K SRINATH REDDY, KAVITA SIVARAMAKRISHNAN

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This article would argue that the formation of PHFI is in response to a widely articulated demand, by several expert committees constituted by the government and academia, to infuse greater public health expertise into the health services as well as for making policy development and research more responsive to India’s public health needs. The construction that the PHFI is driven by a foreign designed agenda, therefore, does grave injustice to such long-lasting Indian advocacy for strengthening public health education.

There is a huge need for qualified public health professionals and well-trained public health functionaries in India, which cannot be met by the limited available institutional capacity for training in public health. The Indian Institutes of Public Health (IPH) to be established by the PHFI would aim to make their education and research activities relevant to India in content and context, while attaining standards which are qualitatively comparable with the best in the world. Each IPH would provide multidisciplinary education which will impart a broad appreciation of the multiple determinants of health (especially the social determinants) and the skill sets needed for designing and implementing a broad range of multi-sectoral actions required to advance public health – there is, therefore, no attempt to propagate a restricted biomedical or technology intensive model of healthcare.

Apart from establishing new institutes, the PHFI would also assist the growth of existing and other emerging public health training institutions as per their stated need, and facilitate the creation of a nationwide network of public health capacity-building institutions – therefore, there is no aim or scope in PHFI’s charter to subsume existing institutions.

The PHFI would like to benefit from a wide range of international partnerships, with public health training and research institutions from all parts of the world. While early partnerships have been established with such institutions/networks in US and UK, efforts are under way to develop similar partnerships with other regions, especially with public health institutions in other developing countries.

On the issue of autonomy and transparency in the working of the PHFI, it needs to be asserted that the representative nature of the public-private partnership that governs PHFI permits an “autonomy”, in terms of operational freedom, while providing for governmental guidance and civil society scrutiny. The PHFI’s commitment to transparency (in purpose, process and products) will enable monitoring and constructive inputs by other Indian votaries of public health who may not be included in the board which has, of necessity, be of a limited number. The soon to be constituted Academic Advisory Committee, Research Advisory Committee and policy-related ad hoc expert committees will provide an ample opportunity for the engagement of a broad range of public health professionals and advocates in guiding the work of PHFI.

The interest expressed by several states so far2 to partner PHFI in the establishment or strengthening of public health institutes, as well as their readiness to infuse public health expertise into their health services, is also an evidence of the wide endorsement of PHFI’s agenda by the principal providers of healthcare in India.

The private, corporate organisations that are a part of the PHFI partnership have also attracted distrust and criticism as they are perceived as being inimical to an equitable public health agenda. Alternately, the interest of corporate donors in supporting public health education should be interpreted as an indicative of the growing, albeit delayed, recognition by several segments of the Indian private sector that health of the people is an essential requirement for accelerated economic growth and that development can be derailed by public health catastrophes. The PHFI is also committed to ensure that conflicts of interest would be avoided and that public interest would always prevail over any sectoral interest. As the programmes of PHFI would be visible in the public domain, any deviations from this commitment should be easy to detect by all champions and defenders of public interest.

Acceptance of financial support from international foundations does not mean that PHFI is contracted to pursue an agenda that is alien to India’s interests. While some of these donors may have emphasised technological solutions to public health problems, their willingness to provide support to multidisciplinary public health education should be seen as a welcome attempt to broaden their engagement. It would be inappropriate to suspect a hidden agenda, when no proof exists, at such an early stage of PHFI’s life. It would be even more unfortunate to condemn PHFI as “guilty” by association, by superimposing the past activities of other organisations on the PHFI’s yet to be undertaken activities.

The PHFI, which has commenced its operations very recently, would attempt to engage with as many organisations, agencies and individuals relevant to public health in India as possible over the next year, to invite their inputs to help shape its evolving initiatives in education, training, research and policy advocacy – it would seek to erect a broad and inclusive platform for the participation by multiple stakeholders, many of whom would be welcome to play the role of objective critics, whose evaluation of PHFI would be based on its performance and not conditioned by preconceived prejudice.

