaria should be implemented through basic health workers, one per 10,000 populations. These workers are to be known as multipurpose workers to look after additional duties of collection of vital statistics and family planning in addition to malaria vigilance and the family planning health assistants were to supervise three or four of these basic health workers. Implementation of the Chadah committee's recommendations in a few years was found to be ineffective and resulted in lapses in both the vigilance operation in malaria and also in the performance of family planning program. During the same period, the states due to paucity of fund were not able to cope up with the burden of the maintenance phase of malaria, and other mass programs such as family planning, small pox, leprosy, trachoma, etc. The issue was discussed in the Central Health Council meeting in 1965. And later in the Central Council of Health Meeting of 1966, it was decided to appoint a committee of health secretaries of the state under the chairmanship of Mr. Mukherjee, the then Health Secretary of Government of India (GOI). Initially, it recommended separate staff for family planning and delink malaria vigilance from the family planning work, but later the committee worked out the details of "Basic Health Service" which should be provided at the block level and some resulted strengthening required at higher levels of administration. The next report was submitted by Dr. N. Junggalwala, Director, National Institute of Health Administration and Education (NIHAE) chairing the "Committee on Integration of Health Services". The committee defined "integrated health services as a service with a unified approach for all problems instead of a segmented approach for different problems and medical care of the sick and conventional public health programs functioning under a single administrator and operating in unified manner at all levels of hierarchy with due priority for each program obtaining at a point of time." 
Phase of multiskilling
Thereafter, in 1973, "The Committee on Multipurpose worker under Health and Family Planning" under the chairmanship of Kartar Singh, Additional Secretary, Ministry of Health and Family planning, Government of India, set the current structure of integrated services. The recommendation of block level regionalization of service and the staffing pattern became the modus operandi of health care delivery till date with minimal alteration or addition. One Primary Health Center (PHC) was recommended for each 50,000 population. And under it one subcenter was for each 3000-5000 (approximately) population depending on topography. Each of the subcenter will be staffed by one newly designated "Female Health Worker" and one "Male Health Worker". The committee designated the auxiliary nurse midwife (ANM) as "female health worker" (FHW) and the existing basic health workers, malaria surveillance workers, vaccinators, health education assistants (Trachoma), and the family planning health assistants as "male multipurpose worker" (MPW). They also recommended a male supervisor for each three to four male workers and one female supervisor for each four female workers. The existing lady health visitor (LHV) is to be designated as "female health supervisor", and the doctor in the PHC should be overall in-charge and the leader of the health team. He will supervise the services of all categories of health workers and supervisors. For the first time, the idea of skill mixing in the most peripheral group of workers was conceived. The erstwhile post of sanitary inspector and the post of public health nurse, the sole public health workers in a PHC, were abolished and even the training for the sanitary inspectors and public health nurses were closed down. Instead female and male multipurpose workers training with an integrated curriculum was introduced. The female multipurpose workers' training course was successfully conducted in almost all the states with central assistance. The training of the MPW was a nonstarter from the beginning in most of the states. 
In the Common Review Mission Report (CRM) of the NRHM in 2007, the current status of the human resources of health is clearly depicted. It mentions "The gaps between the generation of skilled human resources and their requirement are large and growing and only a massive expansion of nursing education can meet the demand." Regarding the MPW training, it states "Pre-service training institution for generating multipurpose workers, both male and female, and their supervisory staff, which have gone into dysfunction in the last decade, need to be revived, expanded, and strengthened." The multiskilling experiment of personal and public health care mix in the most peripheral workers miserably failed as there was no backup support from the next cadre of workers, i.e. male and female health supervisors. The training was inadequate, and the service condition was not attractive for the male and female workers to undergo training for health supervisors. The report further recommends innovation in human resources development for the health sector. If one has to think of renovation rather than tinkering with some managerial options, e.g. contractual appointment, recruiting workers from the immediate residents, incentives to staff to work in hitherto underserved area, and introduction of multiskilling and multitasking, than one should think about a new cadre of worker meeting the current needs of public health services. Human resource development strategies under NRHM seem to be an ad hoc arrangement. In the Common Review Mission (CRM) report with the augmentation of numbers and better training of the existing workforce under the NRHM program, the review mission observed "Of the 13 states visited almost all have reported increased performance in terms of absolute attendance and to a lesser extent in terms of quality of care." This is most obvious for institutional deliveries where the Janani Suraksha Yojana (JSY) has put pressures on the public health system and to a large extent on increased outpatient department (OPD) attendance in general. This definitely is an indication of a positive impact on the "Personal Health Care Service" component and not the public health care component. With the increased awareness on health and the availability of health services, the demand for personal health care service will increase in geometric progression and will eat up most of our health budget and at the same time it is not going to improve the health indicators such as IMR, MMR, or general morbidity. To have an impact on the health indicators, we shall have to develop our public health care services. For any major innovation, one has to know the basic requirement of a health care package and its delivery system based on conventional public health knowledge and concept.  It is said that the health system requires getting the right number of service providers with the right skills to the right place at the right time.  Health manpower in India is not only numerically inadequate, but also inadequate in type or kind. To appreciate the deficiency of a right kind/type of health workforce, one has to analyze the situation on the basis of the existing conceptual framework under public health administration. The conceptual framework of service delivery is beautifully depicted in the John. J. Hanlon's book on "Principles' of Public Health Administration".
