India's public health management cadre policy

The 21^st century witnessed a rise in life expectancy from 68 years (in 2001) to 73 years (in 2020) globally.¹ Several nations continue to face challenges in addressing the Social Determinants of Health (SDHs) and other health determinants. A multidisciplinary public health workforce is often encountered in several countries influencing the health systems’ landscape.² Within this landscape, public health management competencies are at the intersection of ‘public health’ and ‘management’ with focus on wider determinants of health, access to health services, towards the improvement of population health.³ Public Health Management skills are invaluable in administrative positions and functional roles that involve planning, communication, community partnership, analysis, organizational leadership, basic public health sciences & practice, budget and financial planning skills, emergency planning and preparedness.⁴

Within India, medical colleges have traditionally produced public health professionals. In the last two decades, training framework of public health professionals has evolved within the country.⁵ In 2012, the High Level Expert Group for Universal Health Coverage for India recommended creation of career trajectories in public health and health management.⁶ In 2017, the National Health Policy proposed creation of a public health management cadre⁷ based on which it was estimated that if the public health cadre is implemented from 2020 with roll-out until 2026 then 33,236 posts will be created to serve in the public health management cadre.⁸

In 2022, the Ministry of Health and Family Welfare (MoHFW) proposed a multidisciplinary Public Health Management Cadre (PHMC) to augment the capability of public health system for disease burden estimation, planning for preventive health services and strengthening public health surveillance to reduce public health emergencies. The MoHFW released Guidelines for Implementation of the PHMC across India (link to Public Health Management Cadre Booklet).⁹ It calls for creation of diverse public health cadres across states. Since public health is a state subject in India, thestate governments are entrusted with institutionalising PHMC. The policy guidelines distinguish the clinical cadre from the public health cadre, freeing clinical providers from administrative tasks. PHMC aims to ensure ‘health for all’ as well as supporting the delivery of all national health programs including those under the National Health Mission, Pradhan Mantri Jan Arogya Yojana (PMJAY), Pradhan Mantri Swasthya Suraksha Yojana etc.

As per the policy document, states will independently develop and implement a plan of action to develop their own (customised) public health management structures for the new cadre based on the Government's guidelines. These guidelines fully empower states and suggest several initiatives like scaling up and expanding public health courses, preparing a roadmap for public health training of in-service candidates etc. However, within the state governments the biggest challenge towards implementation of these guidelines would be availability of the trained technical expertise in public health and broader health workforce management related issues. The states would need to develop appropriate plans for setting up these cadres with appropriately structured entry into the cadre, career progression, staffing norms (including numbers, human resource policies etc.).

To overcome these barriers and supporting states in implementing the rollout, a dedicated team would be needed with experience of working closely with the public health system. This team may liaise with the states and offer individualized support and handholding through its representatives located at the state capitals. Additionally at state level, collaboration with public health agencies and experts (who are primarily engaged in public health research and service delivery) will also be necessary and helpful. A PHMC advisory unit at the Central level will be helpful in formally interacting with the State Health Department and other stakeholders and help building coalitions for developing a health need based public health workforce at the state-level.

Another immediate challenge is related to, educational planning for public health professionals.¹⁰ At the state level, planning for public health education institutes can be evidence-driven and needs-based, focussing on development of public health focussed professional competencies (within the local context). To enhance the ability of public health professionals and achieve wider health goals, there is a need to focus on health systems issues such as equity (of access to health services) and ethics (moral problems in health services) which may be taught within public health courses offered at medical and public health schools. The PHMC should also be encouraged to drive research process within core public health functions such as: planning, monitoring, evaluation, surveillance, investigation, and analysis. This research capacity will help develop our competence in health workforce related domains such as staffing, skills mix, equitable distribution of health human resources, development of rural pipeline etc.

The release of this policy document is an important milestone for the Indian public health system as it provides a transformational opportunity for shaping the future design of health systems, from local to national level. We hope that PHMC will contribute towards realizing Universal Health Coverage and achieving the Sustainable Development Goals.

Contributors

RT contributed to the conception, design, literature search, analysis and interpretation of data, drafting of the manuscript HN contributed to the conception, design, drafting and reviewing of the manuscript, and critical revision thereof SZ contributed to the conception, design, reviewing of the manuscript, and critical revision thereof.

Declaration of interests

None.