Attract more talent to public health
I am sometimes asked, “What really is public health?” The term refers to the health of populations, in contrast to clinical health, which considers one patient’s well-being. Public health also has a larger prevention component — for example mass immunisation programmes. It has multiple components: disease surveillance, epidemiology (transmission routes of diseases), designing programmes for scale (supply, demand, advocacy components), monitoring and evaluation, effective management, financing and more.
India’s polio programme is one of the world’s great public health successes. Surveillance was precise, household by household, reaching even the remotest areas. There was active engagement with the community, involving religious leaders. There was creative use of media. Remember Amitabh Bachchan’s catchy “sirf do boond (just two drops)” appeal delivered in his trademark baritone? Logistics for safe distribution of vaccines were carefully worked out. The polio programme was much more than a techno-medical campaign. Indeed, its success was in the seamless coming together of business, social and medical skills.
Seen from this perspective, India’s public health system has a problem of too little and too many. It is well known that there are too few doctors in rural areas: One for over 11,000 citizens against the global norm of one for 1000. Our focus this week is on the added problem that even within those meagre numbers, there are too many doctors, and not enough specialist managers and social scientists, especially at the sub-district level. Clinical doctors valiantly manage everything from disease surveillance to data reporting and accounting, and they are often ill-equipped.
Doctors flock to more lucrative private practice in cities. Newly minted MBAs head for enticing jobs in business. It is very difficult to get people to take on rural service. The problem can be resolved only if it is made mandatory. Public health service should be required, without option, from anyone who has had the benefit of an education in medicine, social sciences, business management and engineering. In 2009, the Union health minister revealed that medical students pay annual fees of Rs 15,000 as against Rs 3.5 lakh spent on them. The Indian Institutes of Technology (IITs) charge a fee of Rs 2 lakh against a cost of over Rs 6 lakh. This is tax payers’ money. It’s time students paid back at least a part of their debt to the nation. Their degrees should be given only after such mandatory service.
Vice-President Venkaiah Naidu recently made a stirring call for three years of mandatory rural service for doctors. Tamil Nadu and Odisha have had some form of required rural service for medical students; various other states are taking steps in that direction. Thailand has had such a system since 1972. The ambit of a medicine course goes beyond medical skills.
Working at the village level, I ask myself: “What if frontline data was being collected thoughtfully, by workers trained in the elements of data sharing and usage? Can we not have supervisors with management training, who are more effective with such data in their hands? Why not simple hand-held technologies used to share data between health workers, developed with inputs from the community? And what if adolescent girls worked as change agents at the village level, guided by those familiar with the dynamics of social change?” All this and more are possible, from my experience.
Over the last 15 years, I have led the setting up of large public health programmes in fields as diverse as HIV and maternal and child health, with an unusual recruiting strategy. I offer positions to just as many people with no background in medical health to speak of, but who have superb business and data analytical skills. I do this, convinced that the best marriage is between medical and business skills. I know it works. After all, I started off in public health with a similar profile.
In election season, political parties are talking about devoting more funds to public health. Perhaps, a chunk of this could be kept for attracting talent. Fellowship programs such as Teach for India, the Gandhi Fellowship and others run by governments have shown that quality talent is willing to stay in the social sector, on acquiring initial exposure.
Over time, mandatory rural service could be extended to other important causes such as education, agriculture, livelihoods and skill development as well.
Ashok Alexander is founder-director of the Antara Foundation
The views expressed are personal