DR. S.C. SEAL MEMORIAL ORATION, 2013
Year : 2015 | Volume
: 59 | Issue : 3 | Page : 172--177
Undoing ignorance: Reflections on strengthening public health institutions in India
Department of Community Medicine, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India
B7/24/2, First Floor, Safdarjung Enclave Main, New Delhi - 110 029
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Lahariya C. Undoing ignorance: Reflections on strengthening public health institutions in India.Indian J Public Health 2015;59:172-177
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Lahariya C. Undoing ignorance: Reflections on strengthening public health institutions in India. Indian J Public Health [serial online] 2015 [cited 2020 Nov 24 ];59:172-177
Available from: https://www.ijph.in/text.asp?2015/59/3/172/164653
Introduction - Missing 'the Critical Mass'
Public health has not received due attention in India over the past several decades, both in terms of trained human resources and finances, and this has been continuing. India joined the public health movement at almost the same time as the rest of the world. However, the momentum was lost somewhere along the way and at present, India is far behind other countries. As per my analysis, the number of trained public health practitioners in India is estimated to be not more than a maximum of 10,000. That translates to one public health practitioner for every 125,000 people in India.
The scant number of public health professionals is not the only problem. These practitioners are either dispersed or are in select institutions and don't get the opportunities for sufficient interaction with each other that would generate new ideas. Thus, the public health community and public health institutions in India, perhaps lack the "critical mass" to be able to initiate useful debate, provide useful contributions, bring pathbreaking ideas to the policy table, and continue the learning and growth trajectory in this field. This is one of my responses to the question why there is insufficient attention and the lack of quality debate on the recent public health issues and concepts in India. There is a need to increase the number of professionals and institutes in this field to go above the "critical mass" to start the fusion reaction and ignite the flame of a public health revolution in India for better health outcomes.
A few decades back, there was a limited number of dedicated public health training institutions, mostly in the major cities. Most of the training in public health was done through preventive and social medicine (PSM) departments in medical colleges. Though the number of trained professionals was small, their quality of training was proven. Today, India has many more institutions and schools of public health; however, the quality of available trained public health professionals is arguable.
In their book An Uncertain Glory: India and its Contradictions while referring to the economic development in India, Jean Drèze and Amartya Sen remark about the "islands of California in the sea of Sub-Saharan Africa." Daron Acemoglu and James Robinson in their 2012 book Why Nations Fail: The Origins of Power, Prosperity and Poverty underscore the importance of strong and inclusive institutional mechanisms in nation-building. Speaking at the annual function of the All India Institute of Medical Sciences, New Delhi in 1970, the first Director General of the Indian Council of Medical Research (ICMR), Dr. C.G. Pandit made the following remark: "I feel that you have created here an 'island of excellence.' But will it always remain a lonely island, or as some others would put it, an ivory tower? Or, on the other hand, will you be helping in making this country an archipelago with many islands of excellence in it? Excellence must not be isolated in islands but must flow into the mainstream of national life."
These three descriptions and similes, though originally used in different contexts, could very well be extended to refer to the current status of public health institutions of India. The few departments and institutions in India are islands of excellence but the majority needs to be vigorously strengthened. The current and future generations of public health students deserve better teaching and training if we wish to see them as public health leaders of tomorrow. These departments and institutions have to rise to the task in order to remain relevant. It is the responsibility of the public health community and leaders of today to ensure that this task is started immediately.
Roles the Public Health Community Can Play
Public health professionals and institutions can contribute in a number of ways as follows:
Strengthening "evidence-to-policy" linkage
Given the lack of comparative reference of India's size and complexity, policy analysis and research in a country-specific context are needed and will always be demanded by policy makers for evidence informed decision-making. There is a need for more focus on program evaluations and impact evaluations to guide policy-making in India. Public health leaders and professionals need to tackle the challenges and align their efforts and research work to address these challenges.
Bringing political attention on health in general and public health in particular
The academic public health community can contribute immensely in this area.
Becoming the window of the medical fraternity to the community
There are evidence and epidemiological data that can be produced only by the public health community. Public health professionals can take the lead and initiatives to promote research on the provision of health services, quality of health services, health financing models, financial protection, etc.
Creating an "answering" community
Decision-making in India on health interventions is often delayed due to the lack of epidemiological data. Questions that should have been asked 30 years ago are being asked today. What is worse is that even today, very little is being done to start the process of answering those questions. The public health community has to proactively work on these questions so that the answers are available in the years to come. There is the need for a paradigm shift from being a "questioning" community to looking for and providing answers to address the complex societal and health problems faced by the people of this country.