Unresolved Health Challenges: Public Health Response

Not withstanding the substantial progress in health indicators since independence (e g, doubling of life expectancy to 63 years, halving of infant mortality to 67 deaths per 1,000 live births), India faces serious health challenges in the form of multiple disease burdens and an inadequate response to this health crisis. Apart from childhood undernutrition and unsafe pregnancies, there is evidence of the resurgence of communicable diseases, rise in non-communicable diseases (e g, cardiovascular disorders, cancer, diabetes), and emergence of other health burdens (e g, accidental injuries). However, the government responses to these needs have been characterised by inadequate government spending on health (only 0.9 per cent of GDP compared to 1.8 per cent by China), poor allocation of the amount that is spent (wide urban/rural disparity, most needy states spend less) and inefficient, utilisation of the allocated resources (e g, 10-25 per cent of funds are actually spent on programme delivery).

It is increasingly evident that this composite threat to India’s health and development needs a concerted public health response to ensure efficient delivery of cost-effective interventions for health promotion, disease prevention and affordable diagnostic and therapeutic healthcare. Since the determinants of health are multisectoral, it is essential to develop a supportive policy framework that addresses and influences all of these determinants. Healthcare too needs to be addressed not only from the scientific perspective of what works, but also from the social perspective of who needs it the most. Equity issues and a human rights perspective, therefore, become important considerations in exercising choices in healthcare.

Public health should emphasise prevention through collective actions to address the underlying causes of disease and foster conditions in which communities or population groups may lead healthy lives. In this way, it extends the ambit of healthcare to the areas beyond medical care. At the same time, the broad domain of public health also embraces essential medical care

Economic and Political Weekly September 16, 2006

and seeks to define its optimal utilisation levels. This multi-pronged effort requires capacity-building for health research, policy development and analysis, programme development and evaluation, health systems organisation and for developing sustainable models of healthcare financing. Scientific research too has to span the spectrum of basic, clinical, social, economic, policy and programme research to be fully informative. Public health practitioners are needed, therefore, with not only technical skills, but also training in meaningfully involving communities in public health, the ability to work in multidisciplinary teams and communicate with government and community leaders.

Public Health Education

The need for relevant public health education and the deployment of public health cadres with adequate analytical skills and in specialised roles in public health administration has been frequently voiced by health policy documents and expert reviews. Much before the PHFI was established in March 2006, there was a growing consensus, even in the mid-1990s at many levels, about the need for many more public health institutions, the need for increasing public health training and the expansion of activities for public health human resource development3 at various levels of health and allied services.

To understand the true significance of the crisis and challenges of public health education one must recall the main recommendations of the Bhore Committee (1946) and Mudaliar Committee (1961) reports, that tried to set the framework of pubic health education in India. The Bhore Committee recommended the setting up of departments of preventive and social medicine (PSM) in medical colleges with the mandate to incorporate the then popular diploma in public health into the training of all undergraduates as the syllabus for PSM, highlighting the need for all Indian doctors to be public health-oriented

public health and a cadre of public health engineers, public health inspectors and public health laboratory workers to be trained by the All-India Institute of Hygiene and Public Health (AIIHPH) and other institutions.

Fifteen years later, the Mudaliar Committee further sought to strengthen public health education in the country by recommending schools of public health in every state to train medical officers, public health nurses, maternity and child welfare workers, public health engineers and sanitarians, dieticians, epidemiologists, nutrition workers, malariologists and fieldworkers. It also recommended university degrees in public health for non-medical personnel, covering general public health, communicable diseases, immunisation, environment sanitation, statistics, school health and the teaching of public health principles and hygiene in primary school, with practical demonstrations. In addition, one year training in pubic health for a large number of medical officers, to carry out public health/ sanitation measures, and higher training of MD/PhD to support public health system policy and development were also recommended.

However, the first two decades of national health planning saw a series of policy trends that impeded the public health system, with many of the Bhore and Mudaliar committee recommendations not being operationalised.4 While academics, researchers and activists had been highlighting the crisis and challenge of public health education from the 1980s, national policy documents gradually began to identify these trends and problems and suggested strategies to strengthen public health education in various ways. For instance, the National Health Policy document of 1982, recommended many strategies of action – foremost of which were the need to formulate a national medical and health education policy and the establishment of comprehensive primary healthcare and public health services within an integrated referral system.

