Need for public health cadres to reach and deliver services
The new National Health Policy (2017) calls for the creation of ‘public health management cadres’ in all states. Even the draft Vision 2032 document of NITI Aayog advocates such establishment in at least 10 states in the next three years and in all states by seven years.
Presently, only Tamil Nadu has a designated public health cadre (PHC), while a few other states have made public health qualifications mandatory for some positions in their health services without creating a separate cadre.
The central government health services, too, do not have such a cadre, though a few high-level positions in the Directorate General of Health Services have public health designations.
The rationale for such a cadre is clear. Many of the health programmes require public health expertise—whether it is control of malaria and dengue, universal immunisation of children, or screening for hypertension, diabetes and common cancers in the community. Unfortunately, in the absence of a PHC, planning and implementation roles in such programmes go to clinicians who may be highly skilled but are not trained to provide leadership for public health service delivery.
Health has many determinants spanning many sectors. The health system is at the centre of health service delivery, but policies and programmes in many other sectors are relevant to the health of a population. Even for effective healthcare, it is not merely clinical competence in individual diagnosis and treatment that matters.
Design, resourcing, organisation and monitoring of health services are also critical to ensure that appropriate care and supportive health services reach the beneficiaries through adequately skilled and suitably motivated teams of care providers. Public health identifies and influences the determinants of health, which operate at the population and system levels, to impact on health at the individual level.
Public health calls for multi- disciplinary learning which has multi-sectoral applications. Whether it is core health system issues such as health financing, health workforce mapping, access to essential medicines, measuring the quality of healthcare, health communication and assessment of healthcare technologies or influencing, water and sanitation, air quality, urban design, road safety, nutrition security and food safety, public health covers a broad mandate. Such training is not imparted in conventional medical education. Specialised training in public health is needed to provide the required knowledge and skills that combine broadband understanding with specific competencies.
Design and delivery of varied health services, especially through the National Health Mission, require managerial skills in budget and procurement, supply chain efficiency, team management, interagency coordination, community engagement and building partnerships with civil society and private sector when needed.
Conventional business management training imparts some of these skills but does not provide the much-needed public health orientation. Efficiency and profit are the mantras of business management while efficiency and equity are the mantras of public health management.
Lack of public health training institutions, which provide multi-disciplinary and health system-connected training, has been an impediment to the creation of PHCs. With the establishment of five Indian Institutes of public health in different regions of India, and many other public health educational programmes commencing in universities and medical colleges, public health education has scaled up over the last decade.
Public Health Management is the flagship diploma programme launched by the Public Health Foundation of India in 2008, with linkage to National Rural Health Mission. Masters in public health programmes are also available in several institutions. It should now be possible for all states to establish a PHC. That would improve the sub-optimal performance of the health system in delivering services while enabling more effective multi-sectoral action to protect health.ksrinath.reddy@phfi.org