Public Health Management Cadre in India: Challenges and Road Ahead

The efforts of developing the health workforce cadres in India have been advocated for a long time. The Government of India released the booklet on implementing the Public Health Management Cadre (PHMC) as envisaged under National Health Policy 2017 was certainly a catalyst for the country. This commentary reviews the course of implementing public health cadre in India and the challenges in establishing the core principles of a Multidisciplinary health workforce. The paper suggests that the proposed cadre needs a swift implementation in the States/UTs to address the impediments to health systems in the country. Keyword: public health management cadre, health systems, health cadre, Human Resource for health


Introduction
The health systems of India face various challenges in addressing the determinants of health and its wider perspectives. The realization has become stronger after the COVID-19 sequel, which gave an opportunity to rejuvenate the long-standing inattention and develop a plan to ponder. 1 The major constraint in the implementation of the service delivery is the deficient human resources for health which indirectly affects the systems quality and access to care. Historically, there has been a plentiful of recommendations to establish a dedicated public health cadre, with most efforts being made to retain allopathy professionals. The Bhore committee (constituted in 1943) impressed on preventive and curative functions and training of medical doctors in preventive & social medicine, and later the Mudaliar committee recommended establishing an all-India health services cadre. 2,3 Various documents of the planning commission, particularly the eleventh and twelfth FYP, followed by recommendations of HLEG in 2012 and the National Health Policy released in 2017, advocated for creating and institutionalizing the public health management cadre into the systems, breaking the biomedical approach to see what trans public health problems are and acknowledging the concept of multi-disciplinarity which has potential to influence and improve the health systems landscape. 4,5 The creation of such reforms would give the health system a stronger base of public health specialists equipped in surveillance, outbreak management, health preventive and promotive actions at the block level itself. However, the perpetuation of the medicalization of health systems and missing out on the other disciplines of holistic health, which directly or indirectly determines the health status of an individual, further led to the weakening of public health. This was due to the distancing of medical education from the other epistemic structures of health and being way too focused on vertical health programmes. 6 • Email: editor@ijfmr.com

Course of implementation
Five years later, a guidance booklet on the Public Health Management Cadre (PHMC) was released in 2022, which suggested creating the cadres stemming into four main pillars, viz., teaching, public health, health management and specialist cadre. 7 The essence of PHMC envisaged was to create an interdisciplinary cadre (para 11.8 of NHP 2017) consisting of sociologists, anthropologists, economists, communications, entomology, housekeeping etc., and perhaps it was assumed that these professions would be mainstreamed. However, these specialisations were not categorised as specialised and significant and henceforth could not find room in the booklet. The majority of the pages talk about the progression of allopathic doctors, for which, of course, there is no debate and is the need of the hour. Besides, the understanding and the discourse of nursing and allied healthcare professions, in addition to dental graduates with public health qualifications in the career progression and where they fit amongst the pillar, is unanswered along with Accredit Social Health Activist, Auxillary Nurse Midwifery and Multipurpose Male Health Workers cadre.
One of the long-standing matters is the principle of contractualisation of human resources in the health systems since the beginning of the reforms of the 1990s. It first began with the hiring of cleaning services and swiftly entered nurses, paramedics and now public health professionals. 8 It was earlier understood that this would increase the efficiency and effectiveness of the health systems, but it has led to a cascade of events, viz. dependency towards contractual employment, minimal remuneration, jobs insecurity, and increased funding onus on NHM, leading to less budget allocation on health by States.

Influences in creating a multidisciplinary cadre
The drafting of the guidance booklet represents less of other professions, such as health economists, sociologists, behavioural sciences, population studies, health statistics etc., as it is generally understood that medicine means health and looks to be a biomedical construct. This has again led to a minimal representation of non-clinical or other cadres in leadership roles in the health systems. Addressing water sanitation, housing, and living conditions are generally left as coordination with other ministries, which in a similar fashion penetrates down up to the district level and, therefore, struggles for coordination and priority. 9 It does get quite convenient for the policymakers to rely on locally available solutions and clinical-based technocrats and less driven by knowledge-based context-driven issues. The decisions get driven or influenced politically, administratively, feasibly, and technocratically, which eventually is a normalized decision-making method. 6

Current Situation of PHMC Implementation in India
Despite the importance of this reform in strengthening the country's healthcare system, none of the states have fully embraced all the core pillars of the PHMC. While some states have taken initial steps towards implementation by focusing on specialist and Public Health Cadres, which aim to enhance the career progression of Medical Officers and Specialists with postgraduate degrees in clinical specialities, the overall progress remains sluggish. This skewed focus undermines the comprehensive approach needed for effective public health functions and highlights the need for foresight in these regions.

The road ahead
The overall picture that emerges from this assessment is the evident slow progress in implementing the PHMC across Indian states. The lack of a unified approach and the neglect of crucial components, such as the health management cadre, raise concerns about the effectiveness of the PHMC initiative in improving the country's healthcare system and therefore needs holism. The PHMC has the capacity to revolutionalise the health systems by addressing the shortcoming of gaps in service delivery and monitoring the programme at the micro level, material management and surveillance with a focused public health approach. This opportunity should be utilised for institutionalising the PHMC into the systems and epistemology of public health rather than investing in the culture of privatisation, seeking international funding institutions, hiring consultancy firms and hierarchical systems with biomedicine dominance. Parallelly, it is important to understand the field of public health education in India, as it is stuck with many unanswered questions. Foremost would be to understand whether the education being provided is people-centred, the relative context of sociology, anthropology, behavioural economics, culture, and gender and why a "one size fits all" approach cannot be pushed into the systems.
For the swift implementation, it is therefore imperative that the relevant authorities and health advocates at Union and State levels take swift actions to address these shortcomings and ensure the comprehensive and timely implementation of the PHMC in all states, with a focus on all its core pillars. Only then can we hope to see a substantial and sustainable improvement in public health management across the country.