In March this year the Prime Minister launched the Public Health Foundation of India (PHFI), a private-public initiative set up to establish five 'world class' public health institutes aiming to train 1000 public health professionals every year. And since then a series of high-level meetings have been organised in an effort to bring in health NGOs who have practised community medicine for decades, and institutions that have attempted to offer courses in public health. The stage is well-set for a 'prototype' institution to be launched soon.
A public health professional is a superspecialist who is a medical or social science graduate trained to view medicine as a social science, with expertise in epidemiology and preventive-promotive medicine. A PH professional acknowledges and incorporates in practice the socio-economic and political roots of health. This conception of a PH professional emerged, ironically enough, in the medical schools of the US and UK.
By the 1960s, the public health professional most often came to connote, in common parlance, a sanitary inspector dealing with water supply and sanitation. Preventive and social medicine as a postgraduate specialisation settled into a low value option.
It seems odd that at a time when there is a resurgence of infectious diseases, so visible and evident that health authorities can no longer sweep the evidence under the carpet, there should be debate about a coherent move to strengthen public health education. On the other hand, there are clearly many unaddressed issues in the McKinsey report that prompted the setting up of the Foundation.
The findings of the McKinsey situation analysis study commissioned by the Ministry of Health and Family Welfare that there was a paucity of public health specialists in the country is hardly a revelation. And the suggested solution to that problemexpanding public health educationis not a spectacular new idea. For over 60 years half a dozen different committees and reports have devoted pages upon pages to the 'urgent' need for public health education for doctors and for establishing institutions offering training in public health. The Bhore committee talked of evolving a 'social physician', and the Mudaliar committee made a whole range impressive recommendations on diplomas and degrees of every sub area in public health that were largely un-implementable because of the inherent infrastructure and financial requirements.
To suggest today that these lofty recommendations were not implemented because of policy trends is to misread history. None of these recommendations was ever accompanied by appropriate funding plans. They were simply not meant to be implemented. The expansion of relevant education and training in health care was an agenda without a time table and with no consideration of its financial requirements. Like so many other aspects of health policy and medical education, policy makers picked up only those recommendations that could be put in place without radically changing existing structures and those that required relatively small investment.
The concept of well-educated personnel in public health working to prioritise preventive care and public health education meandered into other avenues, such as the training of several cadres of low-skill functionaries, and the community health worker in all its 'avatars'. The chasm between public health practitioner and the medicare professional remained un-bridged. Today all kinds of interest groups are trying to trace and claim the lineage of the Bhore committee's 'social physician'.
The need for imparting systematic education in public health and create a specialist cadre is imperative. Over the recent decades this absence of a public health perspective in health care and medical training has been articulated in different fora and the academia, notably, the Medico Friend Circle and the JNU's department of social and community medicine and the Community Health Centre, Bangalore. However, there has been no concerted move to structure a well-developed programme for imparting such training and education that would enrich medicare with a different perspective. There have been independent experiments in these areas in some medical colleges, although none have been widely replicated. In this sense, the idea of promoting systematic education and training in this direction has had a long gestation.
The trouble is that progressive movements have often not quite recognised this process; nor the fact that without presenting pragmatic alternatives, even the best-argued critique can be turned on its head. In the unlikely event that the PHFI's grandiose scheme of five schools is jettisoned, what will take its place? Even if a significant anxiety is about the inappropriate course content that might emerge in the process of sourcing experts from US universities, is there an alternative curriculum, content-method-materials that may be proposed?
Apart from these issues is one that has not been adequately posted: Just where will these new public health experts be employed? Although notionally there is dearth of such experts, in reality the health care system has no location for them. What will this annual output of 1000-odd young medical and social sciences experts in public health do in India? In the absence of a thorough overhaul of the system to integrate public health perspectives and create well-paid, responsible and authoritative locations for them, is it not likely that they will find easy options and employment in universities abroad? And there perhaps, cynics might comment, they will research public health policies and design interventions for the home country that stand no chance of adoption?