It is described as under Conceptual framework. The health service package required for a community appears to fall into three broad categories or groups: (i) those concerned with the protection and care of the individual, (ii) those that focus particularly upon factors in the environment that may be inimical to man, and (iii) the variety of services provided by a variety of disciplines or professions in support of the first two categories." 
The focus of the first category of service package is on an individual or a family and the services included are promotive, preventive, curative, and rehabilitative services. This category of services can be described as Personal Health Care Services. Personal health care focuses on individual namely, case, beneficiaries, at risk individuals, target individual, or family. Besides all institutional curative services for sick persons, this type of services also constitutes a major activity in all the major National health programs aimed to address different Health Problems at the family level, i.e. Malaria Control, Revised National Tuberculosis Control Program (RNTCP) (case detection and treatment), Reproductive and Child Health (RCH) and National Rural Health Mission (NRHM) (identify the beneficiaries, risk group and provide appropriate intervention package).The focus of the second and third categories of service packages is on the community as large and can be described as Public Health Services. It also includes promotive, preventive, curative, and rehabilitative services. Public health services are aimed to protect the public/community from the factors in the environment that may be inimical to man and also aims to deliver a need based comprehensive health care package to the community/public in need. This requires planning, organizing, and help of other supporting services provided by a variety of disciplines or professions. The first category of service package includes environmental sanitation, food hygiene and sanitation, epidemic disease control, hygiene in working places, school health, health promotion, Non-Communicable Disease Control, Disaster management or any other public health emergency, and also delivering the public health components of the existing the National Health Programs. Besides planning, organization, and providing health services to the community, the second category of service package includes supporting service package from other departments such as woman and child, social welfare, water resources, environment, food and agriculture, finance contributing to the health of the people. This seems to be the basis of the strategies of convergence of health-related services to reach the community in India's Rural Health Mission.
To deliver the two distinct categories of health service package we shall need two distinct group of trained personal, one to deliver the personal health care service package and the other public health services package. Defining the activities in delivering the services is an important step in the proper manpower development. The activities related to the personal care is to treat all the persons who attend any static or health institution or detected during the field visits by the worker or through extension clinics. Besides these routine activities, it also includes providing comprehensive (curative, preventive, and promotive) health care to the individuals and family during any emergency such as flood, earthquake, etc., or in different working environment such as industry, and institutions namely school, crθches. Here the focus is on individuals at best the specific families. The training requirement in such categories of worker will be specific as they require a specific skill and competence. And that was the reason, Bhore Committee's recommendations consisted of two distinct categories (i.e., comprising of public health nurse and sanitary inspector for delivering public health services and the others to deliver the personal care services) under the leadership of to specific medical officers. Due to the paucity of resources, the later committees recommended integration of services at the peripheral level and resort to multiskilling of peripheral health workers. However, one can appreciate how difficult it will be for a peripheral health worker with a less than school final level education and training of one and half year to two years to do all the personal care services, which includes all the stages human life cycle, "from womb to tomb," and also provide public health services by organizing and involving the community. Are we not overestimating the capability of such a worker? One can only appreciate if one has an idea of the basic activities/tasks under public health services. They are as follows:
Recording and analysis of health data: Under this, different specific activities are: collection of data related to births, deaths, marriages, divorces and modifiable diseases, maintenance of registers of individuals with specific long-term morbidity and disability, conducting special surveys to determine the prevalence and resultant disability from various diseases, collection and interpretation of morbidity data from various sources such as PHC, hospitals, nursing home, etc., maintenance of records on the number of qualified manpower, quantitative, qualitative resources available, facilities, and the types and extent of health services provided through various voluntary and public programs, and periodic evaluation of community health needs and services. Health education and information: Under this head the activities are stimulation of the public to recognize health problems that exists, to study the resources available for meeting the problems, and to develop and put into action program designed to solve them; cooperation with and assistance of official and voluntary organizations such as education, civic youth, and other community groups to develop health program: Organization of Behavior Change Communication sessions in different patient groups, vulnerable at risk groups, parents, adolescents, youths, and other specific groups; use of mass educational and information media; development of well-rounded program of professional education.Supervision and regulation: The activities includes: protection of food, water and milk supplies; control of nuisance, sanitary disposal of wastes, and control of water and air pollution, chemical and radiation hazards, noise abatement; prevention of occupational diseases and accidents; control of human and animal source of infection, regulation of housing; inspection and licensure of hospitals, nursing homes, and other health facilities: inspection and licensure and revocation of permits of eateries, restaurants, hotels, motels, and other public buildings such as cinema theatre, etc.Provision of environmental health services: as necessary, solid waste and sewage disposal, drainage and larvicidal, treatment of mosquito breeding areas and residual spraying for vector control; rat proofing of buildings and other rodent and insect control measures.Administration of personal health services: In this group, the activities included are: immunization against infectious diseases; advisory health maintenance services such as growth monitoring of children, antenatal, post-natal clinic, etc.; case finding surveys of the general population cancer detection program, school health program, to detect various diseases under different National programs; provision of diagnostic aids to physician such as laboratory services, special health clinics, and diagnostic center.Operation of health facilities: It includes operation of subcenter, primary health center, health community health center, and first referral units, general or special hospitals.Coordination of activities and resources: The activities include are provision of affective leadership in meeting community health needs: encouragement of coordination of various official and voluntary agencies to avoid duplication and overlapping; inter-sectoral coordination with other related departments.
