CHLP NATIONAL WORKSHOP 2016.pdf
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I
CHLP National Workshop 2016
Mainstreaming
Alternate paradigms:
From teaching to
learning facilitation in
Public Health /
Community Health
Background Papers
(Towards a India Relevant
Framework and Curriculum)
1
SOCHARA-SOPHEA
2th & 3th September, 2016
CONTENTS
SI. No.
1
Content
Report of the Expert Committee on Public Health System, GOI -
Pages
b6
Extracts (1995)
2
Capacity Building For Public Health In The Asia Pacific Region
7-17
- A policy reflection for UNESCAP, Bangkok (2004)
3
Policy, Academic and Research Agenda for Public Health in
18-21
India - PHFI Inaugural workshops (2006)
J’'
4
Public Health Education In India - Some Reflections
22-35
Public Health Education Policy 1946-2002
-
Public Health / Community Health Initiatives since 1970
Reflections on Public Health teaching, learning,
competency building Challenges
mfc meeting (2007)
5
Public Health in India Score (www.community.in)
36-42
6
Community Health Learning Programme of SOCHARA: 52
Week Curriculum________________________________
Community Health Oriented, competency based modules by
SOCHARA for training in India (RGIPH-MPH Honors Course)
- Values orientation in Public Health
- Socio-cultural and Community Health
- Plural Health Systems___________________________
Public Health System in Karnataka
- A state public health charter
- Strengthening State Public Health Capacity and HRD
(2013)
Mission Group on Public Health, Karnataka Jnana
Aayoga
43-46
7
8
47-68
69-82
'
I
4
CHLP NW 02092016
Background Paper -1
•7
1.
•
•
REPORT OF THE EXPERT COMMITTEE ON PUBLIC HEALTH SYSTEM, (1995)*
The committee constituted on 8lh March 1995, consisted on Prof. J S Bajaj, Member, Planning
Commission, Chairman, Dr Jal Prakash Muliyll, Deptt. of Community Medicine, Christian
Medical
College,
Vellore.
Member,
Dr
Harcharan
Singh,
Ex-Adviser
(Health),
Planning
Commission
Member,
Dr N S Deodhar, Ex-Officer on Special Duty. MOH&FW, Member, Dr K J Nath, Director, All
India
Institute
of
Hygiene
&
Public
Health,
Calcutta.
Member,
Dr K K Datta, Director, NICD, Delhi, Member-Secretary
The Terms of Reference of the committee were as follows - to comprehensively review:
a) the public health system in general and the quality of epidemic surveillance and control
strategies in particular;
j’;
b) the effectiveness of the existing health schemes, the institutional arrangements and the
role of the States and local authorities in improving the public health system;
c) the status of the Primary Health infrastructure (sub-centres and primary health centres) in
rural areas, especially their role in providing intelligence and alerting the system to respond to the
signs of outbreak of diseases and effectiveness of the district level administration for timely
remedial action; and
d) the existing Health Management Information System and its capability to provide up-to-date
intelligence for effective surveillance, prevention and remedial action.
The final report presented on 6th July 1996 was 246 pages. The recommendations of the Expert
Committee were as follows (pages : 11 -20)
E-IO.I Short-term
E-IO RECOMMENDATIONS
E-IO.I.I Policy Initiatives
E-IO.I.I.I Review of National Health Policy
The National Health Policy was formulated and adopted in 1983. During the years since then major
changes have occurred through continuing population growth, rapid urbanisation, industrial revolution,
changing health and demographic scenario, appearance of new, emerging and re-emerging health
problems etc. Newer technologies are also available. In view of the same, the National Health Policy
needs a careful and critical reappraisal. The committee, therefore, recommends constitution of a
Group of Experts to prepare the draft of the new National Health Policy by the end of 1996.
E-I0.I.I.2 Establishment of health impact assessment cell
There is a need to enhance the capacity and capability of the Ministry of Health & F.W. to undertake
health impact assessment for major development projects, industrial units etc. so that the project/
industrial authorities could be appropriately advised & guided to incorporate proper intervention
measures/ changes as the case may be. All large projects of different ministries should invariably
have health component in the proposal itself and this should be examined and approved by the
Ministry of Health & Family Welfare. Regular analysis of various public policies and practices of other
ministries viz. agriculture, industry, urban development, rural development and environment, which
have direct link with the health of the people, must be considered as an essential prerequisite for a
meaningful inter-ministerial co-ordination.
E-I0.I.I.3 Surveillance of critically polluted areas
Health impact and environmental epidemiology related to air, water, and soil pollution need to be
monitored 'and evaluated particularly in the critically polluted areas in the country. Ministry of Health
and Family Welfare should initiate actions in this regard urgently, in co-ordination with the Ministries of
Environment, Industry and Urban Development. Measures such as a properly maintained data-base,
mapping of the vulnerable areas, immediate intervention where possible and continuing surveillance
need to be initiated as a well structured programme of action.
* Government of India, Ministry of Health & Family Welfare, Nirman Bhavan,
New Delhi 110 01
I
*
£-.0X1.4 Search
.Uema.Ue S.ra.egy,
Uniform health care strategy for the entire c®untQ7^a? Gnomic etc The committee recommends
reasons: graphic, socio cultural1 H“l«’ S'™CeS
that allocation of adequate funds to the Ce^r®„ , SyStem Research and Intervention
SXX 2.."“ “uSTsSeh -esuns ar. ut»sed to improv, th. h.aith car. «.e-y I
services.
e-4..1XSUnl(o™.dopUcn^
XiStX..“
all State health
SJ and adopted enact.d <0 suit icc.i and
national needs.
E-10.1.1.6 Establishing National Notification SystemjNatiothe state from
National Heaith Re^ <« *<»••" »’
states.
E-10.1.1.7 Joint Council of Health, Family Weham and ISM & ^XXsed to make a Joint
E-10.1.1.8 Establishing an Apex Technical Advisory Body
™s;Tse%T<^^
health issues p0|icies
.stadishm.nl of broad based Ap.x T.chnica,
Advisory Body to advise the Ministry of Health & Family Welfare.
E-10 1 1.9 Constitution of Indian Medical & Health Services constitute Indian Medical & Health
The-Committee reinforces in the strongest terms the need to
Services without any further delay.
E-10.1.1.10 Administrative restructuring
E-10.1.1.10.1 Organisational set up of the ministry
E.to.l.t.10.1.1 MOS. ot th. functions of th. Union Minishy off
technical in nature and, theretore. require le‘'hn|?a
, „JL & Family Weilar, may consider
therefore, strongly recommends that the »» M
'n“he shgle department so created
□X'XicXedSp as indicated aboie. The department of iSM and Homeopath, ma,
also have to be similarly restructured.
E-10.1.in0.1.2 The Department ot Health
=r. and OCHS sboulc
?o°.ra;%
a^^^
assessment CeU and Health Manpower Division should also be established.
E-10.1.1.10.1.3 All the major technical divisions under the Union Ministry
2S' “IZS’XdXnd suggest appropriate corrective step or steps for
improving their various activities.
E-10.1.1.11 Health Manpower Planning
...... .... ?f~
Institute of Health Manpower Development.
2
»
J
E-10.1.1.11.2 The committee reiterates that recommendations contained in Bajaj
country.
available, these could be I operated by general category health professtonals through
appropriate training in health services administration, management and epidemiology.
rt’SS
seboe,. c<
XS
Tropical Medicine, Calcutta.
,
E-I0.I.I.13 Strengthening and upgradation of the Departments of Preventive and Social
Medicine in identified medical colleges
The committee recommends that some of the existing medical colleges wh
programme of up gradation of few identified departments of preventive and social
the medical colleges could be taken up during the last financial year of his IPlan and during
the 9th Plan period at least 25% of existing departments may be s'mi|a|rly
1h
Sj
availability of additional funds by the Planning Commission to the Minist£- of Heahh & F.W. »
this regard. These centres could be linked through a network so that the facilities could be
. t
maximally utilised.
<7
academic and technical skills and the students are benefited from the practical expenenc
the programme managers at the fte'd level.
E-I0.I.I.15 Establishing a Centre for Disease Control
The committee is of the view that National Institute o Communicable Diseases, Delhi should
be substantially strengthened through capacity building into a National Ce
for Disease Control on the pattern of similar advanced centres such as CDG, Atlanta.
and developing appropriate referral system.
cSiilXSposlltos of Directors .. the State level has led to dtolnttsratlorr of earlier
integrated pattern Of medical and heath administration. Earlier practice needs t® be restored.
It Ys9also recommended that functioning of the Department of Health being mos«y ‘ha^of
technical nature a technical man should be the head of the Department of Health instead of a
bureaucrat.
The 'committee Recommends to establish epidemiological unit if not already existing under the
National Disease Surveillance Programme.
