Bridging the health policy to execution chasm
Context: 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
• The ‘public health and management cadre’ is a follow up of the recommendations made in India’s National Health Policy, 2017.
• Covid has convinced policymakers that there is a need for a public health cadre
Implications of having different cadres
• 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 which was exposed by the CORONA pandemic.
Public Health Cadre
• India will set up a central public health cadre for medical professionals along the lines of Central services officers recruited through the Union Public Service Commission.
• The public health cadre will help the government in implementing healthcare policies. We do have public health departments in medical colleges, but the public health cadre will play a much more important role.
• The cadre should be the implementing arm of the public health policies. Hence, the framework is being constituted within the health ministry,” the official said.
Need For Public Health Cadre
• The need for a public health cadre and services in India rarely got any policy attention.
o 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
• The initial threat of avian flu, the Swine flu pandemic; 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.
• Then the COVID-19 pandemic changed the status quo. 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.
• 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.
Benefits of having public health cadre
• 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.
Challenges in implementation
• The effective part of implementation is interplay: policy formulation, financial allocation, and the availability of a trained workforce.
o In this case, policy has been formulated.
• The Government’s spending on health in India is low and has increased only marginally in the last two decades.
• 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 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
• 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
• As States develop plans for setting up the PHMC, all potential challenges in securing a trained workforce should be identified and actions initiated.
• Helping States:
o 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.
o States which are likely to show reluctance need to be nudged through appropriate incentives.
o The mapping and an analysis of human resources for public health and then scaling up of recruitment are logical.
o It needs to be ensured that in an overzealous attempt to achieve numbers, the quality of training of the required workforce is not compromised.
o Setting up these two new cadres should be used as an opportunity to improve and standardise the quality of training in public health institutions
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.