On April 16, the Centre mandated the formation of two new cadres to strengthen health system at both central and state levels
By Dr. Abdul Rouf
PUBLIC health encompasses many different disciplines and areas of study, including epidemiology, biostatistics, vaccinology and immunology, program planning and evaluation, policy and health care management. Public health, at its core, is about the prevention of disease and limiting the impact of the disease once it has occurred.
Public health has gained critical importance now more than ever as the world continues to try to slow the spread of COVID-19. It is not only the most vital intervention in reducing the number of cases, but also to lessen the burden on the healthcare system. Since the COVID-19 pandemic started, there has been a need for better preparation as there can be another global pandemic in the future, and this is where a dedicated Public Health cadre is very important. Although India has made considerable progress in public health in recent past in terms of decrease in infant mortality rates, under-five mortality rates, and maternal mortality ratios, all sensitive indicators of health system performance. Yet, the country’s health system continues to face many challenges, now mainly in the form of emerging diseases and their better control.
An important feature contributing to improved health outcomes not only in the developed world but also across select states in India is the presence of a dedicated, efficient and adequately resourced public health cadre. With professionally trained public health professionals/ community medicine specialists and often the support of robust public health regulations, these cadres have contributed to improved health, environmental, and developmental outcomes.
Developed Countries have made vigorous efforts to invest in public health. For over hundreds of years, this commitment to population health in the form of strengthened departments of public health with separate budgets has helped protect its people from exposure to disease, environmental threats, and helped to increase life expectancy. In 2016, the Ebola outbreak raised concerns about the poor preparedness of Public health systems globally. Now COVID-19 has altogether exposed the weaknesses of the Public Health structure across the world including our country India. There is evidence that the countries with well-established Public health systems have better outcomes of the COVID-19 pandemic and emphasize on the need for strong public health services that go beyond health establishments.
Public health cadre has more relevance in times of pandemic like COVID-19, as it allows more service providers to screen and treat a greater number of patients, and patients who may have been infected with the virus no longer have to travel to the hospital or the service providers for evaluation. Even the Board of Governors issued Telemedicine Practice Guidelines in midst of the COVID-19 pandemic to avoid movement of people and crowding of healthcare establishments.
Moreover, from well-trained Public Health experts (MPH, MD Community Medicine specialists) in independent and locally accountable public health teams within local authorities to the robust engagement of community-level workers, these institutional arrangements for public health delivery have made a significant effect in improving community health outcomes. The structure of public health in India, where health is a state subject is haphazard. Although, public health interventions are delivered by various functionaries from the auxiliary staff to higher administrative levels, except few states (Tamil Nadu and Maharashtra) these are not organized in a separate/dedicated systematically trained public health cadre. In addition, the absence of a comprehensive Public Health Act in most states means that health officials lack the regulatory authority and powers to enforce public health legislation adequately. The lack of a separate public health directorate further compromises their independence, effectiveness, and efficiency.
The state of Tamil Nadu has been running with this cadre system since before independence and acting illustriously higher than the country average in various fields, like immunization coverage, maternal and child health as well as disaster management. Similarly, Maharashtra has a stratified cadre system for public health medical officers. In Odisha, there has been a recent systematic human resource reform with the partial fulfilment of cadre-based system introduction at the block level and above. It is already in place since 2017 and the Odisha model has gained its popularity and momentum. Different other states like Chhattisgarh, Arunachal Pradesh, Bihar and UP are in progress at various levels. In West Bengal, proclaiming ‘The Calcutta Declaration’ on public health December 1999 demands for need-based and scientific cadre structure with rationality at various levels is awaiting implementation.
As China and India are the two most populous neighbours experiencing very close post-independence ages, comparability in the health sector can be drawn. Following the Soviet Union’s public health delivery model, China implemented a countrywide organized bottom-up health care delivery initially targeting the rural villages and urban poor providing basic preventive, curative and referral services. For this, they trained pre-existing ‘village doctors’ who were given basic as well as skill-based training. Thus over years designated public health cadres were created who are still working to bring about the country’s wonderful health success story. Public health services in Sri Lanka since September 2011 have delineated population-wise human resource availability. Health workforce in Latin America and Caribbean (LAC) countries enjoy a much amicable working ambiance like as, determining their employment conditions, clear salary scales, top-up incentives over salaries, etc. Among these countries, Costa Rica and Jamaica have been able to develop designated health cadres at the PHC level to reach vulnerable populations effectively. In Uruguay and Columbia education on health has become more accessible which has been complemented by high salaried placement. These countries have also focused on workplace safety, promotion of health, and promoting satisfactory working conditions which have shown results in the form of low attrition and better health care services.
As we have seen, the COVID-19 pandemic has led to disruption of routine healthcare delivery services in the country with the closure of routine outpatient departments, immunization clinics, antenatal services, and other services because the health systems are overwhelmed and both direct mortality from a pandemic and indirect mortality from other vaccine-preventable and treatable diseases increase dramatically. Past experience from the 2014–2015 Ebola outbreak suggested that the increased number of deaths by measles, malaria, AIDS, and tuberculosis were due to the failure of the health system and that it exceeded the deaths from Ebola outbreak alone.