3
■
ThT corn^tteT is ho?ethe°vio SUtbe7!hOry mechanism at the Sub-district level:
mechanism at the sub districtleveT3
'S 3n '’9ent need to institute appropriate supervisory
E-IO.I.1.20 Community Health Centres:
Health Sdences VaX^T'J? Central cSt re?nf unit: The National Education Policy in
recommended placement of one ni,Nir hZurh Counci1 of Health & Family Welfare in 1993 has
and if this is implemented the sam^ vJll cobnlT?3''51
6 ,Cornmunily health centre (CHC) level
system.
me w c°ntnbute immensely in strengthening the public health
specialists E up ^he^XowlSityTmonito^^
3t CHC
S^h'level
6''61,
Public health expert is available at
speciality in the population covered hu^HCe
ordato^
child suclval. physicij fo<co”
'S su"ested that each of ‘he
9 Jhe pU^ ‘C health Pr09ramm® Pertaining to 1 their
Lh™ '
Bnn"’9'. P“'lla,rician '■» immunization and
conM pr.9ramme.
for disability ,imte,io„
E-10.1.1.21 PHC/Sub-Centre level
services at PHC/S^b^entre/vhllge level should hJnUri'lY .e.or9anizati°nal structure of the health
should decide the nature, structure and orforitiM 7 b
t0 ‘he Panchayati Rai institutions which
services at the vitiag, lere,
" X8““““VaSitlT
de"''e'y
E-10.1.1.22 Village level
as PanchayarSwaL^Raksha^wil^oravideb 31
Villa9e Health Guide in the new envisaged role
level in enhancing community awareness and pSpation.0* t0 ‘b® Panchayat system at tha village
E-10.1.1.23 Prevention of Epidemics:
epidemics can be preve^ted6^ a^aDoroDriatp03191616^ prevent outbreak of ~ diseases. However
freedom from disease is appropriatesureeillance0 Th?^® machanism is established. In fact price of
of the Fourth Conference of (^Central Counc^of Health xT'®!® u??,®3 W'th the recommendations
of a National Disease Surveillance Proaramme ^ J o
Y elfare (1995) Posing initiation
experts. i„ ,artou8
|Mautes. ,«i
Institutes at the na^onarregteiterandfstete°X|Dabno9
illanc® Pf09mmme, several national
public health laboratories will be appJopLfel^ke I so S?h®»
h1®^®' C0"egeS and imP°rtant
and expertise available in these institutes oromotlv cottJ *he response caPablllty becomes faster
authorities at the district level to respond to arTepTde^
by the executive health
prepare guidehnerfo™^^^
Communicable Diseases should
the guidelines at predetermined interval and send o all hM^'8'0? °f a,National Task Force. update
should include, detai,s ot me mechanism
Registration sXmrstbse’quSZmed'is'umev'o}^09'1 l}e’islrafcn Scheme. Sample
causes of death should be continuousivJmpro ed by enteroinX8 . °eath'Rural). certification of
gives more relevant data in the context of the entire countrj"
9
P® and C°Vera9e 50 lhat il'
th. pattern ot MMWR (Morbidity M.rteti.y Week,, ReportiUSed by’S "a’nd
4
* SBHI techs an
",
i
r
i
Communicable Diseases may take up the responsibly for the same. pBHI jmay cointinue _o act
nodal agency for diseases, which are being reported on a monthly basis The diseases. u
International Health Regulations and the diseases under National Health Regulations hav n9 eP'de^
potentiality should be the responsibility of NICD, which has the due expertise in appreciating
problem and initiating action accordingly.
With the expansion of HMIS to other states and its establishment <on a firm
‘J® ePld^
intelligence component could be appropriately dovetatled within the HMIS and®
"e eDidemiC
states be taken uo where HMIS has been satisfactorily established incorporating the epiaemc
intelligence component in the light of the experiences of MICD epidemic prone
oroiect and NADHI Projects of CMC, Vellore on a pilot basis. If found successful, it will further
strengthen the HMIS in its response capability. This could form part of operational research support to
the proposed National Disease Surveillance Programme.
E-IO 11.23.6 The committee recommends that the Epidemic Diseases Act provisions should be made
available to all the health authorities and the provisions under the Act could be continuously revie
/
5 “s Jnale? group to■ « more comprehend In rhe light o< the latest soientrhc mlormahon
available..
IS's2:.eUS^“^
of infectious diseases management.
Ministry of Healths Family Welfare should take up the issue of water qua ity "’on't°r'n?
J t
Ministries of Rural Areas and Employment and Urban Affairs and Empioyment and
a f®"
studies in different locations in the country to examine the feasibili y
th *
based and affordable model of water quality monitoring and develop National Action Plan in t
regard based on pilot study results.
The comniitteenend!?sKathe recommendations of the 1995 Bajaj
jTrtth°f planning
Power Committee on Urban Solid, Waste Management in India, constituted by the Planning
Commission with regard to collection, transportation and safe disposal of
^as‘®Sthe Baiaj
industrial and hospital wastes etc. The committee, also endorses the suggestion of the
j j
Committee, that it is essential ~ to evolve a National Policy as well as an action plan for management
of * solid waste.
E-IO.1.1.27 Inter-sectoral Co-operation:
E-IOII 27 1 Large number of health schemes are implemented through the A Ministry of Health &
Family Welfare ?n addition, there are large number of schemes having tremendous impact on human
health and quality of life. These schemes are being implemented through several o^her m.n.stnes^
Rut
different aoencies are involved and co- ordination between these agencies is not so ea y
actXedXZXZ i: :<
op™. <hat Un.» and unless a ^anechan 1- ^22
and co-operation is established involving all concerned and guidelines indo t.ng derailed
responsibilities in respect of all participating umts precise!^eva"
X is expected of
schemes appearing to be technically sound, the same will not be able to deliver what is expected or
them in terms of effective improvement in the Public Health System.
E-I0.I.I.28 Non-Governmental organizations (NGOs):
.
fhroi.nh an
The committee recommends that the NGOs should be increasmgly involved through
appropriately developed action plan with suitable funding.
E-I0.I.I.29 Involvement of ISM & Homoeopathy:
Natinnal
The practitioners of Indian System of Medicine can be gainfully emp'oyed in the area o NatKjn
Health Programmes like the National Malaria Eradication Programme, Natl°n.a'X °Xn nutrition
Programme Blindness Control Programme, Family Welfare and universal immunisation, nutation
5
programme etc. Within the health care system, these practitioners can strengthen the components of
(i) health education, (ii) drug distribution for national disease control programmes, (m) motivation tor
family welfare, and (vi) motivation for immunisation, control of environment etc.
E-10.2 Long-term
The recommendations of the Bhore Committee that the Ministry of Health should be under the
charge of a separate Minister is being followed and is currently in practice. However, the
members of the committee are of the opinion that the several activities linked with the human
health are presently undertaken by Ministry of Welfare, Ministry of Human Resource
Development, Ministry of Urban Development, Ministry of Environment, Ministry of R
Development etc. The work of sanitation and environmental health was earlier with the
Ministry of Health but now it is being undertaken by several ministries viz.
Environment and Forests, Ministry of Rural Areas and Employment, Ministry of Urban Anairs
and Employment and Ministry of Chemicals. It has been further seen that the inter-sectoral coordination which is very vital in successful implementation of various programmes is not
readily available through a formalised mechanism resulting in poor achievements under
various programmes. Therefore, involving all the activities pertaining to human health,
creation off a new ministry such as Human Welfare may require serious consideration.
Alternatively a National Council of Human Welfare be constituted under the chairmanship of
Prime Minister of India, and other members being Deputy Chairman, Planning Commission,
Ministers of Concerned Ministers, eminent medical and health professionals ana
representatives of professional organizations and NGOs etc.
. >>
6
CHLP NW 02092016
Background Paper-2
2.
CAPACITY BUILDING FOR PUBLIC HEALTH IN THE ASIA PACIFIC REGION* (2004)
Introduction
1. The historic sixtieth session of UNESCAP held in Shanghai, through its resolution 60/2 on 28th
April 2004 gave a “Regional Call for Action to enhance capacity building in public health”. It
recalled the Millennium Development Goals, especially those that were health related, and the UN
General Assembly resolution 58/3 of 2003 to enhance capacity building in global public health. In
a significant step it has mandated the formation of a Health and Development subcommittee
which is scheduled to have its first meeting in December 2004.
2. The Asia Pacific region, with 62% of the global population, has several strengths. The region has
shown consistent economic progress and dynamism over the past few decades, which in turn has
contributed to improved living conditions and health of people. It also has a wealth of rich cultural,
spiritual, health and healing traditions. However poverty, hunger, disease and disability continue
to afflict significant proportions of the population, with growing intra and inter-country inequities in
income levels. Current global macro-economic policies and trends have also affected the region,
resulting in loss of livelihoods, increased rural distress and migration, environmental pollution and
destruction, and an increase in conflicts. These deeper socio-economic and environmental
determinants have a major impact on the health of people and enhance the transmission and
incidence of disease.
3. The cost of diagnostics, drugs, and of health care in general, are increasing, while public
expenditure on health and health care is declining. Health gains achieved over five decades are
beginning to reverse in some population groups and countries. Inequities in health status and
access to health care are growing.
4.
In more recent times HIV/AIDS, SARS and avian flu provide a wake up call and a challenge to the
health systems of countries in the Region. Older, long standing problems such as tuberculosis,
malaria, diarrhea, anemia and under-nutrition take a heavier toll in suffering and death but do not
attract media or political attention. There is therefore an urgent need, and an opportunity to
revitalize public health and its practice, and strengthen health systems, building on the
infrastructure, experience and expertise, developed over the decades.
5.
