|DR. B.C. DASGUPTA ORATION
|Year : 2015 | Volume
| Issue : 3 | Page : 167-171
Enabling public health education reforms in India
Director, Public Health Education, Public Health Foundation of India, New Delhi, India
|Date of Web Publication||7-Sep-2015|
Director, Public Health Education, Public Health Foundation of India, Plot No. 47, Sec - 44, Institutional Area, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Zodpey S. Enabling public health education reforms in India. Indian J Public Health 2015;59:167-71
Adam Smith stated that the "capacities of individuals depended on their access to education."  Public health education is vital for producing high-quality, competent, and motivated public health professionals and thus, enhancing their potential to contribute toward achieving health goals. The Lancet Commission on Education of Health Professionals for the 21 st century, a global independent initiative, called for comprehensive global reforms in the way health professionals are educated and made recommendations for advances in transformative learning and utilization of the power of interdependence in education.  The important features of this report were that it adopted a global outlook, a multiprofessional perspective, and a systems approach and highlighted the fundamental linkages between the education system and health system. 
At the beginning of the 21 st century, we are experiencing several public health challenges. There are glaring gaps and inequities (both within a country and between countries) in terms of health and related indicators. We are confronted with new emerging health challenges viz. new infectious/ environmental/behavioral risks, rapid demographic and epidemiological transitions, and the growing burden of noncommunicable diseases including injuries and the increasing complexity and costs of health systems. The Lancet Commission has highlighted that health professional education has not kept pace with current health challenges mainly due to the fragmented, outdated, and static curricula; mismatch of competencies with the needs; weak teamwork; gender stratification and narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital dominance over primary care; production of ill-equipped graduates; major imbalances in the professional labor market; and weak leadership to improve the health system's performance. 
We are cognizant of the fact that there has been a lot of progress in the field of education for health professionals in the last century. Three generations of educational reforms have taken place with the first generation of reforms beginning in the 20 th century that instilled a science-based curriculum in the universities. Around the 1970s, the second-generation reforms shed light on problem-based instructional innovations. The third-generation reforms that need to be adopted now should be systems-based, bringing in competency-driven approaches to instructional and institutional designs. The Lancet Commission calls for a broad reform movement, encompassing instructional design on what we teach and how we teach and institutional design focusing on institutions or universities that should implement instructions. It is emphasized that in order to have a positive effect on health outcomes, the professional education subsystem must design new instructional and institutional strategies. In instructional design, the approach should be competency-driven and interprofessional, bringing together health professionals to work as a multidisciplinary team. It should emphasize on the use of information technology to empower health professionals during training and in the field. In institutional design, better coordination is required between the education system and health system to ensure that the health professionals trained are competent to respond to the health needs of the communities. In addition, global partnerships, associations, and networks are needed to better leverage educational resources from around the world.  Recommendations, therefore, call for four immediate-to-long-term enabling actions to create an environment that is conducive to specific reforms: Mobilize leadership; enhance investments; align accreditation; and strengthen global learning with the ulterior aim for transformative and interdependent professional education for equity in health. ,
Emphasis on transformative learning is the most important fundamental driver of health professional education reforms for the 21 st century. Informative learning is about exchanging information and developing concrete skills. Its purpose is to produce experts. It is important but not enough. The next level of learning is formative learning that is about socializing students with a set of values. Its purpose is to produce professionals who are guided by a code of conduct. Transformative learning is the highest form of learning that revolves around developing leadership attributes. Its purpose is to produce enlightened change agents who are aware of the social determinants, work effectively as teams in a health system, bring in a new flavor of professionalism based on their service orientation, and can use global resources to address local priorities. 
