Public health System in India

In Context

Recently ,it has been observed  that Public health is a separate profession requiring a specific set of competencies.

About Public health System

• 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). 
• Four ‘A’ s(academics, activism, administration and advocacy ) has been used   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.
  • Activism : 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. 
  • 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 micro planning of programme delivery, team building, leadership as well as financial management to some extent. 
  • Advocacy:  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. 
• Application :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. 

Major Issues 

• Poor understanding :Public health is essentially multi-disciplinary and means different things to different people. Many have a poor understanding of it and they are  not 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.
• Lack of specific competencies: 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. 
  • 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.
• Qualification related issues : Historically in India, public health has been medicalised as it was largely a medical college-driven discipline. This has resulted in denying nursing, dental, and other health professionals to contribute more to public health.
  • They do not become public health professionals as they may not have the necessary skills. 
• Other challenges : Poor expenditure on the health sector
  • India lacks affordable health care services for the marginalised sections.
  • Lack of robust public health infrastructures like hospitals, primary health centres.
  • Lack of number of Doctors and Specialists as per the population of the country.
  • Lack of awareness among the people

Suggestions 

• 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.
• There is an urgency to focus on all the three levels of primary, secondary and tertiary healthcare, it is imperative that the government look towards improving primary health care as a public good.

• There is a need for an increase in expenditure on health so that India can improve existing facilities as well as add more of them.