Capacity building for public health and strengthening of health systems in response to the
emerging problems and social context will need to be done through a process of dialogue,
consultation and international cooperation. This will be undertaken within the region, with public
health professionals in the region and with community participation. Collaboration with WHO,
UNICEF, FAO.UNDP, ILO and other international and bilateral agencies will be explored with a
strong focus on building local capacity and self reliance, rather than being dependant on external
experts and consultants. Special focus will be given to the needs of least developed economies,
landlocked and island developing economics and economies in transition. Sharing of human,
technical, knowledge-based and financial r&sourqes within the Region will be encouraged through
institutional mechanisms. Given the mandate and traditions of ESCAP multi-ministerial support
and involvement will be sought for capacity building in public health. Reviews using participatory,
qualitative and quantitative methods will be undertaken with strengthened monitoring and
evaluation systems, in order to assess the health, social and economic impact of the strategy an
to learn from innovative approaches and processes that may be used. ESCAP and its member
countries will work in close partnership with the World Health Organization, including its regional
and country offices. The public health expertise of the WHO is a valued asset. It will be drawn
upon extensively for strengthening public health capacity in the Asia Pacific Region.
ESCAP in turn will
* A Policy Document prepared for UNESCAP Health Unit by Dr. Thelma Narayan, CHC, Bangalore
7
contribute through its mandate of working on the economic social and ^^^^SgSons
£
Evolving Definitions of Public Health and Primary Healthcare
Public heath is an evolving, dynamic concept. The practice of pub'ic heaith XatonTiS
improved economic and living conditions, have resulted in major health ga ns. for populations
several countries around the world since the early nineteenth century. This took.place through
social policies introduced even before the development o vaccmes ®nd ant.biotics They
included measures to improve sanitation, hygiene, water supply, housing, nutrition, social
y
6.
etc.
The Primary Health Care (PHC) approach as a strategy to attain the international social goalI of
Health for All by 2000 was articulated at the landmark Alma Ata Conference organi
y
inri inYcef in 1978 7t drew on community level experience sand challenges from countnes in
XZSSwXX*; I. receded a
7
J>
‘
PHC expanded the scope and strategies for public heaith throughi merecasing
ities
democratic political processes over health and related services. It *X£nS mechanisms for
greater voice in health systems through decentrahzabon and '"^“ss™ inter sectoral
participation in health decision making. Moving beyond b'o^ediane PHC stequity
collaboration to address the deeper determinants of health. It was rooted in pri p
q y
and sS°X m Mln and he’alin c. In
^^=’%"„dedte
to
emphasized self-reliance at individual, community and national level, and
of appropriate technology to serve peoples needs. It promoted social means to reach these
goals. Primary health care not unsurprisingly met with resistance early on.
The International Association of Epidemiologists also ^fines pubhc bea^t Xrnote^nd
8.
and disease produced discomfort and disability in the population (JM Last, 1995).
9.
More recently the Oxford Textbook of Public Health (2002) ^XXesoui-ces'to'a'ssureThe
process of mobilizing and engaging local, state national and >nternabonal resour es o ass
conditions in which people can be healthy." It recognizes that
[ social conditions
major influences on the health of communities and that basic econo
impact directly on people’s health and wellbeing.
....... I can experiment with social arrangements for
10. The initiative for public health capacity building
'■ gre'ater’invoivement of people, particularly the^poor and vulnerable ‘n
^^X^ei^as
and environmental or developmental determinants o^eal •
by some communities and countries. The need and ch
¥
g
been articU|ated in the
Health Organization is
«' O'"'
current times and challenges in the regional context.
Strategies for capacity building in Public Health
8
“ 'he
f.
11. Human resource development- Developing a pool of well-trained, competent, highly motivated
professionals and workers in public health is a priority for all countries in the region. There is an
urgent requirement for a range of public health skills and competencies - including specialist
epidemiologists, policy analysts, health administrators, program managers, trainers, health
economists demographers, statisticians, researchers, social and behavioral scientists, public
health nurses, health promoters/educators, laboratory technicians, social workers, multipurpose
workers, health assistants, community health workers, health animators and others. While
specialization in sub-sections of public health will be inevitable, the key focus should be on
training more multi purpose, integrated, socially relevant, public health generalists at different
levels.
12. Planning and forecasting the numbers of trained staff in public health required at different levels of
the health system is a task to be undertaken by each country. Based on a needs assessment,
numbers retiring per year, and overall attrition rates, the numbers to be trained every year can be
calculated, keeping in hand a reserve stock of personnel who can manage leave vacancies,
respond to emergencies, undertake consultancies etc. Most important is the policy recognition
that in order to achieve effectiveness, relevance and quality, some positions at specific levels in
the health system will necessarily need professionals with competency and training in public
health. The tendency to appoint clinicians to public health positions, and to be susceptible to
political compulsions, needs to be avoided if public health objectives are to be met.
13. Public health staffs are often given a lower social status as compared to clinicians, though their
jobs may be more complex and thankless. This results in lower morale and self-esteem and
needs to be rectified through an enabling environment with adequate recognition, remuneration,
and encouragement. Considering the complexity of their tasks and the multidisciplinary multi
tasking nature of their activities, they should be given opportunities for professional growth. Along
with these reforms a realistic focus on outcomes, impact, quality, integrity, and responsiveness to
feedback from the community, is required.
14. Team work in public health is crucial for it success. Adequate training is needed in team
functioning with clarity about roles and responsibilities and lines of communication. Supportive
supervision, trust building and problem solving exercises are essential.
Public health
professionals can be drawn from both medical and social sciences streams and should not
become doctor dominated.
15. Continuing education of staff is essential, given the rapid growth in knowledge and the contextual
changes that are occurring. Distance education courses, workshops, seminars, newsletters and
access to electronic means of updation need to be well developed. Accreditation systems at
district or state levels for public health staff will help to ensure basic standards with mandatory
requirements for attending a certain number of courses and achieving competencies required for
different levels.
16. Ability to work with communities and local government functionaries, with community
organizations, and community leaders both informal and formal, is an important skill for public
health professionals. This is best developed through experiential learning and in-service training.
17. There is an urgent need to build capacity in developing an evidence based approach for public
health interventions. Investment is required in training and retaining research professionals
competent in qualitative and quantitative methods. Their findings would be used by a
multidisciplinary policy team for developing, reviewing and evolving public health interventions.
Skill development is required for recording and reporting systems to be strengthened, with
adequately disaggregated data collection to measure differences in social groupings. Analysis
and utilization of data for decision making should be done as close to the point of data collection
as possible. This in itself will enable capacity development closer to the community.
18. Capacity needs to be developed across sectors to deepen the understanding of the inter-sectoral
dimension of health and health action. We need to strengthen the ability to dialogue and involve
counterparts in other departments of development, be it food, water, sanitation, environment,
women and children’s welfare, education, agriculture, labour, and other departments.
Training Methodologies for Public Health Practitioners for the Asia -Pacific Region
9
I
professionals.
20. Ileducational
!s impo^l
<o- and processes of ea",'"9’*!?5{ cdontinue to have a major influence
methods
health professionals. Two foundational
Jat
’i°ts proximlty with state
have been the biomedical scientific ro
thJ’then dominant social context often linked
power. These developed historically within the ®
interface with people in
aaiicXe-.
Developmenl el l»j*^**£
M.Ul> » Menllly and
.Sedenoe has k..n oaln.d.
projects in the voluntary sector, in
.h__p methods initially evolved through working
transformatory learning processes^ While l hese methods mt * fessiona|s who flnd lt a
with communities, they have also been used in the educati^P
persona) growth
more liberating, meaningful and mot,va‘'"9 ?.
jt inc|Udes experiential learning in
Besides theoretical content and competences it
teamwork, social skills,
community based programmes, seilI awaif
spiritual and ethical dimensions of
understanding culture and community y
' . change in the method of teaching
health and public ethics, among others. This qual.tative change m
personal
learning, enMneee soda, f
so™ netao.K among puMIe
motivation, prevents burnout and helps the creation
health workers.
21. These aspects have not been a^e?uat®^t’na|S^
Public
programmes in the West. While mt
.
. linkaaes with training centres in the west
and practice of public health is a necessary.
Training Approaches
22. Medical officers of Primary Health Centres a^the{|]®Je|l®e°J ^bTadequately trained in
play an important role as leadersmopfn,e®'thDtractice in several countries a large proportion
x, public health and health munngement. kn pra
and are more clinically oriented,
do not have a post-graduate tluabJ.,ca‘,°" ''" th .ninqJfor at least 6 months which would
They will need an in-service public health t
g to
experientjal training under
r Ab — r
imP0,,anl
to supplement the traditional public health components.
23. Participatory training methods that are’
helpful.
SXX o. pa,«p.ms msidss PPPMln, . d«p.r
understanding of the issue.
10
I
24. Team training of primary health care teams for up to 5 -7 days is also a useful method to
enhance the quality of public health work. Training is undertaken together as a team to
understand each other and internalize the goals and objectives of their collective
endeavors.
Their different roles and responsibilities are clarified.
Systems for
communication, recording and reporting, measuring indicators of progress, getting
community feedback and of participatory reviews can be discussed. This process helps in
bonding together and creating better working relationships. Efficacy of public health work
depends to a large extent on the cohesiveness of the teams, their conflict resolution
mechanisms, and the feeling of community among themselves, which need to be
constantly developed and nurtured.
25. In several countries there has been good inter-action between health systems, and
integration of indigenous systems of health and healing into the national health system.
Indigenous systems and practices that are beneficial to health cold find an explicit place in
national health policies iand systems, rather than being a parallel system that is under
resourced and sometimes subaltern. This spirit of mutual cooperation between systems
needs to be reflected in lhe training of health workers and health professionals.
Training Content
26. Both traditional public health, as well as the new public health, recognize the close links
between the underlying determinants of health and the health status of populations.
