It is common for heads of health services at national, state or district levels in India to be orthopaedic or cardiac surgeons or ophthalmologists who have no training in public health. There is also suboptimal representation of public health professionals in State and Central advisory bodies of health. During the pandemic, many doctors with no training in public health provided expert advice on public health issues. This is because it is felt that public health does not require specific competencies, and anyone can do this work.
A poor understanding
Public health is essentially multi-disciplinary and means different things to different people. Many, even within public health, have a poor understanding of it. For example, recent Central government guidelines specify an MBBS degree to be a prerequisite for becoming a public health specialist. Some people have commented on the exclusion of grassroots public health workers — ASHA workers, auxiliary nurse midwives and multipurpose workers — from the cadre.
Part of this confusion comes from not being able to differentiate between public health as a discipline and the public health sector. All those who work for the State or Central government are public sector health workers, but they are not doing public health. Providing medical care at a primary health centre does not make the person a public health professional. Also, health workers have no training in public health; they are grassroots-level service providers. Asking them to be part of public health cadre trivialises the profession of public health. It is important to understand that public health is a separate profession with a specific set of competencies.
I use four ‘A’ s — academics, activism, administration and advocacy — to describe public health work. Academics refers to a good understanding of evidence generation and synthesis by having a good grounding in epidemiology and biostatistics. These competencies are also critical for monitoring and evaluating programmes, conducting surveillance, and interpreting data and routine reporting.
ADVERTISEMENT
If academics is the brain behind the discipline, activism is at the heart of it. Public health is inherently linked to ‘social change’ and an element of activism is core to public health. Public health requires social mobilisation at the grassroots level by understanding community needs, community organisation, etc. This requires grounding in social and behavioural sciences. It also includes the study of how non-health determinants, including social and commercial factors, influence health and how these can be addressed.
Administration refers to administering health systems at different levels: from a primary health centre to the district, State, and national level. This includes implementing and managing health programmes, addressing human resource issues, supply and logistical issues, etc. It includes microplanning of programme delivery, team building, leadership as well as financial management to some extent. A good understanding of the principles of organisational management and health administration is key for acquiring this competency.
The final function is related to advocacy at different levels. In public health, there is little that one can do at an individual level; there must be communication with key stakeholders to change the status quo at different levels of government. This requires clear enunciation of the need, analysis of alternative set of actions and the cost of implementation or non-implementation. Good communication and negotiation skills are critical to perform this function. The related subjects are health policy, health economics, health advocacy and global health. These four functionalities can be applied to any specific or general problem such as environment or nutrition or infectious disease and can be considered to be similar to super-specialisation in other medical fields. Pandemic management required all the four competencies in equal measure.
Training
Training in these competencies in India is provided through a three-year MD in Community Medicine and a two-year Masters in Public Health. The first is exclusively reserved for doctors (the extra year is devoted to provision of medical care), while the second is open to non-medical persons as well. In addition to classroom teaching, public health trainees are posted in communities and at different levels of the health system. Such exposure helps them put all these competencies together to evolve into trained public health professionals. The trainees develop a systems approach and a long-term perspective, which are the crux of this discipline. This is different from a clinical approach, which is focused on individuals and where the time-frame is usually short, if not immediate.
None of the four core public health functions need a medical qualification. The training mentioned above has nothing to do with the human body. Unlike clinical disciplines, it does not divide humans into organs or systems. It is important to recognise that the organ-/system-based medical training inculcates a deeper but narrower thinking as appropriate to it, but this is inappropriate for a broader public health approach aimed at working with communities or health systems. While one could argue that medical knowledge helps understand health issues better, one could also contend that this is not the most effective use of the years spent learning medicine.
Historically in India, public health has been medicalised as it was largely a medical college-driven discipline. It is the resistance of this medicalised public health fraternity that explains the continuing need for a public health professional to have a medical degree. This has also resulted in denying nursing, dental, and other health professionals to contribute more to public health. This needs to go in national interest.
Many doctors and other health professionals work at the grassroots level and develop a good sense of public health due to their inclination. But they do not become public health professionals as they may not have the necessary skills. Nevertheless, they are valuable. Clinicians with training in epidemiology and biostatistics would not qualify to be public health professionals as they lack not only other essential and critical expertise but also an appropriate perspective. Short training or even a year-long distance learning course cannot create a public health professional in the same way that it cannot create a physician or a cardiologist.
It is critical that health professionals, the government, and the public recognise public health as a specific set of competencies and give it the importance that it deserves. The Health Ministry’s recent proposal for the creation of cadres for public health professionals and health management at the State, district and block levels is a welcome step. However, it is not sufficient. There is also a need to look at the quality of public health training being provided. Only this will attract the best and the brightest people into this discipline, which is very important for the nation’s health. This is one lesson that we should learn from the pandemic.
Anand Krishnan is a Professor at the Centre for Community Medicine at the All India Institute of Medical Sciences, New Delhi. Views are personal
ADVERTISEMENT