Contributing to policy debate
While discussing the issue of purchase of health services from the private sector in India in the context of drafting the 12 th Five-Year Plan (2012-17), it was seen that the Planning Commission and the Ministry of Health and Family Welfare had different views as were the opinions among various other stakeholders. These differences are understandable as the evidence is not straightforward. A World Bank report of 2007 supports the role of the private sector while Oxfam in its 2009 report titled "Blind Optimism" was equally critical of the private sector. A more recent review had given mixed findings. This is where there is a major role for public health practitioners in India. The public health community, no matter where it is working, needs to be proactive, accept the challenge, collect and collate the evidence and contribute to policy debate. There is a need to come up with good analyses as well. Some possible areas of work could be how to integrate health programs, what are the best options, has the free medicines schemes had any effect on facility attendance and out-of-pocket expenditure, etc.
Establishing more numbers of functional rural/urban health training centers
The first few rural health training centers (RHTCs) were set up in Singur, Poonamallee in Tamil Nadu and Najafgarh in Delhi in 1952. The concepts of these RHTCs should have been extended to a number of other states and places in India by now. However, the ground reality is that very few departments of community medicine or PSM in medical colleges or the schools of public health have attached and functioning rural and urban health centers for a multitude of valid and not so valid reasons. The health centers affiliated to medical colleges often exist only on paper to fulfill the mandatory requirement of the Medical Council of India (MCI). Further, only a few of these are actually involved in providing outreach services. The time has come to be honest and accept the realities. Public health institutions have to accept the responsibility of making affiliated centers functional. Considering the fact that these functioning health centers were envisaged nearly 60 years ago, it would not have been ambitious to expect that by now these would have graduated to "health and demographic surveillance sites" in each of the medical colleges. There is a need for leaders in public health to work in this direction. The performance of public health institutions and professionals could and should be judged by their contribution to their immediate environment, whether for medical colleges or in the community.
Innovating to attract talent to public health institutions
Mechanisms for the parallel entry of teaching faculty members, short-term and visiting faculty members from nonteaching areas, and international faculty on the subject matter has to be established. Leading and autonomous institutions such as the All India Institute of Medical Sciences should welcome nonteaching professionals to join as short-term faculty members. This simple approach, if adopted, has the potential to revolutionize the landscape of public health teaching in India. Indian medical and public health training institutions are missing a lot by not allowing the parallel entry of subject experts.
Expanding the breadth, depth and quality of work
The scope of work being done by public health professionals and institutions needs to be expanded to include critical reviews on economics, health policies, and other more topical and contemporary issues. Public health training requires a broader and in-depth understanding, more than what is written and can be taught through standard textbooks of public health. Students of public health have to be encouraged to read beyond the standard textbooks and develop a broader societal understanding through reading beyond the medicinal field, including social sciences and other similar aspects. A people-centered, integrated, and strong health system can only be developed with people who have a good contextual understanding. The broad health topics (and books) in these areas should be part of the curriculum to stimulate critical thinking among public health students. Public health teaching and training in India need to be geared up for the next level. Students need to be taught new concepts, and the decade-old textbooks and curricula need to be updated. There is a need for transformational change. Each one of us in general and professional associations such as IPHA have to, there is no choice left, take lead in bringing these changes.
Making public health a skill-based training and trained professionals employable
The quality of training of many young professionals in public health is often reported to be suboptimal. It is not the fault of the young and naive student who joins the course. She or he joins the MD or MPH or any other course with expectations of the highest quality of teaching and training during that period. The problem is in the teaching curriculum and approach. Students must get to see the public health facilities and models at the most remote localities, work there for some period of time, and replicate the successes. The public health community needs to guide their efforts.
Improving quality of research activities and published work
The concerted and systematic efforts has to be made to increase the quality of research being done at public health institutions, including the departments of community medicine. The aim should be to have one's work published in not just any journal but in high-impact, peer-reviewed journals. The work on the next level of evidence in the hierarchy, such as systematic reviews and meta-analyses, should be increased. All these require sustained and systematic capacity-building efforts. Needless to say, there has to be a premium on quality research by academic incentives that is the responsibility of top-level policy makers.
In addition to conducting primary research, global evidence should be interpreted and contextualized for informed policy- and decision-making in India.
Mentoring the next generation of public health professionals
Many young graduate students have a keen interest in pursuing advanced studies in public health and so are many postgraduate (PG) students in community medicine/public health. All of them are very keen to learn and are enthusiastic to work at the field level. However, their enthusiasm is thwarted by limited learning opportunities and almost no mentorship. Each senior public health professional could mentor a few young professionals.