Teaching curricula for public health however are still dominated by biomedical
components, based on a reductionist paradigm. Consequently public health interventions
tend to be narrowly focused, vertical programmes; lacking a societal process element. For
instance the delivery or social marketing of public goods such as diagnostics, drugs
vaccines, condoms etc are given much greater importance than social relationships and
processes through which change can occur and where people have a voice. The
contextual complexities of social, economic and environmental determinants of health are
discussed and researched in very few schools of public health across the world. The Asia
Pacific region could be a potential leader in introducing systematic teaching and research
into these issues with a public health perspective in order to protect public interest and
human rights and to reduce social inequality, with resultant benefits to the health, and
wellbeing of people.,
27. Content areas to be covered in the training would include
• Guiding principles and values of public health, which include social justice and equity
in health and health care; health and access to health care as a fundamental human
right; health as central to sustainable development; community participation and selfreliance; good governance, oversight and accountability.
• Public health ethics and law
• Food security and nutrition
• Poverty and health inter linkages
• Gender perspectives on health
• Macro-economic and trade policies and health.
• TRIPS, GATS and implications for access to medicines and to health care
• Conflict, violence, disasters and health
• Environmental health issues with corporate and government accountability
• Peoples social movements, peoples health movement
• Environmental health movement
• Population movement; migration, urbanization.
28. Preparation of learner friendly teaching material and modules; developing a critical mass
of teaching staff in the region; and establishing centres that research and inteivene in
these areas, will need to be undertaken in a systematic manner. Enhancing and
disseminating databases on these complex subjects will also need to be undertaken.
Developing Centres of Excellence for Teaching and Research
11
J
29. There is a need for a number of centres of excellence for teaching and research in public
health and community health in the Asia Pacific region. While countries with large
populations may have more than one centre, smaller countries could share a centre or
send their professionals to recognized centres. Mechanisms for generation of financial
and technical resources could be developed. Regular exchange and electronic netv'for^9
between academic and research centres In the region, and close collaboration with WHO
regional and country offices would be beneficial. Mapping of existing centres and
resource groups in the region could be initiated by the secretariat. Scholarships could be
established for least developed economies. Electronic methods of communication could
be institutionalized so that whenever required rapid mobilization of expertise and quick
sharing of information is facilitated. These centres will be the nerve centers for knowledge
generation and application, and will need to be very dynamic and alive. Countries are
advised that the leadership, management systems, library and information centres and
financial security of these centres are critical areas fpr development. Their purpose would
be to be socially relevant to the public heath related issues and concerns in their countries
and neighboring areas. Interaction and alliance building with the local health services,
NGOs and social movements would enable them as a group to impact on the determinants
of health.
Strengthening Health Systems Financially
30. Health systems form the basic skeletal framework for public health action. Over the past c®nturY
public sector health systems in the region have undertaken preventive health work, heakh
promotion, communicable disease and outbreak control, and other measures on a countrywide
basis with resultant public health gains. However over the past decade a weakening of the pub ic
health system has taken place in'some countries where decision makers have uncritically
supported and promoted the privatization of the health services. In other countries investment in
public health systems has been consistently low and unproductive. In these cases there is a
need for strengthening of public health systems to meet public health goals, and to privatize
further The Commission on Microeconomics and Health has pointed out the critical importance
of adequate investments in health in the public sector and the economic and social benefits of
these investments. Countries have been strongly encouraged to increase their public health
expenditure up to the minimum norms.
31. There I an urgent need for countries in the region to build national and local capacity in health
financing and in establishing and running National Health Accounts Systems. Capacity building in
financial management with accountability and transparency for health institutions at sub-district
and district levels and for primary health care is also required.
Capacity Building for Priority Public Health Problems
Environmental health, water, sanitation and waste disposal
32. Despite significant improvements, there is a long standing lack of access to water and sanitation
facilities for a significant section of the population particularly the poor in some countries of the
region. This is compounded by new challenges. Groundwater is being used faster than it is
being recharged. If water conservation strategies are ineffectively implemented, drinking water
shortages are predicted to occur. Contaminated water is a vehicle for disease transmission.
Poor quality and inadequate quantities of water are estimated to account for about 10/o of the
total disease burden in developing countries. Privatization of water is reducing access for the
poorer sections of society. Industrial and chemical pollution of rivers, groundwater and water
bodies and agricultural runoffs contaminated by fertilizers and pesticides are rapidly growing
areas of concern.
33. Countries are encouraged to ensure universal access to safe, potable water supply by 2010.
Inter-sectoral action between water supply and sanitation boards pollution control boards
departments of health, local government bodies communities and consumer groups is essential
to ensure adequate provision and utilization of water, without wastage, and to undertake health
12
g
5
promotion and public awareness campaigns so as to reduce prevalence of water and sanitation
related diseases.
34. There is a need for adequate technical capacity in the region to work effectively and efficiently on
this issue. Time bound goals and indicators could be set to reduce mortality and morbidity due to
the following conditions:
a) water washed disease - scabies, trachoma
b) water based diseases - schistosomiosis and dracunculiasis (guinea worm disease)
c) water related diseases- malaria, filariasis, dengue fever.
d) Waterborne disease - diarrhea, dysentery, cholera, typhoid, hepatitis A, amoebiasis,
giardiasis, helminthic infestation / intestinal worms, camphlobacter etc.
Prevalence and incidence rates will be collected and analyzed through the disease
surveillance system / health information system, for which capacity is also being developed.
35. Capacities need to be strengthened for accelerated interventions to ensure access to household
and environmental sanitation facilities (toilets^ drainage systems, sanitary waste disposal). This
will help minimize disease spread by the faecal-oral route of transmission, which continues to be
widespread. Control of these diseases requires a combination of interventions including improved
water quantity and quality, sanitation systems but also food hygiene and good personal hygiene.
This requires health promotion, advocacy, social mobilization in addition to infrastructure
development and regulation. A multi-sectoral approach involving public health engineers, sewage
boards, and departments of urban and rural development, water supply and elected
representative and community members is critical.
36. Capacities to handle waste management in a. professional, toxic free manner are also urgently
required to be developed. This area has become very complex over the past few decades and
encompassed household waste; solid waste at village, town and city level, non-biodegradable
waste; hospital and health care waste; hazardous industrial and chemical wastes; nuclear waste;
agricultural wastes etc. Some waste disposal methods, such as incineration are themselves
toxic. Short and long term consequences on public health and the environment are significant.
37. In addressing issues of water, sanitation and waste disposal, the role of the state is important.
Public health specialists need to work to collaboration with public health engineers and a host of
stakeholders, including the environmental justice movement and legal advisors. Adequate
sensitization and awareness regarding the issues need to be ensured in the training and
continuing education of all public health workers. A few would opt for more specialized training in
this area. This stream would need to have an institutional base wherein their higher education,
job opportunities and career planning would be considered.
-J-'
38. The public health system would required the skills and capacity to pick up instances of impact on
human health following environmental pollution from industry, including the chemical industry,
agriculture (pesticides, fertilizers etc) and the dumping of toxic waste. This is a major emerging
social and health problem in the region, which has become the global manufacturing base at low
economic cost. Health and safety of workers and communities need to be safeguarded. Other
major environmental, issues affecting human life, health and wellbeing including climate change,
global warming, ozone layer depletion etc, need urgent research and action. Health impact
assessments of new technologies, industries and development projects need to be undertaken.
Environmental epidemiologists and occupational health specialists are still scarce in the region
and need to be trained in larger numbers. They would need to work closely with government
policy makers, health providers, NGOs, the environmental movement and communities.
Nutrition
39. The public health systems of many countries in the region are inadequately equipped to address
the challenges of nutritional deficiencies and under nutrition, or the emerging challenge of noncommunicable disease which have a food, diet and lifestyle component to their causation. The
magnitude of nutrition related health disorders in the Asia Pacific region is large. The impact on
mortality, morbidity, vulnerability to other infections and disease, disability and economic
productivity is enormous. However the significance and potential for positive health and
development impacts through policy measures has often not been adequately understood or
13
acted upon by policy makers and public health practitioners. Advocacy, sensitization, capacity
building and effective action on nutrition deserve the highest priority.
40' SSSSSs SSSxs
wise nutrition mapping would provide an information base. Centers for nutrition r®s®®r®J n®®d
support and the findings and recommendations from their work need to be acted upon and a o
introduced into training programmes, public education and policy interventions.
41 Broader issues of agricultural policy, food diversity, food security, international trade and pricing of
agricultural products are issues of national and regional priority. Public health po’icy workers and
practitioners need to have a general awareness about these issues. They needI to ^d®
their specific roles and responsibilities in regard to nutrition security, and in improving the nutnt on
status of people of different age groups, at individual and community levels and through
integrated health and nutrition interventions.
-p
•>*
Disability
42 The Asian and Pacific is home to an estimated 400 million persons with disability, the biggest
number in the world. A large majority are poor, and lack social opportunities
a“®s® J00^
rehabilitative care, that can enable and assure a meaningful productive life. Many disabilities are
also preventable.
43. The first Asian and Pacific Decade of Disabled Persons (1993 to 2002), and the recently launched
and dignity of persons with disabilities; improving disability measures for policy use, promo> ing
active participation of women with disabilities; poverty alleviation among people with disabilities,
among others.
44 The public health community in the Region needs to be capacitated and encouraged toJoin
support and expand these initiatives. Multi-ministerial and inter- country cooperation, already
initiated, will be further strengthened. Active participation of persons with disability ini p anning
oversight and reviews will be ensured. There will be a special focus on children with disability.