The most recent and comprehensive analysis and required response, was by the Expert Committee on Public Health System 1996, constituted by the government of India.5 After 50 years of national planning and policy evaluation, it stated that public health services do not have requisite number of senior level public health professionals, and stated that this was compounded by many programme managers at national and state level who lack any public health orientation or public health qualification. It suggested many strategies for action to strengthen both the public health system in the country and the public health education. The recommendations on the latter were:

Six years later, the National Health Policy 2002 reiterated these concerns and reaffirmed the urgency to strengthen the capacity for public health education.

The unmet need for public healthoriented personnel is, therefore, far from a post facto justification to create “an army” of public health professionals.7 Clearly the gap in supply and demand has only widened in recent years since the needs for public health training and practice have now expanded, not only to address the unmet needs of the government sector, but also to ensure that sustainable public health practices are adopted in the increasingly prominent private sector as well provide public health expertise to the voluntary sector which is becoming an increasingly important provider of health services to disadvantaged populations and vulnerable groups.8

Emergence of the PHFI

The framework of the PHFI was evolved through a situation analysis study initiated by the ministry of health and family welfare and conducted by McKinsey in 2003-04. The results of the study were then presented at the National Consultation on Public Health Education in India convened by the ministry of health and family welfare in 2004.9

This report appraised the current situation in public health education, to identify the need for a supportive foundation to strengthen the architecture of public health in India. Researchers, policy-makers, teachers and health practitioners in the government and NGO sectors who were interviewed articulated a lack of sufficient public health expertise in policy development across sectors and stakeholder groups, noted the absence of skills in programme design, delivery and evaluation as well as health system management and public health research.

An important lacunae identified was that the MD – community medicine was open only to medical graduates, lacked a multidisciplinary content and in-depth training in several core public health relevant subjects, such as health economics and social sciences, while even the curricular content of epidemiology is also suboptimal. The MPH and MSc courses were limited in the number of students that they catered to and they were challenged by the small size of faculty and deficiencies in course content. The PhD programmes were inadequate in number and there was insufficient impact on public health. And finally, even the shortterm training programmes were limited in coverage of present public health functionaries and lacked an integrated approach. While some of the existing institutions offered fairly high quality public health education, their limited capacity fell for short of the latent and increasingly articulated demand for public health professionals in the state health services.

The study also indicated that there were two key deficiencies in the public health response in India. On the human resource side, there is a dearth of public health professionals in the government health machinery – around 10,000 public health professionals, of various categories, would be required on an annual basis at different levels of the health services from the primary healthcare officer to the central level public health functionaries, to equip the government machinery with a qualified public health workforce. Even the best institutions are small in scale, suffer from a serious faculty crunch and run programmes with limited curricular content or restricted trainee profile. Moreover, there is a wide difference in the quality of existing public health professionals due to lack of set academic standards.

Finally, the study also noted the absence of employment opportunities for public health professionals in government services, as there is neither a mandate for public health qualifications nor a meaningful career track for those who qualify themselves in public health. With regard to support structures, it identified three key limitations: absence of a surveillance system to collect and disseminate timely and accurate data; limited applied research that can utilise available data to shape policy; and the absence of a credible entity that utilises even the scarce available research to help shape policy. There is a need to address the problem in an integrated manner, simultaneously working on both supply and demand sides of the problem.

The national consultation reviewed the results of the study and the following recommendations were made: (1) establish new institutes of public health; (2) assist existing institutes to enhance their capacity and output; (3) promote research in prioritised

(Govt of Uttaranchal)

The PHFI Mandate

The PHFI was therefore constituted on the model of a public-private partnership and was formally launched on March 28, 2006. The launch itself included workshop discussions on the PHFI mandate, which sought to draw upon the advice of public health trainers, administrators, researchers and academia.10

The PHFI will undertake the role of establishing new IPH, to enhance existing institutions and network them to form a closely integrated group which will pursue the mission of strengthening public healthrelated research, training, policy development, programme development and evaluation.11 Each IPH would, therefore, form part of a broader effort to be undertaken by the PHFI to strengthen various activities needed to advance the public health agenda in the country, in collaboration with a broad array of partner institutions and agencies.

