Agenda for Strengthening Master of Public Health Courses in India: FRAME India Initiative

Abstract

India needs a skilled and responsive public health workforce. Masters in Public Health (MPH) has emerged as an important source of these professionals in addition to postgraduation in community medicine. Since 1990, many universities and schools are offering MPH course with little quality control and standardization resulting in concerns on the employability of graduates. One of the concerns is that MPH programs, though borrowed from US model, need to be adapted to the Indian context and also maintain its interdisciplinary nature. This requires a review of eligibility criteria, competencies, curriculum, exit exams and career pathways. The FRAME India Initiative, by a group of like-minded senior faculty from publicly funded MPH schools, aims to develop a shared understanding on these issues. It will work with all stakeholders to ensure that the goal of strengthened and standardized MPH programs in India is met.

INTRODUCTION

Given the high burden of multiple diseases, environmental threats, health system weaknesses, and persistent health inequities, India urgently needs a skilled and responsive public health workforce. Recognizing this, a public health cadre has been proposed by the central government (some states already have it), and robust efforts are on, though much needs to be done.[1,2] At the same time, public health competencies are needed outside the government/public sector, including in academia, development, and industry sector work domains.

In this context, the Master of Public Health (MPH) degree has emerged as a critical qualification for professionals aspiring to contribute to public health practice, academia, research, and policymaking. The need for a multidisciplinary public health workforce and competency for monitoring and evaluation of public health programs has been articulated.[3,4] Globally, the MPH degree is recognized as a professional qualification aimed at developing competencies essential for public health using multidisciplinary and evidence-based approaches. After obtaining an MPH, two options are usually open for career advancement – an academic PhD (Doctor of Philosophy) program or a practitioner-oriented DrPH (Doctor of Public Health).

Johns Hopkins School of Public Health was the first to offer a one-year certificate in public health (CPH) in 1920, which was transformed to MPH. At about the same time, British India had a Diploma in Public Health (DPH) in a multitude of institutions, which had gradually declined. In India, the MPH program was introduced in the late 1990s, drawing significantly from global—particularly American—models of public health education.[5] Since then, there has been a mushrooming of both public and private institutions offering this course in India, which is a positive sign, but a lack of quality standards and uniform regulations is a cause for concern. The Indian MPH programs, largely modeled on the US framework, adopt the same five core disciplines – epidemiology, biostatistics, health management/systems strengthening, environmental health, and social and behavioral sciences. The US model also focuses on strong career alignment, structured mentorship, and national accreditation, which we could learn from.[6,7]

There have been past efforts at mapping the MPH courses and institutions, as well as defining competencies and course structure. As per one of the reports “as of January 2024, a total of 129 MPH programs were being offered across India. Of these, 116 are general MPH programs, and 13 are specialized, such as those focused on Epidemiology, Health Systems, Nutrition, and Social Epidemiology. All general MPH programs follow a uniform duration of two years yet vary significantly in content, structure, and delivery. The programs are unevenly distributed across six zones (Central, East, North, North-East, South, and West), with the North and South zones hosting the highest number of programs—35 and 26, respectively, raising concerns about regional disparities in access to public health education. Only 27 programs were housed within dedicated public health schools or centers, while the rest are embedded in various faculties such as allied health sciences, management, commerce, and paramedical sciences.”[8] Most MPH programs are offered by University Grants Commission (UGC)-approved institutions, including central, state, deemed, and private universities, with a few being National Assessment and Accreditation Council (NAAC) accredited. The authors recommend systematic reform, including a standardized curriculum, accreditation, and improved governance.

Despite the structural resemblance to the US programs, the current Indian MPH suffers from several shortcomings. There are some very specific issues in the way these programs are structured and delivered in the Indian context that demand attention, particularly health system strengthening aspects. The India-specific issues are listed in Box 1.

Box 1.

India-specific issues in the MPH curriculum

1. Contextual relevance of the current MPH curricula, given that the Indian public health system functions within a very different socio-economic, cultural, health system, and governance framework from the US and other developed countries.

2. Appropriateness to the current disease burden and new-age public health challenges like mental health disorders, antimicrobial resistance, emerging infectious diseases, etc.

3. Diversity at the entry level, with students with a wide variety of backgrounds – from medicine, allied health sciences, to social sciences and law – join the course, making it difficult to produce graduates with similar exit-level competencies.

4. Highly theoretical classroom-based approach of teaching with limited field-based experiential learning, resulting in a mismatch between training and ground-level requirements.

5. A wide variety of institutions offer this course, from medical colleges to social sciences universities, as well as agriculture universities. The students have a very varied exposure to the health system.

6. A high degree of medicalization of public health in India, resulting in a neglect of social and behavioral sciences. In many quarters, there is opposition to the MPH course, which is seen as a competitor for MD Community Medicine.

7. Higher and more sustainable funding and resources for MD programs in Departments of Community Medicine in medical colleges, not usually seen in public health departments in public university settings that usually offer MPH courses.

8. Poor regulatory or quality oversight on these courses due to a lack of a centralized accreditation or uniform competency framework.

9. Aligning MPH programs with the National Education Policy (NEP) 2020 and University Grants Commission (UGC) framework, which advocates academic flexibility, credit transfer, and multiple entry-exit options.

10. Ill-defined job opportunities for this cadre within the government sector and an expectation from MPH graduates to be competent in diverse settings, from community to policy making, as epidemiologists to managers to researchers.