Promoting Mental Health
45. Mental illness takes a heavy toll through the long-term suffering of affected persons and their
families. Patients continue to experience stigma and discrimination, and the' ffeatment and c:
of the mentally ill persons is still an orphan area in most health systems. Mental and emotional
health, tobacco and alcohol related problems and violence have been widely ^9n'z^ d“r'^
the past decade, as major public health issues. The time now is to act This is a complex issue
of human behaviour and social relations in an increasingly stressful e"viron^®"tb
personnel working in primary care settings in both the public and private,^ctor need to be tramed
adequately to recognize and diagnose mental health problems. Treatment °Ptl0ns '^®
currently available should be widely accessible. In order to make this a reality there is a need to
enhance the number of psychiatrists, clinical psychologists, counselors and social wo Jers and
also to take appropriate measures to reduce their migration. Drug patenting issues wiH neecI t
be considered to ensure availability of newer drugs at affordable prices. More important y
■ initiatives to promote positive mental health and to bu'ld ^ring supportive commun'ties need to
be expanded through training of trainers and other methods. These mciude parenting skiUs Iife
skills education, meditation and yoga. Parents, school teachers religious bodies, and community
leaders all have an important role. Legal, regulatory and related capacities will need to be
strengthened to dealt with control of tobacco, alcohol and substance abuse.
Infectious Disease Control
46. Old and new infectious diseases take a heavy toll in terms of disease* burden_and mortality m
risk of transmission within and between countries has become higher with
the region. The i._.. - - -
14
social instability, conflict displacement, migration and increased mobility. Capacity building
tor contro! of infectious diseases is one of the highest priorities in the region. This needs to
oe implemented with a sense of urgency in a time bound manner. Infectious disease control
r^hire!t-W,deSpread pub,ic education and awareness, sharing the known scientific features
ot the diseases, stressing preventive and control measures at individual and community
level and minimizing misinformation which results in fear and panic.
Government
departments of health education and health promotion need to be alert, up-do-date, pro
active and creative, using a mix of communication methods and interacting with mass media
groups.
Health systems need strengthening with adequate budgets, trained health
personnel, good laboratory facilities, supply systems for drugs and consumables,
communication systems and disease surveillance systems/health information systems. Inter
country collaboration needs improvement. However, most importantly there is a need to
focus on the developmental determinants of these diseases through intersectoral
muitiministerial interventions, as many of these diseases thrive in conditions of povertyi
There is a need to ensure that dominant paradigms eg the bio-medical approach, and
anT103!!!-intt,tUt!OnS d° not monoPohse P°,icy making. Independent implementation audits
and pub ic hearings can be utilized to elicit peoples perspectives on how effective and
accessible infectious disease control efforts are. Capacity building is required for all these
components.
M
47.
uberculosis, malaria, filariasis, dengue hemorrhagic fever and vector borne diseases need
special attention, and close collaboration with WHO control programmes. However, rather
han managing a multitude of vertical, single disease focused programmes, countries in the
gion could adopt an integrated primary health care approach wherein early detection
comp et® tr®atment, recording and reporting systems function through comprehensions
Pomary health care centres dispersed in the community. Health promotion and community
participation are integral components of the approach. Most countries have over the past 3 decades established a primary health care infrastructure. This needs to be strengthened
guarding against policy advice from international financial agencies and others who suggest
a targeted approach with enhanced privatization. The international community and public
dkl? exPerts pave universally recognized the important role of the state in infectious
i ‘ *ase contro1 through public health systems, popular education and people’s participation
In the current neo-liberal context this role needs to be re-inforced.
48. Newer problems of HIV/AIDS, SARS AND Avian flu have been addressed by the UNESCAP
over the past few years in its resolutions. The recent 3x5 initiative of the WHO, which aims
o increase access to treatment is welcome as a timely response to the severity and
UNFSCAP
10 the treatment access campaign. Dialogue between
UN ESCA Pa nb WHO will help to enhance coverage and capacity building in Asia as early as
Possible. Newer treatment protocols, simplified procedures, etc will be adopted, monitored
and constantly updated as new knowledge becomes available, after reviewing its social
applicability. Most importantly countries could use the existing provisions in the WTO
causas to ensure adequate supply of good quality, generic drugs at affordable prices.
Lessons could be learnt from Thailand, Cambodia, India and other countries. Health
education efforts regarding these diseases should not generate fear but spread positive
messages. Methods of positive living for persons already infected could been encouraged
use of adjunct therapies such as herbal remedies, massage and other forms of healing that
recognized not to cause harm will be encouraged. Life skills education and women’s health
ernpowerment that has already been initiated in most countries will be expanded through
widespread capacity building.
49. The regron is faced with a double burden of diseases with non-communicable diseases (NCD)
aacidants ,akln9 a hea*y toll. The Pacific island countries, Japan, China, Australia
ew Zealand have already initiated health promotion campaigns through the
government, voluntary sector, private sector and professional associations to bring about
testyle changes such as adequate exercise, healthy diets, stress management, compulsory
use of helmets and seat belts, rules about drinking and driving etc. With an ageing
population these measures are necessary to reduce the burden of cardiovascular diseases
hypertension, stroke, diabetes and other NCDs. Abuild up of capacity in the public and
private sector for management of these disorders is necessary.
Ratification of the
15
w
Framework Convention for Tobacco Control J^TC) and implernentaton
bans on
advertising and sponsorship of tobacco products, smokingi i p
P
including
curbs on smuggling, would help control the epidemic of tobacco related diseases, inciuaing
cancers in the Region. Other measures for prevention, control and care of ca
to be instituted.
50 The health internet work project of the WHO has piloted the use of the '"temet and
information and communication technology (ICT) for providing easy
s °ict offers
information on important public health problems to health Pr°v'ders and ' hea|th lralning
great potential and needs to be widely used. Internet based puMro hea th train ng
programmes are being designed. The use of hand held computer y
field for recording and reporting will greatly reduce their burden of work.
Community capacity building for public health
51. Traditional public health has been critiques for being rigid, witha techno-managerial
bureaucratic approach which leaves little scope for the creative, empowering and enaDi g
Kmmunilles .0 colieoM, .ddress th.
X”,
Thpm is an oooortunitv now for a change in paradigm based on greater cot™™ Y
participation and control, with mechanisms for social accoun^ab'!^inq^^XbaTvision of
progress in achieving goals. We could move forward towards achraving the global ws an o
better health for all, based on the universally accepted premise that the Right to Heat
Health care is a basic human right.
52. Capacity building for public health is therefore understood inits■broadest sense.^ This wih
involve representation from all sections of communities inc u i g
ons with HIV/AIDS
with disabilities, disadvantaged section of society, the elderlV’ a, P
tions basedon
and other illnesses, so that their perspectives, concerns, and valuable suggestions
lived experience, will help to evolve the strategies.
53. Where elected representatives function at the level of local bodies and have ^^“65
for health there is a need for innovative training to enable them to improve
9
of the public health system. This exercise may take a few years, but has proved to be
effective in several places such as Kerala state in South India.
additional responsibilities and burdens to women who are already overworked
g
55 Self-help groups of persons living with particular illnesses who also become advh
preventive and promotive action play an important role.
hi\//aids at all levels of health decision making has significantly altered t
p
SXS pXS
XioftfrS Oha-t™ and soaseqo.o, cbatos
would bear great fruit
interest.
16
3
58. Experience across the region has shown the great value addition of involving communities
with health institutions through a variety of institutional mechanisms that include:
a) Setting up health communities at health centre and sub-centre level.
b) Establishing boards of visitors, help-desks and help-lines run by volunteers in hospitals
and elsewhere.
c) Mandating local bodies or elected representatives with specific constitutional
responsibilities for the governance of health institutions and programmes
d) Making adequate provisions for the citizen’s right to information to include the heath
sector as well.
e) Establishing mechanisms for participatory management of health institutions, making
space for community voice to be heard and responded to.
All these efforts help to increase community ownership and management of health
institutions.
59. .Information and communication technology (ICT) could be used proactively by governments
to overcome the digital and knowledge divide in health. The necessary infrastructure will
need to be established and skill training undertaken. A community participatory model to the
Health Inter-network project being piloted by WHO has shown that the sharing of health
information with communities, health workers and staff from health related departments using
a mix of communication methods including ICT served an unmet information need.
60. Communities have also participated actively and effectively in participatory action research
that study some of the developmental determinate of health such as environmental an health
consequences resulting from industrial pollution, use of pesticides, mining etc. Community
involvement in the research as river-keepers measuring water quality, as community patrols
measuring air quality or as bucket brigades has enabled them to gather evidence and
become agents for change in a positive manner.
61. Public campaigns on health related issues have become increasingly common in the region
as well as globally. The women’s movement has been effective in increasing gender f
sensitization of health policies, in promoting reproductive rights, and in raising gender
concerns in health research and in medical education. One of the current campaigns is to
increase women’s access to primary health care and to reduce violence against women.
The people's health movement has been campaigning for a revitalization of the spirit and
principles of primary healthcare. The Peoples Charter for HIV/AIDS has resulted in formation
of the Asian Peoples Alliance for Combating HIV/AIDS (APACHA). The Peoples Charter for
Health of the PHM has also become a rallying point for a campaign to reduce wars, conflicts
and violence. The pulse of people can be felt and responded to by listening to the issues
raised by people's campaigns and movements. This is an important third fore that is
countering the threats to peoples health caused by corporate globalization, liberalization and
the commercialization of health care.
