By Dr RP BHATT
One of my close friends told me recently to write a paper on strengthening of public health resources and system in the country and to submit it to the journal of public health, as he felt that I am a qualified person having much ground level experience of running various health programmes in the country.
In my heart of hearts, I smiled at the ignorance of my friend. The majority of medical doctors in India, who are primarily clinicians (good or bad we are not sure, as only their dead patients may be asking them questions in their dreams on why they had not been given the best treatment) are least interested in public health as an important subject to practice and, thus, this is the most neglected area in the healthcare sector. It is all a mixed and unorganised system given labels such as “comprehensive health care”, a great confusion in itself. There is nobody directly responsible for the people as far as their public health needs are concerned. It is all unscientific and full of myths and beliefs from personal hygiene to safe drinking water to vaccination or sanitation or infection prevention.
All of us now in the age group of 65-70 or more still remember our childhood days, especially in small towns in the remote areas of the country where every morning the drains were swept and washed by the dedicated staff of local municipalities and afterwards some fresh lime was also sprinkled for disinfection purposes. The importance and basis of the procedure done was also clear to the staff. In my own small neglected and remote hill town, which was not comparable to the neighbouring town of Nainital (the summer capital of United Provinces in British times), this was done regularly. The city of Nainital in those days was comparable to any town in Europe as far as sanitation and public health hygiene was concerned.
In 1943, the Government of India constituted a committee under the chairmanship of Joseph William Bhore, an Indian civil servant and Dewan of Cochin State. The task entrusted to this development committee was to survey the existing position regarding health conditions and health organisation in India and to make recommendations for future development in order to improve the public health system in India. The committee consisted of pioneers in the healthcare field of that time, who met frequently for two years and submitted their report in 1946.
In a nutshell, the Bhore Committee developed the policy framework of a Primary, Secondary and Tertiary health care system with accurate functioning at each level and scope of work with the human resources attached at each level, their functions, controls and expected outcomes in the years to come. Finally, making a policy matrix for a responsive, efficient, comprehensive and result oriented health system. Public health was integrated with clinical and curative medicine in this entire endeavour. Subsequently, based on this report, organisational development was also worked out in the states by appointing a single official in the district with huge paraphernalia to supervise and monitor all the functions of the health system. An organisational structure was placed at sub-centres at the level of panchayats manned by an Auxiliary Nurse Midwife (ANM) and, in between, the Primary Health Centres (PHC) and Community Health Centers (CHC) were structured at block and Tehsil levels of the district.
Following this committee’s recommendations, various reforms have been done in the public health sector from normalisation of blocks to abolition of posts of Civil Surgeon and District Medical Officer of Health (an equivalent and independent public health expert looking after only the public health management in the district very efficiently due to long trusted, well governed, established system of public health practice including water testing and food testing labs in the district with all concerned staff and strong financial allocations and authorities under his or her control).
The food control and drug control departments, among the main components of public health management, are now separate departments running under the control of District Magistrates in the district and the Secretary, Health, at the state level. There is complete dichotomy between the existing Medical Department (now Health has been actually replaced by the word Medical) and the drug and food control department. This is so more or less same with little variation in all the states of the country. Public health has been grabbed by the bureaucracy, as have all other technical departments, as additional charges without any accountability and responsibility regarding performance. These encroachments on the Medical and Health Departments in all states, more so in the north has been done in the last 30-40 years through a regular and slow process, because of which the damage is not visible and realised by the elected politicians heading these intricate departments, who have no experience or background to run public health systems. This resulted in policy failure and bad implementation of the Bhore recommendations in word and spirit. This resulted in complete failure and chaos in the field of epidemic control and disaster management in the country leading to pain and sufferings and also unbearable economic losses now.
