In April this year, the Union government released a guidance document on the setting up of a ‘public health and management cadre’ (PHMC) as well as revised editions of the Indian Public Health Standards (IPHS) — for ensuring quality health care in government facilities. For a country where politicians take pride in inaugurating super-specialty hospitals and where the health focus has traditionally been on medical care or attention on treating the sick, these two developments to strengthen public health services are welcome.
A background, the fallout
The ‘public health and management cadre’ is a follow up of the recommendations made in India’s National Health Policy 2017. At present, most Indian States (with exceptions such as Tamil Nadu and Odisha) have a teaching cadre (of medical college faculty members) and a specialist cadre of doctors involved in clinical services. This structure does not provide similar career progression opportunities for professionals trained in public health. It is one of the reasons for limited interest by health-care professionals to opt for public health as a career choice.
The outcome has been costly for society: a perennial shortage of trained public health workforce. The proposed public health cadre and the health management cadre have the potential to address some of these challenges. With the release of guidance documents, the States have been advised to formulate an action plan, identify the cadre strengths, and fill up the vacant posts in the next six months to a year.
The revised version of the IPHS once again underscores the continued relevance of improved quality of health services through public health facilities. This is the second revision in the IPHS, which were first released in 2007 and then revised in 2012. The regular need for a revision in the IPHS is a recognition of the fact that to be meaningful, quality improvement has to be an ongoing process. The development of the IPHS itself was a major step. Nearly two decades ago, in many countries including India, there was limited attention on ensuring quality. Increasing access to health services and improving the quality of care were perceived as a sequential process: first focus on increasing access and then a thought may be given to ensuring quality (which rarely happened).
Role and relevance
The voices for having public health services and workforce in India have always been few and feeble. Understandably, the need for a public health cadre and services in India rarely got any policy attention. Arguably, the reason was that even among policymakers, there was limited understanding on the roles and the functions of public health specialists and the relevance of such cadres, especially at the district and sub-district levels. At best, epidemiologists were equated with public health specialists, failing to recognise that the latter is a much broader and inclusive group of specialists. However, the last decade and a half was eventful. The initial threat of avian flu in 2005-06, the Swine flu pandemic of 2009-10; five more public health emergencies of international concern between years 2009-19; the increasing risks and regular emergence and re-emergence of of new viruses and diseases (Zika, Ebola, Crimean-Congo Hemorrhagic fever, Nipah viruses, etc.) in animals and humans, resulted in increased attention on public health. In 2017, India’s National Health Policy 2017 proposed the formation of a public health cadre and enacting a National Public Health Act. Yet, progress on these fronts was slow as usual.
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The COVID-19 pandemic changed the status quo. For months together, everyone was looking for professionals trained in public health and who had field experience; they were simply far and few. It became clear that ‘epidemic’ and ‘pandemic’ required specialised skills in a broad range of subjects such as epidemiology, biostatics, health management and disease modelling, to list a few. In the absence of trained public health professionals at the policy and decision making levels, India’s pandemic response ended up becoming bureaucrat steered and clinician led. Every struggle in the pandemic response was a reminder that a clinician, no matter how skilled in the art of treating a patient, or a bureaucrat, no matter how experienced in administration, could not fulfil the role of the epidemiologists and public health specialists, who are specially trained to make a decision when there is limited information about a pathogen and its behaviour.
A continuing role in care
A public health workforce has a role even beyond epidemics and pandemics. A trained public health workforce ensures that people receive holistic health care, of preventive and promotive services (largely in the domain of public health) as well as curative and diagnostic services (as part of medical care). A country or health system that has a shortage of a public health workforce and infrastructure is likely to drift towards a medicalised care system. In 2022, there is greater clarity on the role of the public health workforce, which is a remarkable starting point. However, the delay in policy decisions on a public health cadre is also a reflection of a long and tortuous journey of policy making in India. These two new cadres have come up late but the focus now has to be on accelerated implementation.
The revised IPHS is an important development but not an end itself. In the 15 years since the first release of the IPHS, only a small proportion — around 15% to 20% — of government health-care facilities meets these standards. This raises a legitimate question on whether development (and revision) of such quality standards is ritualistic practice or whether these are considered seriously for policy formulation, programmatic interventions and for corrective measures. If the pace of achieving IPHS is any criteria, there is a need for more accelerated interventions. Opportunities such as a revision of the IPHS should also be used for an independent assessment on how the IPHS has improved the quality of health services.
Drafting of well-articulated and sometimes near perfect policy documents, even though in a delayed manner, is a skill which Indian policymakers have mastered well. However, the implementation of most such policies leaves a lot to be desired. The IPHS implementation in the last 15 years is one such example. It is difficult to predict the outcome of the PHMC guidance document; however, the past can guide the process.
The effective part of implementation is interplay: policy formulation, financial allocation, and the availability of a trained workforce. In this case, policy has been formulated. Then, though the Government’s spending on health in India is low and has increased only marginally in the last two decades; however, in the last two years, there have been a few additional — small but assured — sources of funding for public health services have become available. The Fifteenth Finance Commission grant for the five-year period of 2021- 26 and the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) allocations are available for strengthening public health services and could be used as catalytic funding — which should be used in the interim — as States embark upon implementing the PHMC and a revised IPHS.
The third aspect of effective implementation, the availability of trained workforce, is the most critical. Even the most well-designed policies with sufficient financial allocation may falter because of the lack of a trained workforce. As States develop plans for setting up the PHMC, all potential challenges in securing a trained workforce should be identified and actions initiated.
One, the level of interest among States in implementing the public health and management cadres needs to be explored and a centre of excellence in every State should be designated to guide this process. States which are likely to show reluctance need to be nudged through appropriate incentives. Two, the idea of mapping and an analysis of human resources for public health and then scaling up of recruitment are logical. However, it needs to be ensured that in an overzealous attempt to achieve numbers, the quality of training of the required workforce is not compromised. Setting up these two new cadres should be used as an opportunity to improve and standardise the quality of training in public health institutions. Three, it would take a few years before the PHMC becomes fully functional in the States. However, the implementation process needs to be started in the next few months to avoid the risk of it becoming a low priority. Four, the success of the PHMC would be dependent upon the availability and the equitable distribution of health staff for all other categories at government health facilities. Therefore, as new cadres are being set, efforts need to be made to fill vacancies of health staff in all other positions as well.
Three years before the COVID-19 pandemic had started, the Indian government had committed, through NHP 2017, to achieve the goal of universal health coverage — which envisages access to a broad range (preventive, promotive, curative, diagnostic, rehabilitative) health-care services which meet certain quality standards, at a cost which people can afford. The public health and management cadres and the revised IPHS can help India to make progress towards the NHP goal. To ensure that, State governments need to act urgently and immediately.
Dr. Chandrakant Lahariya is a physician, public policy and health systems specialist and an epidemiologist, based in New Delhi