62. Use of the principle of subsidiarity in decentralization of health care services, with appropriate
training, management and preparation of people, helps to bring services closer to people.
However it is necessary to take adequate measures to ensure a focus on primary health care
and public health.
References
ESCAP (2003 a) Tacking HIV/AIDS as a development Challenge (E/ESCAO/CESI/4).
ESCAP (2003 b) Investing in health for development (E/ESCAP/CEST/5).
ESCAP (2003 c) SARS: Lessons for public Health (E/ESCAP/CEST/6).
ESCAP (2003 d) Report of the Committee on emerging social issues on its first session
(E/ESCAP/CEST/Rep).
ESCAP(2004 a) Resolutions adopted by the commission at its sixtieth session - 60/1 Shanghai
Declaration.
Detels R. Me Ewen J.Beaglehole R, Tanaka H, (2002) Oxford Textbook of Public Health Fourth
edition, Oxford University Press.
Last J.M (ed) (1995) A Dictionary of Epidemiology Third Edition.
Epidemiological Association. Oxford University Press.
17
International
«r
c
CHLPNW 02092016
Background Paper- 3
POLICY, ACADEMIC AND RESEARCH AGENDA FOR PUBLIC HEALTH IN INDIA (2006)
3
PHFI Inaugural Workshops
A summary of the key suggestions raised by workshop’ PartciP^
evolves its academic, research and advocacy age> .
aovernrnent academia, research
participants who were invited from a wide variety of backgrounds g
institutions and civil society
A. Stimulating demand for public health professionals
PHFI shouM address lire pereepta pl puMe
1.
P'°SSs K5ionTa™%TeaS
that they are at the bottom of the pyramid in terms of status ano posiuons a
y
professionals and enhance their self confidence an esteem as very important members
Se NGOseSorand the civil society in India have made great contributions tc> P^^^
2
maintaining the perspectives and practice of public health and giving it a n
and the
community health perspective, inspite of the OPPO^..^ ‘"‘^nce and hadition.
mainstream. PHFI must tap these resources and build on thjs rich p
e
accountable
3. Public health services and systems especially by governmen. need tob® m^e
and NGOs and civil society have done his by evolvmg the concepl^ne p^
Movements and rights based approaches to healt
effective and accountable.
PHHrmmustLPk°iXS sPectorab1eninvo?ve in advocacy and other “*®smodel focusjng on drugs
S v?cS" »9:
—“3 "e heaidr modure that t.eus.a on pd*
5.
“ S”-*
,hose
We'need to expose the community and health systems to the.benefits of^traineeI public health
6
7
‘hXXTJXemant systems tn 9»™t and other sectors atso need medtttcaM to
8.
“3 ^JXXXTS oreated tn th. NGO and the private sector and a« the
9.
12. SK^rle0
h.a«t. per— «=
“ cfear ".SnVrn^S
. private
£S"o8i
sector or an individual who has done something in t .h® f'e‘J °f
13. Public health specialists and health workers shoulc> ^P^t a d^
must not see workers as impediment but as help in their
18
other and specialists
expePnence of
r
<
s
have an awe and respect for life, nature and the community. The present market economy is
moving in the opposite direction.
16. Public health is a vast multi-disciplinary field and we must have a clear plan about the type of
public health skills and capacities we need at different levels and also where the products of these
institutions will be placed in the health system.
17. We need to replace clinicians and generalists managers of India's health systems and national
health programmes by public health professionals who are both problem analysts and problem
solvers and are promoted as equivalent to the best in medical and engineering.
18. Beyond producing public health professionals, we should also seriously re-look at promoting
public health perspectives and skills to all cadre of health professionals including health workers.
Some of this may need to be taught in the local vernacular and inter-sectoral coordination should
be important part of the training.
19. We should be cautious that the PHFI institutions do not glamorize public health and make them a
privileged professional class that will not go to the remote districts and areas of country. We need
less glamorous and more practical field oriented public health practitioners.
20. Public health practitioners need to be of different types - some practitioners, some teachers,
some managers. We need to keep these distinctions in mind.
21. We should promote PHFI in a collaborative mode building on existing initiatives and experiences
and promoting a new group of professionals that will create energy and synergy needed to
inculcate a deep sense of respect for public health and improve the practice of public health in the
country.
(based on inputs from
Arjun Rajagopalan (Sundaram Medical Foundation), Vijay Aruldas (CMAI), T Sundarraman (SHRC),
N.K. Arora (Clinical Epidemiology Network), Salim Habayeb (WHO SEARO), Amarjeet Sinha (MOHFW),
Zafrullah Chowdhry (Gonoshasthya Kendra-Bangladesh),
N.H. Antia (FRCH), Thelma Narayan (CHC/SOCHARA), Vinayak Hussein (MOHFW),
Sunil Kaul (ANT), Arvind Mathur (WHO India office)
B. Creating & Sustaining Excellence, & Relevance & Designing the PHFI Institutes
1. A core group of people need to be passionate about this institution and a shared vision.
2. Detailed planning exercise should be undertaken to make sure we plan exactly what is
needed / to happen.
3. Every institution must have its own philosophy and must respond to real life problems not
just theoretical issue.
4. The centre should be multidimensional and develop knowledge, skills and attitudes.
5. There should be strong and effective leadership.
6. Facilities for community based learning process (learn it in the field) with a strong focus
oh primary health care, which is the weakest link in our present medical education.
7. External embedded cycles?? (Shah Ebrahim)
8. The institution needs to emerge with a Vision and Mission not just be designed and
staffed.
9. It must encourage a culture of learning that is constant among both students and faculty.
10. A core faculty team that have vision I capacity provided with a career development
programme and judged by outcomes.
. «•
11. Autonomy for institution.
12. Building capacity to solve problems
13. Institutions should be residential to have better chance to orient students and faculty to
values and institutional culture.
14. PHFI institutions should work in partnership with NRHM and other governmental
initiatives. Isolated work will not succeed.
15. The institutions should promote field exposure and dialogue with the community to have a
lived experience of poverty and inequity which will make an impact on the hearts and
minds of the students.
16. Excellence should be measured not by number of papers published but by the concrete
output that the student or the faculty contributes to the community.
17. Public health is too serious a matter to leave only to health professionals - hence the
public and community representatives should be deeply involved with the institutions.
18. The PHFI institutions should not promote internal brain drain leading to collapse of other
institutions but must work in the context of a collaborative network.
19
19. There should be career tracking within the system of public health for all students who
graduate from these institutions.
20. Identify all the existing institutional and community experiences from which students and
faculty can benefit.
(based on the inputs from
Jahar Saha (IIM), Shah Ebrahim (LSHTM), J.P. Muliyil (CMC-Vellore). Sanjana Bharadwaj (UNICEF),
K.R. Thangappan (SCTIMS), Madhav Menon (NLSUI). Sneha Bhargava (AllMS), Mirai Chatterjee (SEWA),
Prem John (ACHAN) and Pat Naidoo (Rockerfeller Foundation)
C. Developing as a reputed research and advocacy group
1. The Foundation should work to foster networking, creating policies and working on areas of
research that are not adequately addressed as of now. It should not compete with existing
research institutions and public health departments which are already doing research in a number
of public healtt) problems - eg., communicable diseases, cancer, diabetes, cardio-vascular
diseases^-etc.
2. It should promote an interaction between research and the health care system - so that locally
generated research that is responsive to an adverse economic situation is used by the health
care system.
3. It should promote the nation wide acceptance of research methodologies and modules that have
been set up by ICMR and other institutions.
4. It should promote interactive dialogue between researchers - biomedical and social and
behavioural scientists and also with advocacy groups, planners and civil society and community.
5. It should promote the spread of research information to the community by more active partnership
with grass root workers.
6. It should also promote evidence based decision making in health care planning by making
available research evidence to help planners.
7. It must strengthen evidence based research in public health in general (only 3.3% of research
papers in 2002 were dealing with public health) and not allow emotion based research.
8. It must strengthen the commitment of public health community to public health research (if
something is not respected it does not get done).
9. It must foster research i.e., India centric and innovative because especially in public health we
have to deal with less resources, large numbers and large distances. Focus of research should be
on poor population not well to do.
10. It must assess new technology critically especially looking at how it can improve the health of our
country and also promote technological innovations.
11. Research priorities could include
a. studying implementation gap and implementation science
b. socio-economic determinants of health including gender disparity, equity and access
c. focus on unorganized sector and its impact on health
d. women’s health
e. starvation and food / nutrition security as a public health issue.
f. decentralization of public health system
9- health as a human right issue
h. health system research which should be fed back to the system to increase efficiency of
the system.
-v.7'
t i. Public - private partnerships and their efficacy
j- Health and social policy research including measurements of existing policy.
12. It should promote evidence based introduction of public health measures for communicable and
non-communicable disease control,
13. The research promoter should be with a strong social medicine and community health approach
and not just the orthodox bio-medical approach.
14. Research partnership should promote links with community based organizations, people's
movement, groups of rational practitioners and PSM departments in medical colleges.
15. Research should reflect on entire health spectrum of disease and problems and systems and not
just be bio-medical in its approach. It should be fostered by encouraging a deeper understanding
of the social, economic, cultural, political and ecological dimensions of health and disease at the
graduate education level and in the orientation and training of young researchers.
16. The research policies supported by PHFI must ensure that the benefits of research must reach
the community I population otherwise the policy should be seen as incomplete.
20
e
a
17. It should balance focus on drugs, vaccines and new technologies with strong commitments to
health system research, health promotion, and approaches that foster education and social
processes.
