In India, it is common for heads of health services at the national, state or district level to be orthopedic or cardiac surgeons or ophthalmologists who have no training in public health. Public health professionals are also sub-represented in state and central advisory bodies for 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 that anyone can do it.
a poor understanding
Public health is essentially multidisciplinary and means different things to different people. Many people, even those within public health, have little understanding of this. For example, recent central government guidelines specify an MBBS degree as a prerequisite to become a public health specialist. Some have commented on 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 working for the state or central government are public sector health workers, but they are not doing public health. Providing medical care in a primary health center does not make a person a public health professional. Also, health workers have no training in public health; They are the grassroots service provider. Asking them to be part of the public health cadre trivializes the public health profession. It is important to understand that public health is a separate profession with specific qualifications.
I use the four ‘A’s – academics, activism, administration and advocacy – to describe public health actions. Having a good grounding in epidemiology and biostatistics refers to a good understanding of academic evidence creation and synthesis. These competencies are also important for monitoring and evaluating programs, monitoring and interpreting data, and routine reporting.
If the academics are the mind behind the discipline, then activism is at the center of it. Public health is inherently linked to ‘social change’ and an element of activism is at the core of public health. Public health requires social mobilization at the grassroots level by understanding community needs, community organization, etc. This requires a foundation in the social and behavioral sciences. It also includes the study of how non-health determinants, including social and occupational factors, affect health and how these can be addressed.
Administration refers to the administration of health systems at various levels: from the primary health center to the district, state, and national levels. This includes implementing and managing health programmes, addressing human resource issues, supply and logistics issues, etc. It involves micro planning of program delivery, team building, leadership as well as financial management to some extent. A sound understanding of the principles of organizational management and health administration is critical to achieving this qualification.
The last task deals with advocacy at various levels. In public health, there is little that one can do at the individual level; To change the status quo at various levels of government there should be communication with key stakeholders. This requires explicit declaration of requirement, analysis of alternative set of functions and cost of implementation or non-implementation. Good communication and negotiation skills are important for doing this job. Related topics are health policy, health economics, health advocacy and global health. These four functionalities can be applied to any specific or general problem such as environmental or nutrition or infectious disease and can be considered akin to super-specialization in other medical fields. Epidemic management required equal measure of all four competencies.
Training
In India, training in these competencies 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 (an additional year is devoted to the provision of medical care), while the second is also open to non-medical persons. In addition to classroom teaching, public health trainees are deployed in communities and at various levels of the health system. Such exposure helps them to put all these competencies together to develop into trained public health professionals. Trainees develop a systems approach and a long-term perspective, which are at the core of this discipline. This differs from a clinical approach, which focuses on individuals and where the time frame is usually short, if not immediate.
None of the four major public health functions require a medical qualification. The training mentioned above has nothing to do with the human body. Unlike clinical disciplines, it does not divide humans into organs or systems. It is important to recognize that organ-/system-based medical training produces a deep but narrow-minded view of what is appropriate for, but inappropriate for, broader public health approaches aimed at working with communities or health systems. While one might argue that medical knowledge helps to better understand health issues, one could also argue that it is not the most effective use of years spent learning medicine.
Historically in India, public health has been medicalized as it was largely a medical college-run discipline. It is the resistance of this medical public health fraternity that explains the continuing need for a medical degree for a public health professional. This has resulted in the exclusion of nursing, dental and other health professionals from contributing much to public health. It needs to go in the national interest.
Many doctors and other health professionals work at the grassroots level and develop a sound understanding of public health because of their inclination. But they do not become public health professionals because they may not have the necessary skills. Nevertheless, they are valuable. Physicians trained in epidemiology and biostatistics would not be qualified to become public health professionals because they lack not only other necessary and critical expertise, but also an appropriate perspective. Short training or even a one-year distance learning course may not make a public health professional in the same way that it cannot make a physician or cardiologist.
It is important that health professionals, government and the public recognize public health as a distinct set of competencies and give it the importance it deserves. The recent proposal of the Ministry of Health to create cadres for public health professionals and health management at the state, district and block levels is a welcome move. However, it is not sufficient. The quality of public health training being provided also needs attention. Only it will attract the best and brightest people to this discipline, which is very important for the health of the country. This is a lesson we must learn from the pandemic.
Anand Krishnan is Professor at the Center for Community Medicine at All India Institute of Medical Sciences, New Delhi. thoughts are personal