Communities of practice
Public Health Foundation of India aims to boost the number of public health officials
13 May 2010
With worrying levels of maternal and child mortality, low childhood immunization rates and 46% of children under three years old undernourished, it is clear that India’s economic miracle has struggled to alleviate the suffering of many of its most vulnerable communities. This disappointing situation was the reason behind the launch of the Public Health Foundation of India in 2006. Professor K Srinath Reddy, president of the Public Health Foundation of India says: “One expects that these [factors] should have receded, given the level of India’s development. But they continue to be problems”.
Of course, the Indian government has begun a number of initiatives to tackle these very obvious disparities in recent years. The National Rural Health Mission (NRHM), for instance, is an ambitious strategy to bring affordable healthcare to underserved rural populations (around 750 million people), and has managed to, among other things, improve immunization rates in some states. There are also a number of disease-specific projects to tackle malaria, TB and eradicate polio.
Continuing problems can be attributed, in part, to the dearth of Indian public health professionals, say experts. In a country that can boast more than 30000 medical graduates per year, there are no more than 400 public health graduates.
Public health has been taught in India for a hundred years. It usually forms part of medical courses and is taught at hundreds of schools including the All India Institute of Hygiene & Public Health, the Indian Council of Medical Research (ICMR) and various departments in medical colleges . So, clinicians have largely been responsible for public health in India.
However, there are disadvantages with that approach. For instance, few specialists have been trained to tackle specific public health problems. There is a lack of health economists, demographers, social scientists, epidemiologists, management experts and specialists in other vital parts of the public health jigsaw.
Without a multidisciplinary approach, many problems cannot be tackled adequately. “Our health policies have not been fully aligned to the root causes of these problems. We had a disease-oriented approach, not a social determinant-based approach,” says Reddy.
In many cases, clinicians are expected to cope with a diverse range of public health problems. So, an orthopaedic surgeon, for instance, may also have to deal with measles, malaria control, immunization, disease surveillance and maternal health programmes as well as budgets, procurement and team management. This is a policy that originated, surprisingly, in the 1950s, within central government. Then, it was decided to combine medical and public health services. “There were no formal public health institutions. Somehow naively at independence it was considered that public health training could be imparted completely through medical schools,” says Reddy.
The lack of adequate economic evaluations of health systems, robust surveillance systems or epidemiological mapping – and research gaps in such areas as behaviour-change – have all taken their toll, he says. “It has cost us quite clearly in the performance of national programmes”.
For instance, the formal system of surveillance today captures only about 30% of the real surveillance information in the field. So outbreaks are sometimes only reported, informally, when the problem is already out of hand.
“If our surveillance systems are in a poor shape now it is because of that lack of public health expertise contributing to policy and the establishment of health systems,” says Reddy.
That public health professionals can effect changes in health indicators is clear in India. Tamil Nadu chose not to amalgamate its medical and public health services and has markedly better health outcomes than other states, according to Monica Das Gupta of the Development Research Group at the World Bank . Tamil Nadu eradicated guinea worm by 1982, whereas the national eradication programme did not start until 1994. It also spends less per capita on health than the national average.
That is why PHFI was created; to fill an enormous public health gap.
New institutes on the way
The plan is to set up as many as 10 different public health institutes all over India. Each will produce around a thousand public health graduates per year. There are three institutes so far – in Delhi in the North, Hyderabad in the South, and Gandhinagar in the western state of Gujarat. A fourth will be launched in July in Bubaneshwar, a city in the eastern state of Orissa. It will be followed by a site in Shillong in the North East, an area that is traditionally underserved. Another five states are in negotiations for further institutes.
The idea is to train public health workers in a variety of disciplines, including health economics and health management. PHFI is also devising and adapting curricula used at other institutions – medical schools and training colleges. For instance it started courses to train the trainers at up to 15 medical schools and institutes around the country. A curriculum has been adapted from existing courses to train field epidemiologists.
As well as teaching, the institutes are embarking on a series of research projects that will create policy recommendations in areas as diverse as social determinants of health, HIV, nutrition, cancer, work-related illnesses and zoonoses.
There are promises, also, of a concerted effort at advocacy and trying to get policy recommendations directly to government. “We are saying it is not enough to produce these recommendations,” according to Reddy. “We have to deliver them to policy makers and civil society.”
For its part, the Indian government seems to have been most receptive to the initiative, and says it has accepted the principle of a multidisciplinary approach. It even put up $15 million to launch the institutes, although they are not legally government entities and are run autonomously. The Bill & Melinda Gates Foundation put up $15m too, and $30m came from private donors. The foundation has other heavyweight international backers, including several US universities, corporations and international funding agencies.
Both central and state governments are able to commission pieces of research from PHFI to help with their control efforts. For instance the foundation carried out a systematic review of polio in 2007 – including social and vaccine strategies – and Tamil Nadu commissioned another on rabies control. A diploma in public health management supported by NRHM – to transform district medical officers around the country – is being implemented by PHFI.
