In a long awaited announcement, made on April 16, the Centre mandated the formation of two new cadres to strengthen health system performance at both central and state levels. The Public Health Cadre and Health Management Cadre will now join a Specialist Cadre of clinicians and a Teaching Cadre to form the four wheels that will transport the health system towards its goals.
The path forward was detailed in a document released by the Union health ministry. Its title, Public Health Management Cadre, suggested a single cadre. That was in deference to the National Health Policy (NHP) of 2017 which proposed a public health management cadre in each state. However, the description in the main text of the health ministry announcement reveals that two separate but complementary cadres are proposed, one for public health and the other for health management. They will have separate recruitment criteria and distinct functions.
A recommendation, for establishing all-India and state-level Public Health Service Cadres and a specialised state-level Health System Management Cadre, was made in a 2011 report of the High Level Expert Group (HLEG) on Universal Health Coverage (UHC) constituted by the Planning Commission of India. Though the 12th Five Year Plan (2012-17) does allude to the need for public health management cadres, no efforts were made to advance their formation, till NHP 2017 enshrined it as part of national policy. Even then, it has taken five years and a wakeup call from Covid to advance this policy to active implementation mode.
In 2008, the Union health ministry asked the Public Health Foundation of India (PHFI) to design a post graduate diploma programme in public health management to provide a hybrid course which combined the precepts and practice of public health with the principles and skills of effective management. This programme was initially meant for government doctors at district and sub-district levels, to support the National Rural Health Mission (NRHM). Later extended to include non-government aspirants, the course was delivered by the Indian Institutes of Public Health (IIPHs) and some other partner institutions. While the graduates of this programme strengthened health system performance when suitable postings provided an opportunity, the absence of a public health cadre did not permit their optimal utilisation.
While a public health cadre is not new to all of India, it was uncommon. Tamil Nadu maintained a public health cadre ever since Independence, with many analysts crediting the cadre for the commendable performance of the state’s health system. More recently, Odisha established a dedicated public health cadre. A few other states require public health qualifications for certain positions in health administration, but did not have a demarcated cadre. Even in the central health services, there was no distinct public health cadre.
The rationale for such cadres is very clear. Public health functions (such as infectious disease surveillance and immunisation) and delivery of national health programmes (for TB, malaria and HIV-AIDS or tobacco-control, cardiovascular diseases, diabetes and cancer, etc) require specialised knowledge and skills. Epidemiology, biostatistics, health economics, environmental health, social and behavioural sciences are among the knowledge domains of public health. An orthopaedic surgeon or an obstetrician, however skilled they may be as clinicians, won’t have the expertise needed to efficiently manage such programmes. Furthermore, saddling them with the tasks of managing such programmes diverts their time from the clinical work they are good at. Both ways, the public lose.
Similarly, such specialist clinicians don’t usually have the management skills needed for budget management, financial accounting, procurement and supply chain management, health information systems, human resource development and deployment, healthcare facility management and multi-sectoral coordination. Even if they do possess such skills, they are better positioned to apply their clinical skills for patient care while persons with management expertise handle the non-clinical functions.
The government has now mandated that the public health cadre would be constituted by doctors who obtain a post graduate degree or diploma in community medicine, preventive and social medicine or public health after the MBBS degree. The health management cadre would be constituted up to 70% with doctors with postgraduate qualifications in public health and 30% with those with an MBA degree and specialisation in human resources, procurement and supply chain, finance, operations and hospital or health management. States have been given the flexibility to adjust these proportions, based on need and availability.
There is a suggestion in the announcement that all new MBBS doctors would be required to acquire public health qualifications in 3-5 years from graduation. That probably applies only for doctors who wish to enter the public health cadre. Other medical graduates may proceed to specialist clinical courses if they wish.
Resistance to such cadres earlier came from clinicians who felt that they would be deprived of administrative posts which carried power, prestige and perks. If cadre structures can be designed to provide for sharply delineated roles, and promotional avenues are clearly defined within each cadre, such conflicts can be avoided. Non-physicians like dentists and nurses too must be provided an opportunity to enter the new cadres after training in public health and management.
Other experts, such as social scientists and health communication experts, must be suitably engaged in public health programmes through contractual appointments even if cadre structures do not provide easy entry. Public health is a multi-disciplinary knowledge platform that must provide scope and skills for multi-sectoral action on the many determinants of health.
If implemented early and in earnest, the creation of these cadres would greatly strengthen the design, delivery, monitoring and evaluation of our public health policies and programmes. It would also enable impact assessment of policies and programmes in other sectors that have ramifications for health, aligning them to public health objectives. As chair of the HLEG on UHC, I am gratified to see a key recommendation of our report now coming to life.
The author, a cardiologist and epidemiologist, is president, Public Health Foundation of India (PHFI)
Views are personal