Recently, several initiatives from various parts of the world have played a key role in fostering and deepening the reforms agenda for health professionals' education, viz., the report of the Joint Learning Initiative on Human Resources for Health (HRH) in 2004, the establishment of the Global Health Workforce Alliance and the Asia Pacific Alliance on Human Resources of Health (AAAH), the publication of World Health Report 2006, United States Agency for International Development (USAID) Capacity Plus Project (2009), United States President's Emergency Plan for AIDS Relief (PEPFAR)'s Medical Education Partnership Initiative (MEPI)-Nursing Education Partnership Initiative (NEPI), launch of the Asian Network on Health Professional Education Reform (ANHER), the development of the World Health Organization (WHO) Global Code of Practice on International Recruitment of Health Personnel, WHO's guidelines (2010) on Increasing Access to Health Workers in Remote and Rural Areas through Improved Retention, the Lancet Commission report on Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World (2010), and the publication of WHO's Transforming and Scaling up Health Professionals' Education Guidelines (2013). ,,,,,,,,, All these initiatives strongly emphasized the need for advancing the agenda of reforms for health professional education including public health education.
Public health education in India is at a critical juncture with a conscious shift from medical schools to public health schools offering Master of Public Health (MPH) and other public health courses in order to create multidisciplinary public health professionals who can assume wider public health responsibilities at different levels of the health care system and in different organizations. Public health education was traditionally a medical model in India, being offered in medical colleges through departments of community medicine and was open for medical graduates only. Currently, several nonmedical background institutions offer various courses in different domains of public health and are open for medical and nonmedical graduates [Table 1].
However, public health education in India is confronting challenges on multiple fronts such as governance, architecture of courses, curriculum and competencies, educational resources, faculty, and assessment.
Currently, there is no mechanism to regulate public health education in India on the lines of professional councils for medical and nursing education. Most of the public health courses are being offered by institutions as a part of university architecture. The University Grants Commission in India has included some programs like MPH in its schedule. Moreover, presently there is no mechanism to accredited/benchmark institutions and courses in public health in India. There is a sudden growth of institutions and courses related to public health in the last two decades. Several of these courses are of variable quality and concerns have been raised regarding the quality of these courses. The need, demand, and supply of public health professionals also pose a difficult challenge on the governance front. If the education system forms the supply side that produces health workforce, then the health system constitutes the demand side of this equation. Unfortunately, presently there seems to be a strong disconnect between the public health professionals which are produced to meet the ever changing needs of the health system. On the one hand, we say that the country needs trained public health professionals and on the other hand, we debate the availability of job opportunities for these professionals. There are no systematic efforts to create a job market and translate this "need" into a "demand" for public health professionals. Presently, only a few states in India have a public health cadre and that too predominantly for medical graduates only. With the changing scenario where public health education is being opened to nonmedical graduates as well, greater advocacy is required to create adequate job opportunities and career pathways for trained public health professionals.  Also, the potential of existing networks and collaborations has not been tapped fully in India. There are several individual and institutional networks that exist in India but their power to break the silos, develop synergistic relationships, and offer an opportunity to share resources and competencies across organization and health systems has not been thoroughly reflected and utilized. 
Then, there are issues related to public health courses that are being currently offered. One of the major concerns that has been expressed in recent years is related to the variable quality of these courses, resulting in public health graduates with different qualities of education. The specialized training programs in some domains of public health are sporadic in India. We have few courses in the areas of health economics, occupational health, environmental health, public health nutrition, etc. Moreover, currently there are few institutions that offer Doctor of Philosophy (Ph.D) programs in the various domains of public health. We do not have Doctorate in Public Health (DrPH) and postdoctoral fellowships in Public Health. With limited capacity to offer doctoral programs in public health, we will not be able to respond to the growing need for faculty for the existing and new public health schools in the country. Most of the courses in public health that are offered in India are face-to-face on-campus programs. Recently, a few institutions initiated e-learning courses in different aspects of public health. However, the scope of distance education is not yet fully explored and tapped in the arena of public health.