The recommendations and matrix suggested by the Bhore Committee was very clean and forward looking but the expectations were high. There was a big mismatch between them and quality of implementation by the health bureaucracy in the country and states in the last so many years. With the passage of time even more deterioration in the governance has led to total deterioration in the health sector and health system development has been replaced by adhocism by the bureaucrats to please the law makers. This resulted specially after year 1980-81 onwards, and we are running an ill managed, ill manned, ill equipped, ill implemented, resource crunched, inefficient, non-responsive and non-sensitive health care system, more so in the area of the public health sector. The discredit of unavailability and lack of quality of services to the poor people of this country was given to ill paid, overburdened, unsupported, thin cadre medical doctors working in the public sector, who are otherwise the best in the world. This has also resulted in a large number of resignations as well as doctors absconding from the public sector every year. They either leave the job to settle in the private sector or go abroad. They got respect and fair rewards for their contribution in outside countries and, as of today, are the backbone of the health systems in many countries of the world.
Not only the core area of public health and curative care but the medical education system of the country has also deteriorated due to day to day intense interference and pressure of the state and the babus in the power. There has been a shift of the medical education institutions from the public and philanthropic sector to the private profit sector and most of them are in nexus initially with the politicians and babus and now with the new entrants, the corporates. In the last 40 years in the country, the medical education ministries and accreditation bodies have become a big money making racket and have started losing their creditability fast. This is also one very strong factor in the neglect of the public health and the steep rise of clinical and diagnostic medicine as evident from a person suffering from fever is going to a tertiary hospital for an expensive consultation followed by pushed investigations for the same ailment, which could be easily treated by a family physician or primary health centre as done in earlier years. The credibility of the system among the masses is at stake due to this rampant non-holistic health care approach practiced in the country.
Let us understand in a simple way what we mean by public health. It is to safeguard the health of the people in a country or in a state. Health being in the concurrent list, it’s the dual responsibility of the centre and state to ensure proper provision of specific interventions in certain areas through a qualitative and sustainable long-term mechanism. These areas of public health are listed below:
1. Enough safe drinking water and hygienic living conditions for the citizens.
2. Reduction in environmental pollution and reduction of hazards for individual citizens.
3. Population stabilisation and definite verifiable improvement in quality of life.
4. Malnutrition and hunger.
5. Sanitation, hygiene, safe sewage disposal, solid and liquid waste management, reduction in biomedical waste, safety from radiation are some important key areas of public health.
6. Drug and cosmetic qualitative control and protection from harmful chemicals.
7. Food safety and prevention of adulteration and junk foods.
8. Prevention of all type of diseases from infections, lifestyle diseases and early detection of malignancies, as well as development of vaccines and preparedness and management of epidemics.
9. Preparedness and response protocols for all disasters – natural, chemical, biological, nuclear.
10. Strategic management including data management, forecasting and surveillance systems for Global health.
As evident from the above, there are many subspecialties of public health from public health engineering to drugs, food control, strategic management to immunisation and so on. Most aspects of these subspecialties are covered under the five and half years of medical undergraduate study in our country. This needs a revisit and strengthening of curricula and more hands-on exposure as the situation warrants. The PG diploma holders of public health (post MBBS 2 years) from School of Hygiene and Tropical Medicine, Kolkata, were employed as officers of health in the district administration before the Bohre committee implementation and continued in employment up till the 1960s. The British set up the School of Tropical Medicine in Kolkata for the development of a public health cadre after the great Spanish flu disaster of 1918 in which millions of Indians and people around the world lost their lives.
This is the need of national urgency that all states seriously start working on the integration of all above public health components under their geographical jurisdiction to develop public health education and practice immediately.
This is the time to decide that the Governments are going to allocate regularly at least 10-15 percent of their GDP on public health, which is essentially the primary and a portion of secondary health only and definitely not the tertiary health which can be taken care by the private sector. For implementation, we can learn from the armed forces to develop a mechanism of implementation (always alert and prepared) led by the public health professionals, full time with various specialists for subspecialties under full control of leadership as a cadre. Some of the states like Tamil Nadu can take the lead as they have already moved and a reason to go further to achieve the objectives of public health system development. The principle may remain the same as the army – ready for combat when there is a challenge and fitness exercises in peace time while developing lateral linkages with all stakeholders on a permanent basis to increase the capacity of the frontline workers and also bring improvement in the health seeking behaviour of the masses.
(Author is a renowned public health policy and management expert. He had been on senior assignments as Chairman of Services Board, the Director General Health and Medical Education. Presently he is contributing in the private sector and working at innovations and Geriatric health as a senior advisor.)