Moreover, surveillance data in India shows recurring outbreaks of gastrointestinal disorders, hemorrhagic dengue fever, as well as large-scale outbreaks of malaria and point toward compromised public health measures. This pandemic has again shown the inability of our health establishments to cater to infection prevention and control guidelines at workplaces because of the profile and design of the establishments. Design and creation of public facilities that ensure the health and well-being of inhabitants maintaining the standards of ventilation, lighting are essential to be constructed adhering to public health norms.
The most important counter move that emerged from the COVID-19 pandemic was flattening the curve to ensure that surge capacity during an outbreak does not overwhelm the healthcare system. To save lives it is essential that prompt actions be taken during outbreaks and for that readiness of mechanisms and lines of action well beforehand will facilitate the same. Even if medical countermeasures are available, the diseases remain a threat for many of the world’s populations, either because of the rapidly evolving nature or because equitable access to effective public health measures is difficult. Although there seem to be many reasons for limited access to vaccines, production capacity does not meet the demand, explosive outbreaks exhaust the available vaccines, or the absence of vaccine during the first wave, but the most important thing which was lacking was surely the absence of robust Public health structure. Our Health system lacks protocols to ensure a smooth exchange of information and cooperation between health establishments, regional entities, and health authorities for maintenance of the supply chain on a demand basis and most important dealing with infodemics (misinformation).
An overall Emergency Response Plan to coordinate the hospital's overall emergency response was lacking. Protocols should be handy for other essential services such as laboratory, food, water, and electricity supply so that indirect mortality can be taken care of.
Most of the COVID-19 SOPs and guidelines were developed using a very low-quality method of Guidelines by Expert consensus. The most sophisticated way of developing guidelines that require Evidence Synthesis (Denovo Guidelines) using systematic review of the primary research was ignored because of the lack of experts from the relevant fields in the committees forming these guidelines and SOPs. During the COVID-19 pandemic, no standard treatment protocols were followed and many therapies and drugs were used even after finding them ineffective or having no proven benefits in multicentric clinical trials, thus exposing the patients to unnecessary side effects and drug interactions.
Traditionally, during the coronavirus crisis, the government of India and state governments resorted to a standard practice of setting up committees and task forces composed mainly of bureaucratic and political loyalties. Most states have appointed current and retired bureaucrats, eminent clinicians, some scientists, and generalists to their panels who have advised cocktails of different prophylactic measures and who have very little or no experience in handling outbreaks. Delhi government constituted a state-level task force comprising 34 members under the Chief Minister, which in turn recommended the establishment of 11 District Task forces headed by District Magistrates. Only Kerala and Tamil Nadu stand out as the ones that had the right mix of experts and implementers because of the better-designed Public Health system developed in response to two Nipah outbreaks. On the contrary, in the USA the Epidemiologist Anthony Fauci who guided six presidents including the USA on HIV, Ebola, and Zika, and now COVID-19 was at the helm of affairs, and his role in advising the government and communicating to the public was appreciated throughout the world.
A specialized workforce (Public Health specialists/Community Medicine specialists) is needed, with the capacity to generate evidence, analyze and immediately come up with solutions to public health problems. National Health Policy 2017 is built on the theme explicitly which proposes the creation of a public health management cadre in all states. Moreover, there is a need to have expertise in epidemiology, environment, demography, statistics, entomology, vaccinology and immunology, program planning and evaluation, policy, and health care management.
The training of epidemiology is currently provided as a part of preventive and social medicine (community medicine) training program to undergraduate students in MBBS curriculum, for providing basic knowledge of public healthcare delivery system of the country, essential to make competent primary care physicians. Master's Degree (MD) in Community Medicine with training in epidemiology, disease surveillance, health systems, health programs, and public health laws is offered in the post-graduation program. The students are additionally trained in research on public health problems and to take up leadership roles in the public healthcare delivery system.
So, the learnings from COVID-19 has provided some important observations for exploring the feasibility of establishing Public health cadre:
1. While health departments have faced numerous challenges during COVID-19, the roots of these problems are institutional silos, poor funding in health, ambiguities over authority, and neglected hospital infrastructure, and poor use of the Public health workforce.
2. Policymakers lack various tools to achieve alignment on the public health mandate and public health governance, from accreditation programs to frameworks outlining the minimum services and capabilities of the health department.
3. During COVID-19 Health department provided data reporting, testing, contact tracing, quarantine/Isolation), but the challenges they encountered were barriers to exchanging information, operational silos, lack of disaggregated data, and insufficient capacity and training that were indicative of poor design and a lack of investment in the public health system.
4. States with separate public health cadres have a fair amount of success in COVID-19 mitigation and control.
Views expressed in the article are the author’s own and do not necessarily represent the editorial stance of Kashmir Observer
- Author is working in the Department of Community Medicine, Government Medical College Anantnag and can be reached at [email protected]
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