Date: 07/09/2022

Relevance: GS-2: Issues Relating to Development and Management of Social Sector/Services relating to Health, Education, Human Resources.

Key Phrases: public health, public health professionals, Medicalisation of public health, Academics, Activism, Administration, Advocacy, Training, cadres for public health professionals and health management, quality of public health training.

Why in News?

• 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.
• There is also a suboptimal representation of public health professionals in State and Central advisory bodies of 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, and anyone can do this work.

Issues regarding public health:

• A poor understanding:
  • Public health is essentially multi-disciplinary and means different things to different people. Many, even within public health, have a poor understanding of it.
    • For example, recent Central government guidelines specify an MBBS degree to be a prerequisite for becoming a public health specialist.
  • Some people have argued about the exclusion of grassroots public health workers — ASHA workers, auxiliary nurse midwives and multipurpose workers — from the cadre.
  • Part of this confusion comes from not being 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 public health professional.
  • Health workers have no training in public health; they are grassroots-level service providers. Asking them to be part of the public health cadre trivialises the profession of public health.
  • It is important to understand that public health is a separate profession with a specific set of competencies.
• Having only medical knowledge for public health is not enough:
  • One could argue that medical knowledge helps understand health issues better, one could also contend that this is not the most effective use of the years spent learning medicine.
  • It is important to recognise that organ-/system-based medical training inculcates deeper but narrower thinking as appropriate to it, but this is inappropriate for a broader public health approach aimed at working with communities or health systems.
• Medicalisation of public health:
  • Historically in India, public health has been medicalised as it was largely a medical college-driven discipline.
  • It is the resistance of this medicalised public health fraternity that explains the continuing need for a public health professional to have a medical degree.
  • This has also resulted in denying nursing, dental, and other health professionals to contribute more to public health. This needs to go in the national interest.
• Lack of necessary skill:
  • Many doctors and other health professionals work at the grassroots level and develop a good sense of public health due to their inclination. But they do not become public health professionals as they may not have the necessary skills.
  • Clinicians with training in epidemiology and biostatistics would not qualify to be public health professionals as they lack not only other essential and critical expertise but also an appropriate perspective.
• Short training duration:
  • Short training or even a year-long distance learning course cannot create a public health professional in the same way that it cannot create a physician or a cardiologist.

Four pillars to describe public health work:

1. Academics:
   • 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.
2. 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.
   • It also includes the study of how non-health determinants, including social and commercial factors, influence health and how these can be addressed.
3. Administration:
   • Administration refers to administering health systems at different levels: from a primary health centre to the district, State, and national levels.
   • This includes implementing and managing health programmes, addressing human resource issues, supply and logistical issues, etc.
   • It includes microplanning of programme delivery, team building, leadership as well as financial management to some extent.
   • A good understanding of the principles of organisational management and health administration is key to acquiring this competency.
4. 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 an alternative set of actions and the cost of implementation or non-implementation.
   • Good communication and negotiation skills are critical to performing this function.
   • The related subjects are health policy, health economics, health advocacy and global health.

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 the 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.
• Such exposure helps them put all these competencies together to evolve into trained public health professionals.
• The trainees develop a systems approach and a long-term perspective, which are the crux of this discipline.
• This is different from a clinical approach, which is focused on individuals and where the time frame is usually short, if not immediate.

Conclusion:

• 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 which can attract the best and the brightest people into this discipline. This is one lesson that India should learn from the pandemic.

Source: The Hindu

Mains Question:

Q. What do you understand by "public health"? How far do you agree that it is a separate profession requiring a specific set of competencies and need not be led by doctors alone? Examine.