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Indian Journal of Community Medicine

Vol. 32, No. 1 (2007-01 - 2007-03)

Editorial

Human Resources for Public Health Service

Human societies around the world are striving hard to improve the quality of life of their people. United Nations has given expression to this aspiration by setting up a number of Millennium Development Goals covering the economic, social, and health dimensions. It is now well recognised that health development is one of the important pre-requisite to realize basic human rights. Therefore, public policies that improve population health should receive due priority. Systematic efforts are required not only for assessment of the health needs of communities and populations but also to plan, organise, and monitor health services so that these needs are met. In view of the scarce resources, most costeffective and sustainable strategies need to be put in place. Therefore, there is a need to evolve and implement a human resource policy to strengthen public health service in India.

Traditionally, illness or disease treatment has received much more attention for restoring health rather than prevention of ill health. Although it is well known that the level of health in a community is dependent not only on the access to personal preventive and curative services but largely on public health services, i.e., environmental sanitation, quality of water and air, housing, and nutrition. Therefore, most of the Indian States and Municipalities used to appoint physicians as Medical Offi cer of Health (MOH) for planning and administering public health services. These physicians would have received formal education in public health such as diploma in public health. However, after the independence, on recommendations of the Bhore Committee, the delivery of public health services and medical services were integrated, and medical offi cer was made responsible for the delivery of the integrated promotive, preventive, curative and rehabilitative service through the Primary Health Centres. Hence, all medical students were required to receive formal education in disease prevention and health promotion. Thus the study of Preventive and Social Medicine, later re-christened as Community Medicine, was started in all medical colleges in India during mid 1950s. As some of the state governments and municipal corporations did not completely merge the public health and medical care functions, few doctors continued to study for diploma in public health, the qualifi cation required for the post of MOH. However, largely physicians, who have acquired public health knowledge and skills while studying community medicine in their undergraduate courses, are entrusted to carry out the integrated public health and medical care functions in India, although in practice most pay attention to the medical care function at the expense of the public health service. A few positions of public health specialist in the central and some state health services are specifi cally available to those who have postgraduate training in community medicine.

In India, community medicine speciality integrates medicine and public health and trains physicians in epidemiology, health promotion, and health management. Every year about 200 physicians complete postgraduate training in community medicine, and thus in the last 30 years, approximately 6000 community medicine specialist have been produced. Most of them either join international non-governmental health organisations or work as community medicine teachers in medical colleges and a few of them get absorbed in medical research institutions. It is ironic that international organisations such as WHO, UNICEF, World Bank, UNFPA, and USAID etc. prefer to employ Community Medicine Specialists but our own central and state health services have not created suffi cient job opportunities for them. It is high time that the positions for MD Community Medicine at the central, state, and district level are increased.

Strengthening of the Departments of Community Medicine in medical colleges in terms of sanctioning of new teaching positions and the related infrastructure is required for increasing the supply of Community Medicine Specialists to central and state health services. Otherwise, the capacity of health services for planning, implementation, monitoring and evaluation of ambitious health program such as National Rural Health Mission will continue to be limited. Investments in Community Medicine education may not yield benefi ts in the short term but capacity built now will serve for many years to come. There is a need also to re-visit the undergraduate and postgraduate curriculum in community medicine to incorporate its various sub-speciality courses in equal proportions, i.e., epidemiology, health promotion, health management, and primary care or family medicine etc. The need for splitting the existing community medicine course into a public health and a family medicine course also needs examination. The course-work also needs to be structured to have a balance of learning in the classroom and practice in the fi eld. Course evaluation of competencies should include not only knowledge and skills but also the attitudes.

Besides the community health physicians, human resources from the allied non-medical disciplines are also needed at various levels of health care delivery system, i.e., statisticians, demographers, environmentalist, engineers, biologist, nutritionists, sociologists, economists, nurses, laboratory technicians etc. Central and State Health Services utilize statisticians, mass media and extension educators, vector biologist, public health nurses, food inspectors, drug inspectors and industry inspectors to provide preventive health care, enforce public health laws and monitor public health services. In the recent past, central and state pollution control boards have also been set up to monitor air and water pollution and to enforce environmental laws.

