Genome #2: AIHS - All India Health Services to enable efficient public health administration
India needs a major reform to move its focus from curative to preventive healthcare
Public health, as CEA Winslow defined in 1920, is “the science and art of preventing disease, prolonging life, and promoting health through the organized community efforts and informed choices of society, organizations, public and private communities, and individuals.” A public health system is a conglomeration of all organized activities that the government takes to ensure good public health. The Covid-19 pandemic has not only driven home the importance of general hygiene, but also the importance of a robust health care system and administration across countries.
The second wave of Covid-19 that hit India around April-May 2021 led to a total collapse of the healthcare system. The initial gap in demand and supply of oxygen severely affected a lot of hospitals, particularly in Delhi, which had to send out SOS calls. This devastatingly led to a loss of lives, which were totally avoidable. While it can be argued that there was a systematic lack of resources behind this failure, but a lack of proper administration and planning also played a substantial role.
Current status of health administration in India
In 1943, in the midst of the second world war, the then Government of India constituted the Health Survey & Development Committee, popularly known as the Bhore Committee with Sir Joseph Bhore as its chairman, to carry out a broad survey to gauge the current status of healthcare in British India. Its findings paved the blueprint for the development of health services in post-independent India, emphasizing the loss of human capital that was taking place due to lack of a proper public health system:
If it were possible to evaluate the loss which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until aradical change had been brought about.
The Bhore committee recognized the rural-urban disparity that existed even back then and recommended for integration of preventive and curative healthcare services at all levels. The current three-tier system of healthcare services in India: primary, secondary, and tertiary is a result of the recommendations of the Bhore Committee (Figure 1).
In 1962, the Mudaliar Committee, also known as the Health Survey and Planning Committee recommended the creation of All India Health Services to replace the erstwhile Indian Medical Service that had been discontinued in 1947, post-independence. It notes:
although abolition of the post of public health commissioner and the complete merger of his organization with the DGHS at the time of independence was a move in the right direction, it has resulted in weakening of the epidemiological, statistical and other aspects of public health activity.
The Indian Medical Service (IMS) was chiefly focused on clinical care in the barracks and civil lines. They had a very limited role in public health or in the healthcare services for the general population. Interestingly, Ronald Ross who received the Nobel Prize in Physiology for 1902 for discovering the transmission of malaria, was employed as a surgeon in the Indian Medical Services when he made the discovery. The IMS operated more on healthcare delivery than as a general administrator of healthcare across the country.
To administer over healthcare facilities, India currently does have a cadre of medical officers who are recruited as officers under the Central Health Services through Union Public Service Commission (UPSC) and has been in existence since 1963. The CHS has four sub-cadres: teaching specialist, non-teaching Specialist, public health specialist, and general duty medical officer. Though the cadre has more than 3100 general medical duty officers it has only 78 public health specialists. The public health cadre has remained largely neglected and is unsurprisingly the smallest of the four sub-cadres. Since the promotions are based on seniority (and not experience or expertise) in CHS, it is possible that the director-general of health services (highest technical post in the cadre) would have zero experience in public health and could still be responsible for implementing the national malaria program - this specialist could be a clinician who has worked in say one government hospital, in Delhi with no exposure to a sub-center, district, or a primary health center. In contrast, in countries like the US, such positions are held by people who have had formal education or have substantial experience working in the field of public health.
An alternative system for health administration
The Mudaliar committee made a recommendation for service on the lines of the Indian Administrative Service (IAS) by arguing that administration of public health requires a comprehensive outlook and experience:
We feel that the personnel dealing with problems of health and welfare should have a comprehensive and wide outlook and personnel selected to work in the Centre should have rich experience of administration at the State level. For this it is necessary that an All-India cadre should be brought into existence.