To conclude this argument and despite all of the above, there are reasons to be optimistic. Recent developments show a positive shift in the research coming out from the PSM departments (and subjects of the theses of PG students) from traditional "knowledge, attitude, and practice" (KAP) or family planning studies to more complex areas such as universal health coverage, health systems, and demographic studies. Many people in tandem need to work-hard and drill the notion to go beyond PG theses or compulsory research projects for masters courses as the main research work of departments and institutions. The institutes need to take up more topical, challenging and inter-disciplinary researches to stay relevant and contribute to the society.
Policy Support to Public Health Institutions
There are a variety of reasons to explain why public health in India has not received its due attention. One more reason is that people who would stand to benefit the most from public health efforts are the poorest of the poor who have no voice. The public health community has to accept the challenge of becoming the voice of these people. One of the important steps to achieve this is to create a favorable policy environment to encourage the public health community and take increasing numbers of steps to strengthen public health institutions in India. A few, indicative list only and not in order of priority, are listed in following paragraphs.
Is sufficient recognition given to public health professionals in India? If Padma awards (Padma Shree, Padma Bhushan, and Padma Vibhushan) are any indication, it may be noted that, of the 137 medical doctors who received Padma awards between 2000 and 2010, only four were trained public health specialists while 68 of the 137 were from superspecialties (i.e., cardiology, neurology, nephrology, urology, and gastroenterology). This reflects that there are either not enough public health persons in the country or they are not doing work that is good enough, or both. Whatever the reason, it requires concrete policy actions to improve the public health scenario in India. Excellence in public health needs to be better recognized and systematic and sustained efforts and mechanisms are needed to create excellence as well.
Opportunities for employment
While of late, attention has been given to increase the number of PG seats in PSM or community medicine, and many institutes have come up with masters courses in public health, there is also a need to create commensurate job opportunities for these public health professionals. If sufficient and suitable jobs are not created, this initiative may turn counterproductive. This may, in turn, deter good students from joining the field of public health and all those who have already joined may start drifting away from public health practice. This could be a disastrous "vicious cycle." This is especially tricky in India where, till recently, the major employer of public health professionals has been the government.
How does one increase the interest of undergraduate medical students in public health? The government needs to develop conducive and promotive policies to encourage public health professionals. Creation of positions and development of the public health cadre need to be addressed by policymakers. This is not likely to happen unless proactive and sustained efforts are made by professional bodies and the public health community.
Salaries and incentives
In 2009, there was an advertisement for the positions of epidemiologist in each of the districts of India under a Government of India project supported by an external agency. There were nearly 600 positions advertised. However, the response to the advertisement was lukewarm and at the completion of recruitment process, many positions remained vacant. One of the contributory reasons was that the posts were advertised with a monthly salary of merely ₹20,000-30,000, subject to negotiation and qualifications. This salary was being offered after 8-9 years of education [Bachelor of Medicine and Bachelor of Surgery (MBBS) and Doctor of Medicine (MD)]. Similar years of education and qualification in other specialties in the government sector fetch at least twice the salary. In the private sector, it could be as much as three to four times. Even graduate medical officers are paid higher than what was being offered to epidemiologists and public health persons. It was, therefore, no wonder that public health professionals did not apply or chose not to join when selected. This same policy would have discouraged many more to not opt for PSM as their subject of specialization for PG studies. This policy aberration is a major disincentive and policymakers need to rectify this urgently and bring epidemiologists and public health professions at par with other specialties in matters of salary. In fact, the study of epidemiology is much more complex than many clinical procedures. More competitively paid jobs need to be created for epidemiologists with commensurate salaries. Public health professionals and associations need to bring this point to the attention of policymakers.
A few months back (in July 2013), the state health society of one of the union territories issued an advertisement for "walk-in interviews" for the posts of medical officers, pediatricians, gynecologists, obstetricians, and epidemiologists among others. The advertisement indicated a monthly salary of ₹100,000 for gynecologists, ₹75,000 for pediatricians, and ₹45,000 for an MBBS qualified medical officer. The same advertisement was also issued for the post of epidemiologists where the minimum qualification was MBBS with a 3-year MD degree in community medicine. The salary offered was ₹40,000-45,000, subject to negotiation. This means that an MBBS doctor would get ₹45,000 as a medical officer but with an added 3-year training in community medicine, he/she would get a reduced salary of ₹40,000 and that too after negotiation! Would such policies ever encourage anyone to join public health? Senior program managers and policy makers need to do away with such harmful policies. Someone needs to correct these ongoing wrongs.
