Human Resource Development in Health Services

The draft National Health Policy (NHP) 2015 is a comprehensive document with a dedicated section, “Human Resource for Health” (Government of India 2015). Javid Chowdhury (“National Health Policy 2015: A Narrow Focus Needed,” EPW, 28 February 2015) has suggested the need for narrow focus on primary healthcare rather than a broad approach. Anant Phadke (“Slippery Slope for Public Health Services,” in the same issue) observes that the draft NHP has not sufficiently addressed issues related to public finance in healthcare. Phadke also feels that the draft has not addressed issues related to regulation of the private health sector. While both articles have tried to analyse the draft policy and address an important subject of education and human resource development in health, we feel there is need for clarity about notions of healthcare, the services in the health sector, medical care, medical education and public health education (PHE).

PHE needs to be given priority for two main reasons. The first reason pertains to empowering communities in health-related matters. The second reason relates to providers of public health services—currently known as primary healthcare, available through primary health centres (PHC) and sub-centres. The professionals involved here include public health specialists, officials (directors, administrators at the district or sub-district levels and other officials), public health engineers, nutritionists and dieticians, biochemists, social scientists and social workers.

Formal training in this area is inadequate and of poor quality. It fails to provide a thrust to basic public health determinants, such as water supply, environmental sanitation and nutrition. Instead, it is more concerned with Western notions of healthcare. In most Western countries, basic public health needs, such as safe drinking water, are provided to all and defecation in the open is practically unknown. We are far from attaining such standards. Sensitisation, education and training of officers at all levels need to be improved if all Indians are to be provided basic minimum healthcare.

The draft NHP recognises the need for expanding primary care from selective care to comprehensive care through complementary human resource strategy. The draft suggests development of a cadre of mid-level care providers through a course that will lead to a BSc degree in Community Health (BSc-CH). Chowdhury indicates the shortage of graduate doctors working in rural areas and the limited role and skill set of the current midwife and nursing staff as the main reasons for such a short-term course. However, it is questionable whether such short-term graduate courses will provide people sufficient training to deal with the exigencies of rural areas. Thus, while Chowdhury’s diagnosis is partially correct, his remedial suggestions are not good enough.

Community Health Course

It has been suggested that engaging agencies like the National Board of Examination (NBE) may help strengthen PHE in India (Sharma et al 2014). Experts have also deliberated on the need of another cadre of health practitioners for rural areas (Garg and Singh 2011).

We feel that many questions related to the format and implementation of the BSc-CH degree course remain unanswered. It is not clear if this course aims to create a mid-level cadre in the public health system to help in the implementation of public health programmes at the PHC and sub-centre levels or if these graduates are expected to provide primary healthcare services. The curriculum of the earlier Bachelor of Rural Medicine and Surgery (BRMS) had a judicious mix of clinical and public health knowledge and skills. Does the proposed BSc-CH course have a greater orientation towards public health? If yes, the High Level Expert Group’s (HLEG) suggestion of making available curative care at the upgraded sub-centres falls flat. We need more clarity on the course’s objectives.

The rationale and real need for mid-level public health cadre should be established through scientific studies and should not be matter of speculation.

The nomenclature, “Bachelor of Science,” clearly indicates that the proposed course is not a medical course. Agencies like the Medical Council of India (MCI), the NBE and state universities of health sciences are involved in medical, paramedical or clinical courses at the graduate and postgraduate levels. They may not be involved in the designing and implementation of courses, like the BSc-CH—the responsibility it seems will fall on the science faculties. The development of any academic curriculum requires clarity of objectives and alignment with subject content. What job opportunities will the BSc-CH students have? Will they get absorbed in the government sector? If not, what are the other career choices for them?

Any good education should lead to improvements in knowledge, skills and attitude domains. For a practice-oriented profession like public health, the teaching domain is necessary but not sufficient. The PHEs need to be imbued with concern for the well-being of society. For many decades, the focus has been more on structures and hierarchy of healthcare. Human resources are being utilised in a “fire brigade approach” to managing national programmes and epidemics.

The rationale for the BSc-CH course seems to be weak. We fear that the gullible students will add to the existing burden of unemployment after undergoing this course. Courses like the BSc-CH, however, may be especially lucrative to the private education sector that is facing difficulties in attracting students to engineering, management and even medical streams.

In the interest of health services and the medical profession, such hasty measures should be avoided. Instead, we suggest that courses providing the required skills to medical and paramedical professionals be introduced under the Bachelor of Vocation (BVoc) degree, recently proposed by the University Grants Commission (UGC). A few universities offer Master of Public Health (MPH) courses, the UGC also conducts the National Eligibility Test (NET) in Social Medicine and Community Health.

We feel that instead of introducing new short- or long-term medical courses, a smarter solution to improve quality and the reach of the primary health services might be to strengthen the role of nursing professionals and ayurveda, yoga, unani, siddhi and homoeopathy (AYUSH) graduates in public health delivery, especially in the underserved areas.

References

Chowdhury, Javid (2015): “National Health Policy,” Economic & Political Weekly, L(9), 25–30. doi:10.1136/bmj.2.4312.279.

Garg, S and R G M Singh (2011): “Bachelor of Rural Health Care: Do We Need Another Cadre of Health Practitioners for Rural Areas?,” National Medical Journal of India, 24(1), 35–37.

Government of India, M H and F W (2015): National Health Policy 2015 Draft.

Phadke, Anant (2015): “Slippery Slope for Public Health Services,” Economic & Political Weekly, L(9), 30–32.

Sharma, A, S Zodpey and B Batra (2014): “Engagement of National Board of Examinations in Strengthening Public Health Education in India: Present Landscape, Opportunities and Future Directions,” Indian Journal of Public Health, 58(1), 34–39. doi:10.4103/0019-557X.128163.