The idea of having dedicated personnel for public health management goes back to 1959 when advocated by the Mudaliar Committee, which observed that “personnel dealing with problems of health and welfare should have a comprehensive and wide outlook and rich experience of administration at the state level”.
It was echoed too, in 1973, by the Kartar Singh Committee, which said that “doctors with no formal training in infectious disease control, surveillance systems, data management, community health related problems, and lacking in leadership and communication skills, with no exposure to rural environments and their social dynamics, nor having been trained to manage a facility or draw up budget estimates, were ill-equipped and misfits to work in public facilities”.
It was also felt that “the medical education that [a doctor] receives has hardly any relevance to the conditions in which he would be required to work, either in the state-run health programme or even in private practice… since medical education is based almost entirely on the western model, and where he is more suitable for the conditions that prevail in western countries than in his own.”
The 12th Five Year Plan and the National Health Policy, 2017 have also strongly advocated establishing a public health management cadre to improve the quality of health services by having dedicated, trained and exclusive personnel to run public health facilities.
Tamil Nadu took the lead in this and there has been a discernible difference in the way health delivery is done there vis-à-vis Uttar Pradesh. For example, in U.P., even in a tertiary hospital, according to media reports, simple record keeping of oxygen cylinders is not followed.
Recently, Odisha, with the support of the Public Health Foundation of India, has notified the establishment of a public health cadre in the hope of ensuring vast improvement in the delivery of health care. Despite the creation of a public health cadre finding mention in various reports and Plan documents, such a service at the all-India level has still to translate itself into reality any time soon due to a series of complex factors.
Why have such a cadre? The idea is on the lines of the civil service — of having dedicated, professionally trained personnel to address the specific and complex needs of the Indian health-care delivery system which is grappling with issues such as a lack of standardisation, financial management, appropriate health functionaries and competencies including technical expertise, logistics management, and social determinants of health and leadership. Doctors with clinical qualifications and even with vast experience are unable to address all these challenges, thereby hampering the quality of our public health-care system. Now, doctors recruited by the States and the Ministry of Health and Family Welfare (through the Union Public Service Commission) are to implement multiple, complex and large public health programmes besides applying fundamental management techniques. In most places, this is neither structured nor of any quality. In the absence of a public health cadre in most States, even an anaesthetist or an ophthalmologist with hardly any public health knowledge and its principles is required to implement reproductive and child health or a malaria control programme. Further, at the Ministry level, the highest post may be held by a person with no formal training in the principles of public health to guide and advise the country on public health issues.
With a public health cadre in place, we will have personnel who can apply the principles of public health management to avoid mistakes such as one that led to the tragedy in Uttar Pradesh as well as deliver quality services. This will definitely improve the efficiency and effectiveness of the Indian health system. With quality and a scientific implementation of public health programmes, the poor will also stand to benefit as this will reduce their out-of-pocket expenditure and dependence on prohibitively expensive private health care. In the process, we will also be saving the precious resources of specialists from other branches by deploying them in areas where they are definitely needed.
The way forward
Such an exclusive department of public health at both the levels of the Ministry and the States will help in developing the recruitment, training, implementation and monitoring of public health management cadre. Doctors recruited under this cadre may be trained in public health management on the lines of the civil service with compulsory posting for two-three years at public health facilities. Filling the post of director general in the Health Ministry from this cadre with similar arrangements at the State level including the posts of mission directors will go a long way in improving planning and providing much-needed public health leadership. Financial support for establishing the cadre is also to be provisioned by the Central government under the Health Ministry’s budget.
Lastly, another benefit will be the freeing up of bureaucrats and their utilisation in other much needed places.
Dharmesh Kumar Lal is a Senior Public Health Specialist at the Public Health Foundation of India, New Delhi. The views expressed are personal