(based on inputs from
Prof. Nirmal Ganguly (ICMR), Prof. Mashelkar (CSIR) , Sapna Desai (SEWA), Abhay Shukla (CEHAT),
Andres de Francisco (Global Forum for Health Research) and Ravi Narayan (CHC/PHM)
***
Compiled by Dr. Ravi Narayan and Sunil George (CMC Fellow)
Community Health Cell, Bangalore.
zs"1 July 2006.
. . U<
21
s
CHLP NW 02092016
Background Paper- 4
4.
PUBLIC HEALTH EDUCATION IN INDIA - Some Reflections* (2007)
4.1 Context: Public Health Education Policy : 1946 to 2002
To understand the true significance of the crisis and challenges of Public Health Education in India
one must recall the main recommendations of the Bhore Committee (1946) and Mudaliar Committee
(1961) reports, that tried to set the framework of pubic health education in India.
The Bhore Committee recommended the setting up of departments of preventive and social me^lc'a®
(PSM) in medical colleges with the mandate to incorporate the then popular Diploma in Public Health
into the training of all undergraduates as the syllabus for PSM, highlighting the need for all Indian
doctors to be public health oriented,- the ‘social physician’. It also recommended post-graduate
training of two types - a shorter training in PSM / Public Health for health workers (three months to
one year); and a longer training for specialists in preventive health work for teaching, research and
administrative needs of the public health system (3-5 years). It also recommended training of nurses
in public health and a cadre of public health engineers, public health inspectors and public health
laboratory workers to be trained by the All India Institute of Hygiene and Public Health and other
institutions.
Fifteen years later, the Mudaliar Committee further strengthened public health education in the
country by recommending schools of public health in every state to train medical officers, pu i
health nurses, maternity and child welfare workers, public health engineers and sanitarians
dieticians, epidemiologists, nutrition workers malariologists and field workers. It also recommended
degrees in public health in University for non medical personnel covering general public heath,
communicable diseases, immunization, environment sanitation, statistics, school health and the
teaching of public health principles and hygiene in primary school with practical demonstrations. In
addition one year training in public health for a large number of medical officers to carry out public
health / sanitation measures and higher training of MD/PhD to support public health system policy and
development were also recommended.
While these recommendations were made in an era when public health was seen as a special skill
and education of health personnel in these skills were seen as necessary for health system
development in India, the first two decades of national health planning saw a series of negative> P™cy
trends that prevented the public health system and policy development from reaching its full potential
with many of the Bhore and Mudaliar committee recommendations not being operationalised. Banerji
(1985 and 1986) and Narayan (1984 and 1991) and Deodhar (2004) have written extensively, on
what happened and why - highlighting the reasons and reviewing policy trends and policy distortions
as well. They focused on many aspects of the health system including medical education and human
resource development in public health education.
Banerji (1985) noted that “both the Government of India and the Medical Council of India had taken
steps to establish upgraded departments of preventive and social medicine. However, these
departments have nofbeen able to attract the quality of scholars who could fulfill the challen9'"9
assigned to the departments and, in the course of the past three decades, moa o. thesei nd
themselves at the very bottom of the prestige hierarchy in medical colleges . In his detai e
epidemiological, socio-cultural and political analysis on Health and Family Pianmng(Services ir> Ind la
he concluded highlighting “the need for managerial physicians that understood health sennee
development as a socio-cultural process, a political process, a technological and managerial^Process
with a epidemiological and sociological perspective". In many ways without using the erm pub c
health professionals’ - he was setting the agenda for public hea th oriented capac'ty bu ding iri the
country. In a later oration, Banerji (1988) made a strong appeal for such an A l ln^Pubbc Health
Cadre . He suggested “... Action to strengthen public health practice must start from the political
16 V 61
_______ __ _________ ____________ _ ___________ ____ ________—
-This paper is based on Power Point presentations - presented recently at a
Health Fellowship Scheme in July 2006 and an earlier seminar at >^ ^on Scho° ° '20P06 .
Medicine on Public Health Education of India, in June 2006, later published in mfc bulletin, December 2006
March 2007
22
5
Formation of an all India cadre or at least strengthening of the existing cadre of Central Health
Services is urgently called for. To improve the quality, it would be necessary for the political
leadership to actively search for highly intelligent and dedicated public health workers and bringing
them together to form a 'critical mass’, which could strengthen the key institutions for practice,
research, education and training in public health”.
Narayan (1991) in a detailed analysis of 150 years of medical education as part of the medical
education anthology process of mfc, noted that “hierarchical trends in medical colleges, non
democratic spirit in curriculum planning and authoritarian methods in bringing about changes in
medical colleges have prevented serious and meaningful change in the inherited structure . This was
probably true not only of the main stream experiment but also of many of the emerging alternatives.
He also commented on the “myths of PSM including a gross confusion between means and ends and
inability to stimulate teachers and students to see the importance of socio-economic cultural and
ecological factors in management of health and disease" - which were the original hopes when the
department was created and integrated into medical education.
Later, Narayan, (1997) endorsed “ the reorientation of all postgraduate education towards the
goals of the National Health Policy and primary health care and enhanced commitment to post
graduate training in public health and allied disciplines. Linked to this would be the development of all
India Public Health Cadres to strengthen the public health services in the country....". This was in the
Chapter on Perspectives in Medical, Nursing and Paramedical Training and Education, the
Independent Commission on Health in India, report by VHAI, New Delhi.
The same report (ICHI 1997) also recommended that “all major states should have at least one
school of public health, along with modern public health research laboratories, smaller states may
collaborate and have common public health schools..". It also recommended that Institutes of Health
and Family Welfare established in many states should be developed into Schools of Public Health.
The analysis by Deodhar (2004), of the regression of public health education in India in the last three
decades is particularly relevant - since it focuses on PSM departments that were primarily set up to
strengthen public health. “Departments of Preventive and Social Medicine have been the victims of
neglect, assignment of lowest priority, low prestige, poor quality of staff, inadequate facilities, the staff
full insulated themselves from the practice of public health and even of preventive medicine"
While academics, researchers and activists mentioned above have been highlighting the crisis and
challenge of public health education from the 1980s, national policy documents also began to identify
these trends and problems and suggested strategies of action to strengthen public health education in
various ways.
■
The National Health Policy document of 1982 identified three significant problems:
1. ‘“Wholesale adoption of health manpower development policies...based on western
models...inappropriate and irrelevant to real needs..."
2. “Continued high emphasis on curative approach led to neglect of preventive, promotive,
public health and rehabilitative aspects of health care"
3. "Prevailing policies in regard to education and training... resulting in development of a cultural
gap between people and personnel providing care"
-------- l~k—ai
It recommended many strategies of action - foremost.......................
of which were *'the —
need-1 to ‘formulate
national medical and health education policy, and the establishment of comprehensive primary
health care and public health services within an integrated referral system.
■
The National Education Policy for health sciences in 1989, which grew out of a response to the
NHP 82 identified the problems as:
1. Medical bias in the entire process of health systems planning and health manpower
development
2. inadequate continuing education for updating existing skills and facilitating acquisition of new
skills and knowledge by health team.
•'
It recommended the following strategies for action relevant to public health education:
1. IEfforts to produce adequate number of first level of specialists in medicine, surgery,
paediatrics, OBG and public health / community health
2. Essential that speciality of health management is recognized and an appropriate step taken to
produce good health managers.
3. Mandatory to establish linkages between health care delivery and education in health
sciences to make the whole system efficient and effective.
23
I
report which unfortunately did not recerve attention it should have received wa
findings and recommendations. (See Annexure 1)
y
rssss
public health qualification.
I, sagged m.ny stogies fd..Coo to Cengthon
KJ® -
«—p"'
rT^To"sX”s
" «>•
8"!l
“
pr's,e5Si0”a'8
.
Mog'pS health schools to be strengthened (AlIHRH) - Essie,n- region end tour regional
'
schools to be set up - central, northern, western
Community Medicine should be
XdVT—S ?«s9"X Chlh. h.® and producing pub.c he*
professionals (at least 25% of existing departments to be upgraded).
SSSeilS .SXi*- Sr services research; In— o,
practitioners of the Indian Systems of Medicine.
?“ S“u'XN" pXiS
■.
aXo
and m—.y
?„SS expertise non existent in private hea.th sector and tar shod o< ,e,uir.m.„l In public
.
health sector.
Il Included the following strategies lor action relevant to strengthening public health systems
medicine dLplines to discharge
personnel -h spec— ^pub. heahh and tardily
°f '"dian
’
?,“e “s “Sib?—“tor adeguate training, to enhance outreach ol pub.c
.
SSX to strengthen d.eenlratised state ie.e, pub.c hea.h systems and in.ot.ing
***•
.
.
P“MC
S?S S ?X“e aSable lor th, entire gamut =1 public health activities at deceniralized
levels".
,17.^0 four broad sets of issues that
A recent review of all these critiques in Narayan
neglected in spite of all the debate,
explains why public health education
(----------- had been devalued or
dialogue and policy recommendations. These include.
social medicine departments, and their
. Nledicalisation of public health by preventive and
well as th fact that these post-graduate
aloofness from state health programme managers, as
•"*,fe ,re"d 15 n" te3in”9"
degrees have been available oi ,
slowly change.
24 .
1
Devaluation of public health as a discipline in the 1960’s and 70s by generalist administrators
and clinicians becoming public health managers and state HRD policies not requiring public
health degrees as job requirement for public health managers. This trend is also seen in a more
subtle way in the NGO / civil society sector as well.