The idea of creating schools of public health in India using a public–private model came about in discussions between the deans of US universities, Indian institutions and, importantly, Rajat Gupta, senior partner of McKinsey & Company – see news story in Harvard Public Health Now newsletter (Gupta is better known for being a board member of Global Fund to Fight AIDS, TB and malaria.)
The first such project in India, it has received high-profile research grants; USAID is helping to fund a child and maternal health project, and the Wellcome Trust has funded the establishment of a Centre of Excellence for Chronic Diseases at the Delhi site (the South Asia Network for Chronic Diseases in India). The Bill and Melinda Gates Foundation is funding a number of research projects at PHFI, including one to analyse in detail the public health systems infrastructure of India.
Masters in Public Health courses abroad are being jointly supported by PHFI and western universities. For instance, Dr Manish Kakkar, a public health specialist (surveillance systems and infectious diseases) at PHFI won the first place under the new scheme to study for a Masters in Public Health at the Harvard School of Public Health (HSPH), before returning to India HSPH paid for tuition fees and PHFI for living and family support costs.
Many grants are directed towards non-communicable diseases, because India is seeing a growing problem with a range of conditions from cancer and cardiac problems to traffic accidents. (The director is a cardiologist with a track record in epidemiology, tobacco use and human rights.) But infectious diseases are receiving special attention too, especially disease surveillance.
Of course, India has been tracking diseases for years. A government Integrated Disease Surveillance Project (IDSP) has been up and running since 2004. The problem is that its reach has been limited, says Kakkar. For instance, plans to roll out a network of laboratories capable of good disease surveillance in each district of India have stalled. “They have struggled to set up 20 labs in the country. There are problems,” he says.
The irony is that India can boast plenty of world-class laboratories and expertise. “We have some of the finest centres of excellence as far as labs go. The other extreme is that labs which respond to diseases and outbreaks are severely lacking in capacity. It’s not only microbiologists that are not available at district and sub-district, it’s also the diagnostic capacity and the quality of testing,” says Kakkar. PHFI training courses should help improve the human resources capacity in such areas, he says. But there are other plans.
Another major strategy will try to better track and tackle zoonotic infections, a big problem on the sub-continent. Around 80% of the populations of India live in close proximity to domesticated animals and poultry, and close proximity provides ample opportunities for disease transfer.
At least 11 pathogens have emerged or re-emerged in India between 1992 and 2009. Many of them are of animal origin. Some occur in the form of outbreaks. Others are endemic, such as brucellosis or bovine TB. Outbreaks in recent years have included Vibrio cholerae O139 (West Bengal in 1992), Chikungunya, H5N1, scrub typhus and even plague. Cases of pulmonary leptospirosis were seen in Mumbai in 2005 , and a rare human case of surra (a disease normally seen only in animals, caused by the parasite Trypanosoma evansi) was also reported in the same year in Maharashtra state .
Previous efforts to get human and veterinary sciences together to directly tackle the most problematic zoonoses have stalled. PHFI says it is trying another tactic to build up trust between the organizations specializing in human and animal health, wildlife, vector bionomics, social and environmental sciences.
PHFI launched the Roadmap to Combat Zoonoses in India (RCZI) initiative two years ago, with help from University of North Carolina (UNC) Chapel Hill, North Carolina State University (NCSU) and RTI International, a private firm.
So far, under the roadmap, an ambitious research agenda containing over 100 different research options has been compiled. The project’s focus is on assessing the burden of disease, profiling the risks and identifying systemic issues. But importantly, 81% are research projects that could be done collaboratively between different disciplines. The idea is that if postgraduates take up these research projects, they may begin to work with different institutions and help foster collaborations that will ultimately result in joint implementation programmes.
PHFI is also establishing training courses that will bring veterinary and human medicine experts together, not just to learn but to jointly assess outbreaks.
But for all these grand plans, PHFI is still in its early stages. It is in its second year of teaching and 130 students are expected to graduate next month – some way off the 10,000 goal. Tough challenges now lie ahead. There is not much room, as yet, for public health posts within the state and central government infrastructure of India. Sceptics say PHFI may end up churning out thousands of public health advocates per year, but there will not be enough government posts to employ them. There may be problems accepting non-clinicians as public health specialists too.
As Reddy puts it: “The first barrier is to get people to accept that there should be a public health cadre and the second to get non-doctors to be accepted as equivalent public health professionals. We think we are getting over the first hump but the second will remain a bit of a battle,” he says.
There has also been some worry about the involvement of the private sector, and the involvement of US universities has raised some eyebrows because of the possible influence on what should be a culturally-specific research and training agenda .
Several other barriers must be overcome too. The PHFI needs university status before it can offer its own Masters courses. In addition, it has not been able to apply for national grants from the Indian government because there is a strict set eligibility criterion for grants in India, including one that there should be a proven track record of research. That may change soon.
Bureaucracy is also a problem. Several other states have come forward with proposals for institutes to be built in their states. Some have even promised funding and land. However, building schedules have often been delayed through an administrative quagmire accompanying such promises. PHFI has already been forced to rent temporary campus space, which is very expensive and cuts into the budget.
But the measure of PHFI’s success will surely be the extent to which it can help to influence India’s health policies and systems and, ultimately, improve health indicators for everybody.
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