Context

In April this year, the Union government released a guidance document on the setting up of a ‘public health and management cadre’ (PHMC) as well as revised editions of the Indian Public Health Standards (IPHS) — for ensuring quality health care in government facilities.

Background

• The need for a public health cadre and services in India rarely got any policy attention.
• Limited understanding: The reason was that even among policymakers, there was limited understanding on the roles and the functions of public health specialists and the relevance of such cadres, especially at the district and sub-district levels.
• However, the last decade and a half was eventful.
• The initial threat of avian flu in 2005-06, the Swine flu pandemic of 2009-10; five more public health emergencies of international concern between years 2009-19; the increasing risks and regular emergence and re-emergence of of new viruses and diseases (Zika, Ebola, Crimean-Congo Hemorrhagic fever, Nipah viruses, etc.) in animals and humans, resulted in increased attention on public health.
• National Public health Act: In 2017, India’s National Health Policy 2017 proposed the formation of a public health cadre and enacting a National Public Health Act.
• The COVID-19 pandemic changed the status quo.
• In the absence of trained public health professionals at the policy and decision making levels, India’s pandemic response ended up becoming bureaucrat steered and clinician led.

Different cadres and its implications

• Lack of career progression opportunities: At present, most Indian States (with exceptions such as Tamil Nadu and Odisha) have a teaching cadre (of medical college faculty members) and a specialist cadre of doctors involved in clinical services.
• This structure does not provide similar career progression opportunities for professionals trained in public health.
• Limited interest: It is one of the reasons for limited interest by health-care professionals to opt for public health as a career choice.
• The outcome has been costly for society: a perennial shortage of trained public health workforce.

Public health cadre

• The proposed public health cadre and the health management cadre have the potential to address some of these challenges.
• With the release of guidance documents, the States have been advised to formulate an action plan, identify the cadre strengths, and fill up the vacant posts in the next six months to a year.
• A public health workforce has a role even beyond epidemics and pandemics.
• A trained public health workforce ensures that people receive holistic health care, of preventive and promotive services (largely in the domain of public health) as well as curative and diagnostic services (as part of medical care).

Revised version of IPHS and significance

• This is the second revision in the IPHS, which were first released in 2007 and then revised in 2012.
• The regular need for a revision in the IPHS is a recognition of the fact that to be meaningful, quality improvement has to be an ongoing process.
• The development of the IPHS itself was a major step.
• The revised IPHS is an important development but not an end itself.
• In the 15 years since the first release of the IPHS, only a small proportion — around 15% to 20% — of government health-care facilities meets these standards. .
• If the pace of achieving IPHS is any criteria, there is a need for more accelerated interventions.
• Opportunities such as a revision of the IPHS should also be used for an independent assessment on how the IPHS has improved the quality of health services.

Implementation challenges

• The effective part of implementation is interplay: policy formulation, financial allocation, and the availability of a trained workforce.
• In this case, policy has been formulated.
• Financial allocations: Then, though the Government’s spending on health in India is low and has increased only marginally in the last two decades; however, in the last two years, there have been a few additional — small but assured — sources of funding for public health services have become available.
• The Fifteenth Finance Commission grant for the five-year period of 2021- 26 and the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) allocations are available for strengthening public health services and could be used  as States embark upon implementing the PHMC and a revised IPHS.
• Availability of trained workforce: The third aspect of effective implementation, the availability of trained workforce, is the most critical.
• As States develop plans for setting up the PHMC, all potential challenges in securing a trained workforce should be identified and actions initiated.

Conclusion

The public health and management cadres and the revised IPHS can help India to make progress towards the NHP goal. To ensure that, State governments need to act urgently and immediately.

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Back2Basics: Indian Public Health Standards (IPHS)

• IPHS are a set of uniform standards envisaged to improve the quality of health care delivery in the country.
• The IPHS documents have been revised keeping in view the changing protocols of the existing programmes and introduction of new programmes especially for Non-Communicable Diseases.
• Flexibility is allowed to suit the diverse needs of the States and regions.
• These IPHS guidelines will act as the main driver for continuous improvement in quality and serve as the bench mark for assessing the functional status of health facilities.

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