While the above-mentioned reviews have been broad and descriptive, they have lacked depth. They have recommended what needs to be done, but not how it is to be done.[9] The Ministry of Health and Family Welfare issued a model curriculum of MPH in 2017–18, which also has many shortcomings.[10] We intend to go to the depth of the issue and make very specific, doable recommendations. Reforming the MPH curriculum does not imply discarding global standards but rather adapting them to the Indian context. Given the vital role MPH graduates are playing and will continue to play in implementing public health interventions, the need for a more contextualized, practice-oriented, and India-specific curriculum, yet of global standards, has become increasingly urgent.

The Lancet Commission recommended moving from informative to formative to transformative learning for health professionals. While informative learning focuses on acquiring knowledge and skills to produce experts, formative learning is about values to produce professionals. Transformative learning is all about producing leaders and enlightened change agents. It also deliberates institutional and instructional design (processes) and educational outcomes. Instructional design, which is the focus of this initiative, involves four Cs: (1) criteria for admission; (2) competencies as defined in the curriculum; (3) channels of instruction or pedagogy; and (4) career pathways or options that graduates have on completion of their course.[11] There is a need to look at competency frameworks for a health workforce that can deliver the full range of both the essential health services and the essential public health functions, including national and international emergency preparedness and response. In this context, outcome-based education (OBE) focuses on aligning teaching, learning, and assessments to ensure student-centered competencies.

Need for this initiative

The starting point for this initiative was a panel discussion in one of the recent public health meetings on public health education, in which some of these authors were on the panel and a few were in the audience. All the panelists expressed concern over the “unemployability” of the MPH graduates who lacked basic competencies. However, most of them end up with a job in our health system, usually as consultants at the district level, and learn on the job! Post this panel, a few of the authors met, which led to discussions on the need for concerted efforts to rectify the situation and the formation of a core group to drive these efforts. This initiative is a result of these discussions.

This initiative will work in three phases. In the first phase, it will work with institutions offering MPH in the major centrally funded universities/institutions and prepare a roadmap/plan. In the second phase, it will reach out to the private schools and state government-funded ones and obtain their input as well. In the third phase, it will reach out to the appropriate regulatory bodies. It is clarified that this is an informal group, and even though individuals have been drawn from reputed institutions, they are not formal representatives of their institutions and are here in their personal capacities. While there are no defined timelines, given the seriousness of the matter, we intend to publish our report before the end of this year.

Goals and deliverables

The overall goal of this exercise is to facilitate a shared understanding and some degree of standardization of MPH programs between institutions in India. This will also assist any new institution planning to initiate an MPH program in thinking through some of the issues that they will have to address. In addition, over time, this initiative intends to provide facilitation materials for various proposed activities. In the longer run, these efforts could aid in moving toward accreditation and common entrance and exit tests for MPH programs in India. The collective hopes to release a Consensus Statement and Report on restructuring MPH programs in India and define an India-specific competency framework with core competencies and standardization of training programs.

Some of the questions that the group has identified for further discussion and scrutiny are as follows:

Entry-level issues

1. How restrictive or broad should the entry criteria for MPH programs be?

2. Is there a relevance and need for courses such as a Bachelor of Public Health as a feeder to existing MPH programs?

3. Is there a need for bridge courses like human biology for non-medical students or social sciences for medical students?

Competency framework and course structuring

• 4. What should be the core and optional competencies for MPH programs in India?

• 5. Should we consider MPH as a general degree or also pitch for specialist MPH courses? Is there room to allow some institutions to provide context-specific, specialized MPH programs?

Quality/standards of MPH programs

• 6. How can we ensure uniform quality of the MPH programs?

• 7. Given the diversity in the intake, how do we standardize the course so that there is uniformity in the competence of the graduates? Or we need not aim for uniformity in competencies, given its multidisciplinary nature.

• 8. How do we operationalize the accreditation process and move toward common entrance and exit tests across institutions/universities?

• 9. If and what should be the structure and role of the Public Health Education Council?

MPH in medical schools

• 10. In the medical schools that offer MPH, how do we manage the dichotomy between MD Community Medicine and MPH?

• 11. What should be the relationship between SPH and Departments of Community Medicine?

• 12. Should we go for Joint MD/MPH/PhD Programs?

Linkages with the health system

• 13. Given that exposure to the health system is critical, as that is where most competencies are practiced, how do we ensure adequate exposure of MPH programs in both health and non-health universities?

• 14. How strong should the linkages be with the local and state government health systems as a part of the MPH programs? How much should the district/state/national program officers working in the health system be involved as part of the training?

Career pathways

• 15. What are the current career pathways in both the government and private sectors in health and non-health fields?

• 16. How do we encourage the development and uptake of DrPH programs which target mid-career bureaucrats and health officials as a non-academic option for people wanting to learn more but not deal with PhD issues?

External context

• 17. How do we address the oversight and regulatory challenge given that the MPH programs are being offered by a multitude of players, most notably- medical schools, social sciences universities, general universities, IITs//IISc? While the National Medical Commission (NMC) does not recognize this course (except for a few restricted to medical graduates), UGC is also not fully equipped to deal with such professional courses.

• 18. How do we align MPH courses with the New Education Policy, given that master’s would be a one-year program in the NEP once the 4-year bachelor’s degree becomes operational? Is there a need or relevance for a one-year Executive MPH program?

This list is only a starting point, and as deliberations progress, more could be added. This communication is intended to convey to the larger public health community the aims and activities of this collective and seek their comments/suggestions. They are free to write to any of the listed authors or to the email frameindiainitiative@gmail.com and suggest more questions or respond to these listed questions.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.