To meet the Health and Family Welfare need of any community besides infrastructure need, one must have adequate number of well-trained staff. Analysis of the different public health tasks will be relevant for understanding the difficulties faced by the existing peripheral workers in the public sector. The first task mentioned is Recording and Analysis of Health Data. The Common Review Mission (CRM) document under the head key findings and subhead of Performance of NRHM Strategies provides us a clear picture. It states "Village plans prepared based on household health data and with involvement of Panchayati Raj Institutions (PRIs) are still an exception" and refers to "many other constraints in data collection and flow," "copies of reports sent above are not yet maintained," and "Health Management Information System (HMIS) is not used adequately to inform planning and responsive corrective action (CRM). " It is clear from the above observation that data may be collected by the peripheral health workers efficiently but at the PRI and PHC level who is trained to collate, analyze, and disseminate the data to the decision makers and supervisors for planning and/or corrective action. The health supervisors are trained to assist the doctor in collating and analyzing the data, but unfortunately the health supervisors' proper input is a rarity and if the doctor relies on the report most of the data will be spurious. If the doctor is over enthusiastic and devotes a major time, it will affect the delivery of personal health care services and operation of health facilities and consequently he will have to face the ire of the unsatisfied patients attending the PHC.
Supervision and regulation and provision of environmental health services are the two most important public health tasks which at present is not being addressed properly both in the public and private sectors. With the abolishment of sanitary inspectors course in the wake of multipurpose worker scheme, both these tasks were amalgamated with the multipurpose workers course. Any conscious citizen will agree that any of our existing trained and experienced peripheral health workers in public and private sphere tackle the kind of environmental pollution and the ever expanding food and beverage industries and their fall out on public health. The existing curriculum of MPW is age old, and the content of training on control of the environment and other public health conditions and emerging public health intervention is outdated. With the changing economy and changes of lifestyle and food habits, there is an increase in the eatery of many kinds in both urban and rural areas as well as there is an increase in the usage of processed food in the community. Both of these changes have emerged as one of the challenges in the epidemiology of food borne diseases, but unfortunately our health workers are not properly equipped with any intervention program. In many of the states, food inspection is done by a different cadre of worker under health department. However, they are limited to the few urban areas and they do not have direct coordination with the existing public health care delivery system. Creating a new department or a bureau does not improve the efficacy, but sometimes becomes a impediment to proper functioning. The other area is implementing the Non-Communicable Disease Control program. The strategy to be adopted is lifestyle and behavioral change. Do we have the right public health workforce to implement it effectively? Public Health foundation an Institution under the patronage of Government of India and the Department of Health rightly emphasized the need to start Masters in Public Health Courses and established few public health institutions that will in time join the Health services and will be placed in the District to improve the planning and management. Will it serve the need as mentioned above? However, delivering public health service is not solely dependent on a trained manager. It requires a well-qualified and competent team of workers who are not burdened with providing personal care. Unfortunately, we do not have any such cadre or any course of study to prepare such workforce. At present, we need a sufficiently knowledgeable well-skilled and competent mid-level supervisory public health workforce who can support and strengthen the performance of the existing community and an Institution-based peripheral health worker with an opportunity advancement in the carriers of existing and new supervisory workforce.