Apart from the broad-based MPH programmes that would form the core of the IPH academic programme, each IPH would also provide short- and mediumtraining to facilitate implementation of prioritised health programmes by enhancing capacity among health system functionaries, across all levels of healthcare, to design and deliver the various strategic programme components. It would also strengthen public health relevant research by promoting transdisciplinary collaboration in the creation of knowledge relevant to public health and facilitate multisectoral coordination of implementation pathways. It would help in critical appraisal of available research and ensure its better utilisation through appropriate advocacy.

Towards this end, the PHFI would establish new schools, assist existing institutions in their growth and network them to form a closely integrated group which will pursue this common mission. In this context, it needs to be clarified that the “autonomous” status of the PHFI includes accountability to its board where representatives of the government and others who represent public interest are present. In partnerships that would involve state governments, the PHFI would aim to preserve autonomy in its administration while accepting the responsibility to closely align with state and regional health priorities and programmes and to develop networks with existing state-run institutions to share and enhance competencies in teaching, research and practice.

Education and Research at the IPH

With the needs of an interdisciplinary approach in mind, the curriculum for the MPH degree, the core course at the IPH would be based on a range of core courses along with the specialisation in subjects such as epidemiology, statistics, demography, health economics, health administration and healthcare financing. Social science disciplines would form an important part of the curriculum for the MPH and a vital component of the research agenda since the context of the social determinants of health is essential to understand and address critical health challenges in India today.

At the same time, it must be recognised that training in public health need not and should not be confined only to longterm postgraduate courses for a few students, but should also address the need to upscale the public health knowledge and skills of diverse groups of health professionals, health system managers and health NGOs who play a vital role as public health functionaries. This can be done through suitably structured short-term and medium-term training programmes. The IPH will, therefore, develop courses to train health and allied professionals in the principles and practice of public health, through structured, multidisciplinary and target-specific educational programmes.

Each IPH would also be reliant on developing networks and symbiotic tie-ups with existing schools and universities. This would by itself ensure an anchoring in existing “India” based education systems, by sourcing an existing pool of academic programmes in the established professional schools and research bodies.

The IPH would therefore be characterised by: A “Hub and Spokes” model in which it would link with multiple institutions and agencies with convergent interests. Training as well as research would be conducted at several sites, with the PHFI playing the role of a catalyst and a coordinator.

To execute this agenda, the creation of a pool of competent faculty and research staff has therefore been a priority in planning the role and function of the PHFI. As one of its first initiatives, a faculty development programme has been initiated. This involves the sourcing of a first batch of faculty from all over India, with a preference particularly towards potential faculty with broad-based field experience in health programmes and projects in rural areas. Some of these faculties are in the process of leaving for training abroad, while others will pursue distance learning courses with established public health schools. Potential faculty already trained and based in India are also in the process of being identified to initiate the training programmes that PHFI will initiate in the first half of 2007. The PHFI also plans to assist existing public health departments and centres to develop their teaching strengths, by supporting programmes for training of that faculty in deficient areas, with a view to their enriching the resource of existing institutions.

The crisis in the teaching and practice of public health has been widely acknowledged by all the stakeholders in the health sector and beyond. Indeed, health activist groups such as the Medico Friends Circle have made a pioneering contribution in the past few decades by advocating the need to locate health concerns, including the crisis in medical education, in an understanding of community needs and rights. While there may be differences in approach to filling the gaps in public health capacity, there is no debate on the pressing need to strengthen public health education, research and practice to appropriately and adequately address India’s critical health challenges and meet its most felt public health needs. Finally, it would be a grave error to tolerate an unacceptable “status quo”, solely due to misplaced apprehensions that new initiatives for change may have suspect motives.

The PHFI and a large number of other institutions and courses that have emerged in the past few years are testimony to new and innovative models to address the challenges in public health education. We believe that it is possible to effectively address the urgent and immediate need for relevant and composite public health education through appropriate training in the precept and practice of public health education, by enhancing the capacity of public health functionaries and by fostering linkages and partnerships with existing academic institutions in India and abroad.

As we navigate the early challenges of setting up the new institutes of public health, it is the learnings and experience from academic and activist players in the area that will be invaluable in anchoring us firmly in national needs. Indeed, it is this dialogue and collaboration amongst institutions, individuals and networks in this critical area that will move us nearer to what are common aims and commitments of social equity and sustainability amongst all who are interested in promoting public health.

EPW

Email: ksreddy@ccdcindia.org

Datanet India