The COVID-19 pandemic is sweeping across the world and here in India. While the number of cases continues to rise across the world, the overall number of deaths attributed to COVID-19 is also rising. The fatalities reported by regions varies widely.
India has reported over 5 million cases and over 80,000 deaths till 16th September. The pandemic has stretched the capacities of health systems globally. Several countries, including developed countries, have witnessed an overwhelming of their health facilities.
Health systems have grown increasingly complex, with multiple stakeholders, and tasked with meeting the health aspirations of populations. The pandemic response has brought public health functions to the limelight. There is much sharper appreciation of the public health roles performed by the various actors in the health system.
The Indian health system has demonstrated a well-coordinated response with a relatively lower case fatality ratio than other countries. The public system has led the COVID-19 response with a strong emphasis on testing, contact tracing, surveillance and health promotion. The health departments have recognised the role of epidemiologists in responding to the outbreak. Routine surveillance activities were widened to bring the complexities of pandemic surveillance within its ambit.
Public Health Experts to Tackle a Public Health Crisis
A greater efficiency in handling the resources assigned to the health system will certainly reap dividends by improving health outcomes. Public health system is to witness one of the most significant structural reforms of the current decade. The Central Council of Health and Family Welfare, meeting under the Chairmanship of the Hon’ Health Minister Dr Harsh Vardhan, has approved the creation of Public Health Management Cadres across India. This decision is a statement of the Central government’s intention to implement the National Health Policy 2017 in letter and spirit. Section 11.8 of the National Health Policy document states and we quote:
“The policy proposes creation of Public Health Management Cadre in all states based on public health or related disciplines, as an entry criteria. The policy also advocates an appropriate career structure and recruitment policy to attract young and talented multidisciplinary professionals.”
It further reads, "Medical & health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training would also be considered.”
Public health skills are invaluable in administrative positions and in functional roles that involve planning, design, implementation, monitoring and evaluation of public programs.
At its very core, the setting up of a public health cadre involves the identification of personnel possessing these skills and assigning public health functions to such trained personnel. It is a departure from the routine where it was assumed that anyone employed in the public health system can ‘manage’ efficiently and effectively. The basic professional training in the health sciences and related fields does not significantly include public health skills for the generalists.
This absence of clear distinction between the clinical work and public health skills was a stumbling block in efficient functioning of the health system. Seniority and duration of service was a surrogate for public health skills. Public health is a specialised role that can be best performed by personnel possessing specialised public health skills. A case in point is clearly evident in the current times.
Beyond the Pandemic
We need specialised teams at the district and block levels with skills in situational assessment, health resource planning, managing surveillance systems, assuring logistics and supply-chain management, set up new laboratories for testing, estimate need for additional hospital beds while maintaining a vigilant eye for any changes in the situation. While the present times have prominently brought these issues to the fore of public consciousness, these functions are also required to be performed in non-pandemic times. Public health personnel who have received special training and possess such skills should be assigned to perform these tasks.
If we do not expect a doctor trained in psychiatry to operate for broken bones, how can someone trained in any other discipline effectively ‘manage’ public health?
This welcome move to create a public health cadre will come with its own challenges in implementation. Individual states will have to move to create the new cadre. New government orders will have to be issued and new sets of rules will have to be notified. States will have to assume a leadership role and drive the agenda.
The structure of these new cadres will have to reflect the heterogeneity among the existing cadres within states. Instead of a one-size fits all, there will be need to incorporate context-specific requirements in the cadres at the state level. Some states have demonstrated progress in setting up such cadres within their local contexts. These examples could help in informing the future models. Individual states will have to design their own mechanisms to oversee the progress towards the setting-up of the cadre. Some personnel from the existing cadre will join the new cadre while some fresh recruitment may be needed in other states. Training needs for the staff will have to be identified and budgetary provisions will be needed for their training. Specific training requirements, especially for senior level staff will also have to be identified. The supply side for producing public health specialists will need closer examination.
We will need state-specific requirements of such professionals in the present and in the future, as well as a clear identification of their functions at each level of the health system. These projections and functions will have to be aligned with the needs of Ayushman Bharat and other national health programs. We need to support of the central and state governments in advancing this agenda. This will certainly contribute towards strengthening the health system and optimally respond to newer and emerging health challenges.
(Professor Sanjay Zodpey and Dr Himanshu Negandhi are with Indian Institute of Public Health – Delhi, Public Health Foundation of India. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)
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