It further recommends,
The All-India cadre besides providing for posts in the Central Ministries (other than Defense) should also have a quota of State posts to which officers from the cadre may be seconded. A percentage of the posts in the cadre should be filled by direct recruitment by the Centre and the balance filled by secondment from the State service and such officers may be used either in the State service or on an All-India basis. The chief objective of suggesting such an arrangement is to get the qualified persons with experience in various fields of work in different regions of the country to be available for the All-India service. The structure of the health services should be on the lines of the I.A.S. in regard to salary scale, its divisioninto senior and junior scales and the quota of each State
To give some context, members of the IAS are recruited through a competitive examination organized by the UPSC. The selected personnel undergoes two-year training in a variety of subjects, including a year-long exposure to all levels of administration. For the first nine years, they are required to work in districts as sub-divisional officers, district magistrates, or as project directors of some rural or urban development scheme. After nine years of service, they can move to the secretariat or work in education, health, rural/urban development, or other commissions. Most of the senior positions in the central government are assigned to IAS officers, who bring with them years of field experience and state-level perspective. The system is designed to provide stability and continuity of policies even if the political environment keeps changing. The system has worked well overall (though it has its own shortcomings of course) and the success can be attributed to the focus on gaining understanding at the sub-district and state level of the institutional context of governance.
India should implement a dedicated cadre for public health - All India Health Services (AIHS) consisting of trained professionals who will be responsible for ensuring public health and will operate parallel to the clinical cadre that is already in place through CHS and other state-level services.
Solving the inefficient delivery of public health services through AIHS
The training in AIHS can follow the model of IAS - the selected personnel will be put on a two-year training period at the district and sub-district levels across states. In these two years, they will gain an understanding of the demand and implementation of public health care schemes at a local level. This will train them in public health, epidemiology, health economics, and institution-building skills over the two years, which can then be used to implement robust strategies for ensuring good public hygiene and sanitary conditions and prevention strategies for communicable and non-communicable diseases at the district, state and national levels.
How will this be any different from the systems we have in place? The current system is more focused on curative healthcare. A service dedicated to public health would ensure that India is better prepared for controlling infectious diseases (like Covid-19), is well-equipped with human and financial resources for the management of diseases in general. An ideal cadre would have epidemiologists that will be responsible for identifying the cause of the disease and devise strategies to control its spread and prevent it from happening again. AIHS would follow the current framework of the health care system at the block, district, and state-level. But in contrast to the existing CHS system in place, AIHS would require the officials to have a public health qualification (through its own or certified training programs) and provide them sufficient training before transitioning them to positions of power. This will ensure that personnel responsible for taking public health decisions really understands the nitty-gritty of how the system works at the sub-district administration level and will have training in public health management to ensure good public health for the entire nation.
The recruitment of AIHS cadre could be done through a special examination that can be conducedted by UPSC similar to the civil services examination, where the doctors interested in working for the government would undergo compulsory training in health policy and would work at district or sub-district level hospitals for a period of five years following the initial training of two years. After the five-year experience, they can then transition to central-level positions with the responsibility of formulating national-level public health plans.
Some states, such as Tamil Nadu and Maharashtra already have a state-level public health cadre in place which has been fruitful in ensuring improved health and developmental outcomes. For example, Tamil Nadu performs better than most other states in immunization coverage for children, percentage of women receiving complete antenatal and post-natal care.
Health is a state subject in India. In order to ensure maximum efficiency of AIHS, health should be made a concurrent subject. At the central level, the Ministry of Health and Family Welfare should operate two separate departments - one for public health and another for clinical health. This restructuring is required since the demands of these two fields are very different, with public health requiring more interventions that are preventive (and not curative) in nature. The central government would coordinate with the states for public health matters as is done for other existing departments such as economic and social planning or education.
Any new reform comes with its own challenges - resistance being the first. Setting up AIHS requires changes in the current system, but its organization would be similar to the current health care system in place, thereby making its implementation easier and hence prone to less resistance from the government. For this reform to be useful, a good start would be to make health a concurrent subject. States should enact Public Health Acts to empower health officials with regulatory authority and power to enforce public health legislation as required. And finally, the government should make necessary legislative changes to grant AIHS enough authority for ensuring good public health.
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