The competency driven frameworks (core and cross-cutting competencies) are also missing in several courses. Still, the traditional model of learning is being followed where the approach of the content based curriculum is used. What we need is the competency-driven educational model where the health system and health needs form the starting point and from which the competencies are derived as its outcomes. Based on this, the curriculum is devised. To quote Lewis Carroll in Alice in Wonderland, "If you do not know where you are going, any road will get you there." The achievement of competencies should be aimed and the expected outcomes of the educational experience should be made explicit.  Moreover, the development of curriculum is considered to be purely an academic activity, with limited engagement of stakeholders from the health systems. The perspectives and felt needs of prospective employers of public health graduates are hardly incorporated in the entire process of curriculum development.
Multidisciplinary approach and the health systems' connectivity are being overlooked in our curriculum too. Public health education must be closely aligned with health systems and community health needs and that should be reflected in the curriculum too as appositely put by Tangcharoensanthiaen and Prakongsai, "Public Health Education that is irrelevant to national health priorities and divorced from public health practice is useless and constitutes a lost opportunity."  To bring the reforms in public health education, transformative pedagogy is a necessitated entity that needs to be channeled in a learning process. The power of innovations in educational resources also needs to be harnessed since innovations are one of the major instruments to enhance learning and facilitate achievement of the desired competencies. Multidisciplinary thinking also needs to be incorporated and reflected in our learning and teaching resources, viz., case studies, innovations stories, etc. We also need to strengthen the sharing of academic resources across academic institutions to break institutional silos. Even the assessment of the graduates should be multidisciplinary and competency-driven, well-aligned to the learning outcomes. The methods for assessment should be internally and externally validated to ensure that the right things are being measured in the right way.
Faculty recruitment, retention, and development also remain important concerns when it comes to bringing reforms in public health education. Adoption of a competency-driven approach in the curriculum and its implementation cannot be an overnight transition unless the faculty gets adequate training in competency-driven learning and teaching processes. Competency-based learning shifts the role of the faculty from that of "a sage on the stage" to a "guide on the side." Faculty members work with students, guiding their learning, answering questions, leading discussions, and mentoring students in synthesizing and applying knowledge.  The paradox in teaching shows that if 30% of "what we teach" is redundant, then 70% of the "way we teach" is redundant. Hence, it is critical to engage in systematic, conscious, and strategic efforts toward faculty development. The need for fostering a multidisciplinary faculty, responding to the challenges related to faculty resource sharing, building partnerships, and enhancing innovative pedagogical skills is the need of the hour. We need faculty champions who can advance these reforms in their institutions, thereby making public health education more responsive to the health needs of the society.
Health is all about people and a strong health system entails a healthier and more developed nation. It is time we showcase "public health" as an important and exciting field and give it the much-needed recognition as a valued profession. The time is ripe for change and a complete and authoritative reexamination of public health education is clearly needed. Systematic and strategic efforts need to be effectuated toward creating a job market and building a public health cadre. Enhancing the quality and relevance of public health education and accreditation of courses and institutions require sustained efforts. Public health education needs to be embedded in knowledge systems through research and practice. Last by the not the least, we need champions and a strong public health leadership to improve the health system's performance and bring about a public health revolution. Leadership has to come from within the academic and professional communities adequately backed by the government and society.
In a world that is constantly changing, our educational system should change as well. In order to realize the goals we envision, a transformative and innovative approach is required across all the levers of public health education: From curricula and pedagogy to the use of technology to partnerships, governance, and programs. Public health professionals are key drivers of the relationship between knowledge and health improvement. They complete the circle of knowledge with the production of knowledge that begins with research, continues with reproduction of knowledge with good education, leading to translation of knowledge into decisions and policy and then successfully toward the implementation of knowledge through action. Finally, the asking of new questions and production of new knowledge by these health professionals again lead again to the production of knowledge. Public health education in India is at crossroads and we must pay attention on how to educate our professionals and make them the vital elements in the entire circle of knowledge.  This could be done very well by enabling public health education reforms in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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