Bridging the gap in health policy implementation

In April this year, the central government released a guidance document on the revised versions of the Indian Public Health Standards (IPHS) along with setting up of a ‘Public Health and Management Cadre’ (PHMC) to ensure quality health care in the government. facilities. For a country where politicians take pride in inaugurating super-specialty hospitals and where the focus on health has traditionally been medical care or the treatment of the sick, these two developments to strengthen public health services Welcome.

a background, result

The ‘Public Health and Management Cadre’ is a follow-up to the recommendations made in India’s National Health Policy 2017. Currently, 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 the same career progression opportunities for professionals trained in public health. This is one of the reasons of limited interest by health care professionals to choose public health as a career option.

The result has been costly to society: a perennial shortage of a trained public health workforce. The proposed public health cadre and health management cadre have the potential to address some of these challenges. Along with the issuance of guidance documents, states have been advised to prepare an action plan, identify the cadre strength and fill up the vacancies in the next six months to a year.

The revised edition of the IPHS once again underscores the continuing relevance of improved quality of health services through public health facilities. This is the second amendment to the IPHS, first issued in 2007 and then revised in 2012. The regular need to amend the IPHS is a recognition of the fact that to be meaningful, quality improvement must be an ongoing process. The development of IPHS was a big step in itself. About two decades ago, in many countries, including India, there was limited attention to quality assurance. Increasing access to health services and improving the quality of care was perceived as a gradual process: first focusing on increasing access and then a consideration could be given to ensuring quality (which rarely happened). .

Role and Relevance

The voice of public health services and the workforce in India has always been low and weak. Clearly, the need for public health cadre and services in India has rarely received any policy attention. Arguably, this was because, even among policy makers, there was limited understanding on the roles and functions of public health experts and the relevance of such cadres, especially at the district and sub-district levels. At best, epidemiologists were equated with public health experts, failing to recognize that the latter is a much broader and inclusive group of experts. However, the last decade and a half has been eventful. Initial threat of avian flu in 2005-06, swine flu pandemic of 2009-10; five more public health emergencies of international concern between 2009-19; Increased risk and regular emergence and re-emergence of new viruses and diseases (Zika, Ebola, Crimean-Congo hemorrhagic fever, Nipah virus, etc.) in animals and humans have resulted in increased attention to public health. In 2017, India’s National Health Policy 2017 proposed the formation of a public health cadre and enactment of a National Public Health Act. Nevertheless, progress on these fronts was as slow as ever.

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The COVID-19 pandemic changed the status quo. For months together, everyone was looking for professionals trained in public health and who had experience in the field; They were just far and few. It became clear that ‘epidemic’ and ‘epidemic’ required specialized skills in a wide range of disciplines such as epidemiology, biostatistics, health management and disease modeling, to list a few. In the absence of trained public health professionals at the policy and decision-making level, India’s pandemic response ended up being bureaucratic and physician-led. Every struggle in the response to the pandemic was a reminder that a physician, no matter how skilled in the art of treating the patient, or a bureaucrat, however experienced in administration, could not fulfill the roles of epidemiologists and public health experts. can, which are specially trained to make decisions when there is limited information about a pathogen and its behavior.

an ongoing role in care

A public health workforce has a role to play beyond pandemics and pandemics. A trained public health workforce ensures that people receive holistic health care, preventive and promotive services (largely within the public health sector) as well as curative and diagnostic services (as part of medical care). Ho. A country or health system that lacks a public health workforce and infrastructure is likely to move towards a medical care system. In 2022, there is more clarity on the role of the public health workforce, which is a notable starting point. However, the delay in policy decisions on a public health cadre is also a reflection of the long and difficult journey of policy making in India. These two new cadres have come late but now the focus has to be on speedy implementation.

The revised IPHS is an important development, but not the end of it. In the 15 years since the first release of the IPHS, only a small proportion of government health care facilities – about 15% to 20% – met these standards. This raises a valid question as to whether the development (and revision) of such quality standards is ritualistic practice or whether they are seriously considered for policy formulation, programmatic interventions and corrective measures. If speed of receiving IPHS is any criterion, more prompt intervention is needed. Opportunities such as the IPHS review should also be used for an independent assessment of how IPHS has improved the quality of health services.

incomplete implementation

Drafting well articulated and sometimes perfect policy documents, albeit in a belated manner, is a skill that Indian policy makers have mastered well. However, the implementation of most such policies leaves much to be desired. The implementation of IPHS over the last 15 years is one such example. The outcome of the PHMC guidance document is difficult to predict; However, the past can guide the process.

The effective part of implementation is the interaction: policy formulation, financial allocation and availability of trained workforce. A policy has been made in this matter. Again, although government spending on health in India is low and has increased only marginally over the past two decades; However, over the past two years, some additional – small but reassuring – sources of funding have become available for public health services. Fifteenth Finance Commission grants and Prime Minister’s Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) allocations for a five-year period 2021-26 are available to strengthen public health services and can be used as catalytic funding. is – which should be used interim – as soon as states begin to implement the PHMC and a revised IPHS.

The third aspect of effective implementation, availability of trained workforce, is of paramount importance. Even the most well-crafted policies with adequate financial allocation can falter due to lack of trained workforce. As states develop plans for setting up PHMCs, all potential challenges in securing a trained workforce should be identified and action initiated.

supporting states

One, the level of interest among states in implementing public health and management cadres needs to be ascertained and a Center of Excellence should be designated in each state to guide this process. The states which are likely to show reluctance need to be addressed through suitable incentives. Two, the idea of ​​mapping and analyzing human resources for public health and then scaling up recruitment is logical. However, there is a need to ensure that the quality of training of the required workforce is not compromised in this over-zealous effort to get the numbers. The establishment of these two new cadres should be used as an opportunity to standardize and improve the quality of training in public health institutions. Third, it will take a few years for PHMCs to be fully functional in the states. However, the implementation process needs to start in the next few months to avoid the risk of it becoming a low priority. Fourth, the success of the PHMC will depend on the availability and equitable distribution of health workers to all other categories at government health facilities. Therefore, as new cadres are being earmarked, efforts need to be made to fill up the vacant posts of health workers in all other posts as well.

Three years before the COVID-19 pandemic began, the Indian government had committed through the NHP 2017 to achieve the goal of universal health coverage – which covers a broad range of (preventive, promotive, curative, diagnostic, rehabilitative) health Envisions accessibility – care services that meet certain quality standards that people can afford. The public health and management cadre and the revised IPHS can help India make progress towards the NHP target. To ensure this, the state governments need to act promptly and promptly.

Dr. Chandrakant Laharia is a physician, public policy and health systems specialist and an epidemiologist based in New Delhi.