Keeping in view the requirements of a manager for providing the public health services in a community or an industrial setting, a course of Bachelor in Public Health is conceived by the Indian Academy of Public Health. The members have deliberated on the job responsibility of such a worker and finally agreed that at the end of the training he/she will be working in a PHC as a Health Inspector and assist the medical officer to plan, organize, and implement all the Personal Health Care Programs as well as Public Health services. The post of Block Health Educator may be converted to Block Health Inspector and similarly like District Public Health Nurse a post of District Public Health Inspector may be created. The promotion to the post will be only possible if the incumbent block health inspector undertakes a Masters in Public Health (MPH) course. Accordingly in the state level, a post may be created for public health personnel that will be filled up by promotion. The course will be a 3 years graduate course with a provision of a major stream (Honors Course) in Environmental Science, Behavioral Sciences, Epidemiology, or Occupational Health and Nutrition. The major course (Honors) will be 4 years. Both the course will have 1 year internship program. While formulating the course due attention will be paid so that it is a competency-based and not a curriculum-based course. The course will be fashioned in such a way that after each of the theoretical exposure, the students will go back to their respective workplace in case of in-service candidates or allocated a community posting under the mentorship of a public health guide so selected by the Parent institute. In this course at least 30% of the seats will be available for the in-service candidates fulfilling the admission criteria of 10+2 qualification. To improve the quality of training, the three levels of the training namely basic health worker, graduate public health course like graduate laboratory technician, and MPH training should be supervised and conducted by the State Health University. Distance learning program through virtual class rooms in the different district training centers may be started under National Institute of Health and Family Welfare (NIHFW) (which can be given a University status for these courses) or under Government run Indira Gandhi National Open University (IGNOU).
Professional responsibility expected of the proposed cadre of worker
Monitor health status to identify community health problems.Able to monitor the physical, chemical, and biological environment such as water, sanitation, and air quality in the community and work places and are able inform the authority for intervention and also be able to carry out any available intervention.Able to monitor food hygiene both prepared and raw food, public eating places in the community, and able to suggest healthy measures.Inform, educate, and empower people about health issues, capable of providing behavior change education to the individuals, family and community for bringing out lifestyle and behavioral changes.Mobilize community partnership to identify and solve health problems.Diagnose and investigate community health problem.Organize and implement health promotional, protective, preventive, and rehabilitative services/program in the area he/she serves.Participate in local planning, implementing and monitoring all national public health programs adapting to the need and resources of the community along with the medical and health officer.Enforce laws and regulations that protect health and ensure safety.Identify common community health emergencies/disasters and initiate action and seek for further help.Able to provide primary health care for common morbidities.
Conduct research for new insights and innovative solutions to health problem.
Graduate public health course/B.Sc. public health
To develop a cadre of public health practitioner who possess the knowledge of different determinants of health and its effect on different health and disease condition in individuals, family, and community and are able to monitor the environment and take appropriate measure if found faulty, and able to assist the Medical and Health officer to plan, implement and supervise comprehensive health care services and implement different National Health Program adapting to the communities health need with a primary care approach.
At the end of the training the students will acquire
Knowledge to be able to
explain the concept of health and disease in a community and the role of different determinants on health and diseaseexplain the principles and concepts of Public Healthexplain how to identify and solve the common public health problems in the community.
Skills to be able to
participate to identify the basic environmental and social determinants of health in individuals, family, and community.participate in the identification of priority health issues of the community and able to formulate appropriate intervention/solution that are practicable and acceptable to the community.participate in planning and management of National Health Programs and other activities of health care and protection of the community.participate in monitoring the physical environment namely quality of drinking water, sanitation, air quality and hygienic condition in the community and in workplace and able to carry out available interventions as per recommendation.participate in the monitoring and evaluation of the implementation of different ongoing health program.participate in monitoring and identification of health emergencies, epidemics and organize preventive activities in the community.participate in organizing medical relief and rehabilitation in case of disasters.provide health education to the community focusing on changing lifestyle and behavior for good health.
Attitude so that he is
aware of the importance of the principles of primary health care principles in community health care.respecting and listening to the community's input on health needs and interventions aim at improving the health status.seeking for and cooperate with group work and collaborate inter-sectorally.willing to learn and teach others continually to improve his knowledge and skill and to pass it over to other members of the team for improving their capacity.
Highlights of the course (B.Sc. public health)
|1||Park K. Park′s Text book of Preventive and Social Medicine. 18 th ed. Jabalpur, India: Banarasi Das and Bhanot Publishers; 2005. p. 776-80.|
|2||Government of India. Ministry of Health and Family Welfare. NRHM-Common Review Mission Draft. Nirman Bhawan, New Delhi, India, 2007.|
|3||World Health Organization. Human resource for Health. 2009. Available from: http://www.who.int/hrh/en-Health work force [last accessed on 2010 Oct 19].|
|4||Hanlon JJ. Substance of Public Health, Principles of Public Health administration. 5 th ed., Part IV. Saint Louis: The CV Mosby company; 1969. p. 334.|