India is currently at the crossroads of important public health reforms. There is a receding yet highly disparate distribution of maternal and child health indicators. Yet, there is a morbid growth in non-communicable diseases. While we have witnessed a marked improvement in healthcare access, we are yet to fully realize the international benchmarks of healthcare.

A health system’s functioning depends on skilled human resources, equitably distributed health infrastructure, patients’ inherent trust and adequate finances. Another critical component of a well functioning health system is leadership and governance. An effective health system has good governance and stewardship, driven by a strong leadership.

India faces a big challenge of inadequacy of a well-functioning workforce. Healthcare in India is largely doctor centric. Systems level issues of financial management, resource utilization, logistics, and social determinants of health cannot be tackled by clinicians. National committees and expert groups have, since 1946, recommended the establishment of a public health cadre in the country.[1]And yet, apart from Tamil Nadu and Maharashtra, no other state has managed to organize its health workforce as a separate, trained cadre that can effectively address these complexities.[2][3]It is important to study the systemic bottlenecksimpeding thecreation of a public health cadre.

COVID-19 has shown that states which set up a public health experts’ group to steer the response or those with public health-oriented professionals were able to respondmore effectively.[4]For similar  pandemicsand health crises that the world may face in the future, a stop gap arrangement of hiring public health professionals cannot be an effective or a long term solution.

The lack of availability of trained public health professional is a result of low salaries,job insecurity and role confusion.[5]In a healthcare delivery system where clinical resources are already constrained it is often challenging for the governance systems to delineate clinical and public health management roles. Yet most of the managerial duties in Indian public health systems are performed by the clinical staff. For example, the nurses in the public health facilities in India are responsible for several administrative duties. Similarly, theMedical Officer at a Primary Health Centre who is a trained clinician,has to manage and implement all National Health Programs and monitor community health workers, alongside providing clinical services. Additionally, heperforms the role of a ‘Drawing and Disbursement Officer’ in charge offund allocation to facilities, in close coordination with the treasury. At the secondary care level too, a clinician is mostly a specialist and has to manage the hospital and administrative functions as a superintendent of the hospital. India needs clinicians for providing clinical care to the community. Managing hospitals and public health programs should be lead by professionals trained for it. Additionally, literature reports that the clinical staffthat spend time on administrative duties have lower career satisfaction, high burnout rates, and are less likely to return to medical duties in the future.[6]

A lack of strong policies around HRH motivation, recruitment, and career progression often lead to several challenges in providing optimum healthcare. Retention of human resources, especially in the most remote and underserved areas is an ongoing challenge faced by our health system.

A strong leadership is needed to address this array of problems. The leadership should be able to drive the quality of care byensuring a transparent system for recruitment with fair incentives and remuneration.[7] Concurrently, there is a need forPublic health management professionals who can ensure effective coordination of the resources (both financial and human resources) and manage the complex processes that make up the health service delivery system.

There is a dire need to lay emphasis on the modern day management approaches which include benchmarking, team-based performance measures and real time information exchange. Public health management courses in India remain grossly undersubscribed. Low salaries and an unclear career path may have a bearing in this challenge.[8] 

Since its inception the National Health Mission has emphasized on the need for health managers. Health Managers are a cadre of human resources who work in a multi-stakeholder and multi-organization environment, playing various significant roles[9] including the following:

  • Hospital Administration – Ensuring efficient hospital operations and outcomes.
  • Pharmaceutical companies and insurance – To assess the experience of populations and analyze the factors affecting health.
  • Public Healthcare Delivery – To ensure effective utilization of resources and implementation of the programs.

Call to action

The following elements are a must to establish a public health cadre in the states in India.

To start with, the relevance of the public health cadre calls for the creation of an enabling environment. In this context the government could make management development programs available for these individuals and ensure a good career trajectory for them in the public health sector. Secondly,their roles should be well defined. Their role must not be limited to managing the public health sector alone but also includenon medical determinants and areas of health. These individuals need to have the right tools in their arsenal to ensure what they do to manage public health programs is measured with the right monitoring and evaluation indicators. Furthermore, the government may consider either qualitatively or quantitatively measuring the impact the cadre creates so that evidence can be generated for future expansion to other states in the country. This could enable efficient functioning of the overburdened and under resourced public health sector Of India.

By Shrikant Kalaskar& Anuradha Katyal, ACCESS Health India

References:

[1]The Health Survey and Development Committee (Bhore Committee, 1946), The High-Level Expert Group on Universal Health Coverage (2012), The Steering committee on the 12th 5-year plan (2012), or the draft National Health Policy (2017).

2 Sanjiv Kumar et. al., “A Dedicated Public Health Cadre: Urgent and Critical to Improve Health in India”, 41(4) Indian Journal of Community Medicine at 253-55 (2016).

3Balabanova D, Mckee M, Mills A. London: London School of Hygiene; 2011. [Last accessed 2021 Jan 15]. “Good health at low cost” 25 years on what Makes a Successful Health System? [Internet] pp. 159–92.

4 V. Geetanath, “Public Health Cadre Need of the Hour” The Hindu July 2, 2020.

5 Srilatha Paslawar, et. Al. “COVID-19: A well-functioning healthcare system is the need of the hour” DownToEarth July 27, 2020

6https://journals.lww.com/academicmedicine/FullText/2017/02000/The_Impact_of_Administrative_Burden_on_Academic.30.aspx

7 https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-6-23

8 https://www.frontiersin.org/articles/10.3389/fpubh.2018.00227/full