"Theory to practice" linkage
Public health institutions, often but not always, have limited exposure to programmatic aspects of health services. There is a need for developing a fluid and flexible mechanism through a systematic approach and policy instruments that would allow the faculty of public health institutions and departments of community medicine to switch to the program implementation in departments and ministries at the union and state levels and vice versa. This "osmosis" is likely to create a win-win situation where the faculty in academic institutions would bring technical expertise and program managers would share their field experience. There are good examples from a few states in this area. These should be followed and adopted by other states as well.
A somewhat related area on linkages is the "policy making - academic institutions - service delivery - resource generation" quadrangle. Academic health institutions, including public health departments of medical colleges, have very limited interaction with district hospitals that are directly involved in the service delivery. There is a very limited linkage with the auxiliary nurse midwife training centers (ANMTCs) and with the health and family welfare training institutions in that district or area. These linkages have to be developed if health outcomes have to be improved. This is the role of the local health leadership and a stewardship function of the state.
Funding for research
Another roadblock in the development of public health institutions in India is the "funding dilemma." There is limited high-quality research coming out from the public health institutions in India. They seem to be trapped by the vicious cycle of the funding dilemma. Traditionally, the quality of research in these institutions has been suboptimal. Therefore, these departments seldom receive sufficient external funding to conduct large-scale, high-quality research. This not only prevents additional research but also hampers the capacity-building of the individuals in these institutions. This stalemate needs to be resolved and a fresh start has to be made, by giving them challenging research projects and a worthy chance to prove themselve. The government funding agencies and external donors should support the capacity-building efforts for the existing faculties and potential young researchers, supplemented by funding support for conducting high-quality research. This could be accompanied by the recognition of academic excellence, publications, and quality research by the consideration of out-of-turn promotions and salary benefits. The parallel entry of subject matter experts on short-term assignments/visiting faculty members has to be given immediate consideration and could be made a regular practice, well-supported by the systematic funding mechanisms. If any field requires a priority in this area, it is public health.
Separate public health cadre
Only a few states such as Tamil Nadu have a separate public health cadre. As and when curative medicine and public health professionals have to compete for the common resource pool, decision makers are inclined toward curative medicine since it produces measurable results in a short period. The end result is ignorance and limited attention to public health. It has been recognized that one way to ensure sufficient focus on public health is the development of a separate cadre. This is one of the many areas on which the decision makers at the highest level need to arrive at consensus, at the earliest possible. Simultaneously, it needs to be explored as to how the existing Central Health Services (CHS) can be used as a platform for promoting and accelerating public health services and efforts in India. This initiative could be started by the Union Government.
Role of states
One of the challenges with health being a state subject and the Union Government running the majority of national programs is that states always have to look to the Union Government for funding and initiatives. Now that a few states are doing much better than the overall economy, state governments have to take the lead in additional public health initiatives such as setting up public health institutions, additional support for departments of public health/community medicines in medical colleges, and an administrative cadre for public health at the state directorates of health and the offices of district chief medical and health officers to count a few steps. Moreover, the public health is likely to benefit more from stewardship of states than union governments, as the states would be the ultimate and most immediate beneficiaries of strengthened public health system.
Public health institutions and training in public health have remained ignored in India for past few decades. It is high time that we set this right. The public health community and institutions have extensive potential to contribute to better health outcomes in India. Strengthening of public health teaching and training in the country and empowering these institutions requires immediate attention. A few steps for this should come from the public health community and institutions. The other actions that are needed include addressing the external determinants such as creating a conducive policy environment and allocating additional financial resources. These improvements cannot be incremental anymore; these need to be transformational and immediate. Public health practitioners and health policy makers have to lead these efforts together.
The time has come that India should quickly achieve the critical mass of public health practitioners, who have received training, which meets global standards and fits Indian needs. This is possible only if the existing and upcoming public health institutions are supported by the sustained policy measures. The public health practitioners and the institutions also have to reciprocate by living up to the expectations of the people. The time has come that the historical ignorance to public health institutions is compensated by extra-ordinary attention and support to this field in India. It is hoped that public health community is ready for this opportunity and would not miss this opportunity as all others in the past.
This article is based on Prof. S.C. Seal Memorial Oration delivered on the 58th Foundation Day of the Indian Public Health Association (IPHA) on September 28, 2013 at Kolkata, West Bengal, India.
The author would like to thank the IPHA for bestowing the great honor to deliver this prestigious oration. Special thanks are due to Dr. Madhumita Dobe, the then Secretary General of IPHA and to Dr. Deepika Sur.
Financial support and sponsorship
No funding or any external grant was received for writing this manuscript.
The opinions expressed in this article are solely attributable to the author, are personal, and should not be attributed to any institution/organization where he has been affiliated in the past or is affiliated at present.