Currently, health personnel working at the primary health care level get oriented to public health during their formal pre-service courses for doctors, health supervisors, nurses, and health workers. However, public health content in allied non-medical disciplines rather remains quite low. Therefore, there is a need for having formal public health courses for non-medical persons at the graduate and postgraduate level such as bachelor of public health and master of public health. Since setting up of these courses will take time, in the interim period, certifi cate courses in public health should be offered to existing workforce with non-medical backgrounds, who are primarily working for public health service delivery. A threemonth public health certifi cate course can be designed to cover essentials of epidemiology, health management and health promotion, which can be delivered in modules of one to two weeks at a time and candidates can be allowed to enrol either on full or part time basis, and the possibility of delivering this course in the distance learning mode should also be explored.

A public health education system needs to be built for medical and non-medical streams starting with the short-term certifi cate courses, undergraduate and postgraduate courses, and proceeding to the doctoral level. The demand for public health education will depend on the career options available for public health professionals with medical and non-medical backgrounds in a balanced way in the current central, state, district and local government health organisations, academic and research institutions. A public health commission having representation of the health services, academic, professional associations, and civil society needs to identify the public health functions at various levels, the background qualifi cations (medical or non-medical) and the level of public health training (certifi cate, undergraduate, postgraduate or doctoral level) required to carry out these functions.

A career progression structure is needed to retain public health professionals in the public health system of the country. For example, at primary health centre level the medical offi cer with MBBS degree besides providing primary medical care is supposed to supervise the planning, implementation and monitoring of the public health programmes in about 25000 population who may need a short term refresher course in epidemiology and program management, and the health supervisors working with him must have a bachelor’s degree in public health. The senior medical offi cer working at community development block level who needs to organise public health surveillance and response besides managing public health programs in about one lakh population needs to have at least two year training in public health, e.g., DPH/ MPH. The district public health offi cers who are required to do public health programming, coordination, monitoring and evaluation need to have a three-year postgraduate training in community medicine covering advanced epidemiology, health promotion and health management such as MD Community Medicine or Dr PH. The state and central level assistant/ deputy/ joint/additional/director of public health should have at least 10-15 years experience as district health offi cers since they will be responsible for developing public health policies, allocation of resources, planning, monitoring and evaluation of public health programs, a short term certifi cate course of 4 week duration on policy formulation, health economics, and program planning and monitoring should be available to them. Besides, the deployment of public health physicians at various levels, public health professionals of non-medical background having postgraduate degree in public health will be required at district, state and central level to assist the directors of public health in carrying out varied types of specialized public health functions.

The career promotion pathways in the health services need to be tied to the professional courses so as to create incentives for acquiring advance public health education so as to ensure availability of high quality technical human resources at various levels of public health services in the country. For example, a graduate public health professional course such as BPH needs to be offered to those who have already completed the short-term certifi cate course in public health, and the postgraduate course such as DPH/MPH should only be available to those who have completed the graduate course. Similarly the doctoral courses (MD/DrPH/ PhD) should be offered to only those who have already completed the postgraduate courses. Medical offi cers who have served 3 to 5 years in primary health centres should be offered a choice of either to continue in the medical stream or to shift over to the public health cadre and depending on their choice, after acquiring specialized training in the respective field, should be assigned the task of either providing medical care in hospitals or delivering public health services to communities. This way a specialized public health specialist workforce over a period of time will be created with suffi cient experience to tackle the emerging public health challenges.

The probability of success or failure of any public organisation to a large extent depends on the quality of human resources it has and the way they are organised. This is even truer for public health organisations since other organisations may cease to exist if fail, but human society cannot take chances by neglecting public health. A sound public health system supported by technically qualified professional public health workforce is required to implement ambitious scheme such as the National Rural Health Mission and for addressing modern public health challenges of emerging non communicable diseases and injuries while continuing to combat infectious diseases like malaria, TB, HIV and be ready to face new threats such as bird fl u, SARS etc. It is easier to raise resources for a specifi c public health initiative as a case can build in numeric terms and success can also be evaluated quantitatively, but it is harder to build evidence for investment in the public health education system which eventually provides a professional public health workforce, the backbone of public health service, not only to detect new public health threats but to successfully confront the existing public health challenges.

Dr. Rajesh Kumar
Department of Community Medicine, PGIMER, Chandigarh.
E-mail: Dr. Rajesh Kumar
Received: 18.12.06

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