Disintegration of public health systems by vertical national disease oriented programmes
rather than sector wide approaches and externally funded projects focused on single disease
programmes rather than on strengthening public health systems. New economic policies also
systemd S°C’al sector exPenditures including health budget further distorting the public health
J
Dialectics of National Health Policy
The challenges of balancing public health / primary health care system development with the
present trends towards privatization of health care and medical tourism and unregulated private
sector development and commercialization of health care has led to inadequate focus on public
health human resource development. This is also linked to new economic policies that focus on
the needs of ‘India’ rather than of ‘Bharath’.
It must however be noted that by early 2000 AD, a National, consensus had begun to emerge
especially in policy circles for comprehensive initiatives in strengthening public health capacities in the
country. This emerging consensus included
need for many more schools of public health / institutions and public health courses to cover
state and regional needs;
need for making available public health training for health and social science professional
other than doctors;
need for strengthening public health planning, management and response to emergencies in
state and national health systems and
need to ensure public health human power development policies at state and central level
that gave public health qualifications, skill s and capacities their due importance.
Any public health capacity building dialogue like the one being undertaken by the medico friends
circle or capacity building initiative like the Public Health Foundation of India must take into account
ese istorical documents, the critiques and the pleas for action and the emerging policy consensus.
■
References
1.
cJZ^Ornmittue
Hea,th Survey & Devel0Pment Committee, Compendium of Recommendations of various
Welfare G^an BhX™ Defhi -TlOOoT''3' BU'eaU Of
'nte"i9enCe' DGHS’ MiniS,ry 0' Hea"h & Fami,y
2.
ConlrPitt®® (1961)' Heal,h Sun/ey & Panning Committee, Compendium of Recommendations of various
WelfareXS BhavaTNew t^hi - mOoT3' BUreaU °f Hea',h ln,elli9ence' DGHS’
Heaith &
3.
PunVppI^V' ^984^ 150 yearS °f Medical Education:Rhetoric and Relevance, Medico Friend Circle Bulletin, No.97-98,
4.
De!?abar (1985)1 Hea,th and Fami,y Planning Services in India - An epidemiological, socio-cultural and political
analysis and a perspective, Lok Paksh, New Delhi - 110 067
AKemative^ara^igm9 Lok PakCsh', NewnDelhi-bflO OB/b
'ndia " S0Ci0,°9y °f FOrma,iO" °f
5.
6.
7.
8.
o3. £^x
eo8i^
,or a new pub,ic Heaith' b c- °as9upta
O997). Perspectives in Medical, Nursing and Paramedical Training and Education, page 23-34, Chapter III,
vhai nao-l? Independent Commission on Health in India, Voluntary Health Association of India, New Delhi, 1997.
1997 (1997)’ Report of the Independent Commission on Health in India. Chapter VI. Public Health Institutions. VHAI,
9.
rnne.hHr,r N S'
Pxub,ic ^ealth System in India with special reference to school of Public health. National
Consultation on Schools of Public Health,. New Delhi, September 2004
10. ■rnr^n' ?au (2,?K°6.)'„Pu^liC.Health and Com™nity Health Education in India - A Historical Overview, CHC Workshop on
mmumty Health & Public Health Education : Towards a New Social Paradigm’, Community Health Cell, Bangalore.
25
a
4.2 Overview of Public Health / Community Health Education initiatives
in India since 1970
quality and quantity of community oriented, public health personnel. A
Zs.;, since th, alternative sector uses ■communi,, be* ™
descnpbon 0, courses.
These are not synonymous.
p
a
hpa|th’ in its
which includes a strong focus on social.
,te
organization of the action as a right and a responsibility
J' I'
These initiatives have been primarily of two types: (a) Mainstream; (b) Alternative.
A.
MAINSTREAM INITIATIVES:
““TcWe’Tme n^ created PSM
dlpieme in
public health and related courses.
There is no directory as
Institutional Network (SEAPHEIN) has began to document hese recently (WH
part of a process to evolve an accreditation sy5'6™ This
9
58 „ a (jeqree of MO in
medical colleges teaching PSM as part of the NIBBS curncu u ,
d 13 ff
Diploma in
Social & Preventive Medicine or Commumty Medicine of 3 years du
ancI
P
Public Health of 2 years duration. All these courses .^ogn'zed by ;he
° " ygiene-Kolkata
of —health ccursas open te other be*
professionals.
Apart from this, wa have the Masters la Cemmunit,He* of MJ.Maste
Chitra; the Masters in Epidemiology of CMC'Ve“°r®. . FDidernjo|OqV from the National Institute of
discipline. Since 2001, we also have a
health programme managers.
Epidemiology - Chennai, which is open to state
.r,ininn hv NIHFW-New Delhi for deputies and
™“ea^
e"S‘n9 inS"tU’“ a"a
»»« »»"
courses .
•
I
Th^'professional networks have contributed to 3 varying
degree,
to the debate and
experimentation in public health education in the country. These include
a)
The Indian Public Health Association> (IPHA) which is a very old
?r£5moXSXZmXXs^
i"
PUMiC Heanh 5,a’m
SStoX or Trevumi.u and Soctai M.dlein. tlAPSM) »hicb is national
b)
association of Teachers of PSM departments with some excep ions^
c)
epidemiology and field based research, making them more public health onen
26
.
J
Some issues relevant to the mainstream sector
J
Seern re!evant' that so many
many institutions and colleges are already running or initiating
public health courses in mainstream institutions, some issues of concern need to be noted. Some of
these are anecdotal and not based on
a comprehensive
comprehensive review
since CHC
CHC has
on a
review but
but are
are valid
valid since
has had
had a
close contact with
mostof
these
initiatives
and
has
participated
in
many
of
the
courses.
W
---------- -II ■ blt
VI
W/V4I QUO.
3
©solving its own public
health course without
any standardization
•----------- vvikilVMk wny
uiui luaiuiLauvil Of
reference to a national consensus.
b)I The Medical Council of India and the National Academy of Medical Sciences have not been
very proactive in recognizing courses opened to non medicos in public health. Therefore, in
exploring accreditation for public health courses for non medicos, each institution is evolving
its own recognition with the local University or other Universities.
C)i There is urgent need for a National Accreditation council - perhaps a Public Health Council of
India - so that all these DPH and MPH courses are part of some nationally, relevant
a^utonomy^
3 counci’ however must encourage experimentation, diversity and
.
d)I
e)1
0
—III
Ij
II
There are no national standards for faculty requirements, course contents, methodology of
teaching, requirements of field centers and field experiences for these newer MPH and DPH
courses. MCI has recommendations for PSM departments and the undergraduate and MD
Jhe WH0’SEAR0 has just started this process since 2000 AD through the
SEAPHEIN network (see details later in the paper).
Mnuly' there 'S urgent need for P°licy advocacy with States, to recognize these DPH and
MPH courses as requirements for specific jobs in the public health systems at state level.
ny then will these education efforts help strengthen state capacity and programme
enectivity. In the absence of such a proactive policy advocacy process, this anarchic
evelopment of institutions and courses could result in the human resources generated
health^ystem^eed
fUel'n9 3 'brain‘drain’rather than responding to the national public
A brief word, about the three professional networks, that should be logically involved in any
°n PUbhc health capacity building in India. The two associations - IPHA and
lAroM have not been working as closely as they should because of a subtle hierarchy
between the three year MD and the one to two year DPH/MPH course, though this is now
beginning to change. In Karnataka state we have managed to bring these two groups in to
one association - The Karnataka Association of Community Health. In addition the INCLEN
network is also not so closely associated with the other two because of the subtle differences
between the clinical epidemiologists and the 'purists’. The dialogue of all this networks with
the policy makers has been relatively weak.
B) THE ALTERNATIVE SECTOR:
hoaifh1^1131176 Se?°r?S 3 term we have used t0 describe a group of public health / community
MDM/nDu?n9i,anTuedUCatlOnal ,nitiat|ves that have not followed the orthodox MD- PSM and
hLuhL? tracks- Th,s sector evolved through the experimentation of a large number of community
ealth action initiators in the late 1970's mostly from the NGO/ Voluntary sector. After many years of
community based action some of these projects metamorphosed into training centres, that could
orient other doctors, nurses and health professionals to initiate and innovate similar community health
training programmes53'^
lnt°
9r°UPS: (3) ShOrt term trainin9 Pra9rammes and (b) long term
Short term training programmes
These include Community Health training programmes of Deenabandhu Medical Mission (Tamil
Nadu) Christian Medical Centre (Miraj); Christian Fellowship Hospital, (Ambilikkai;, Tamil Nadu),
Institute for Rural Health Management - (Pachod, Maharashtra); International Nurses Service
Association, INSA (Bangalore); THREAD (Orissa), Child in Need Institute - (Kolkata). Many of
these courses, were particularly popular in the 1970s to 1990s. Some of them have now been
discontinued.
ii. NGO Networks like VHAI, CHAI and CMAI also started short courses in community health
planning and management particularly for their member institutions.
in. Some educational institutions like St John’s Medical College-Bangalore (3 month course in
Community Health), and NIMHANS -Bangalore (one month course in Mental Health Care), also
started such short term courses.
. i.
27
3j
Long term training programmes
The Voluntary Health Association of (ndia ev°^a
i.
for Health
’9’3 ™s ”m8 iS
for a year. A distance learning module was also attemp e .
ii.
In 2003 the Society for Community Hearth'
science
Bangalore) - has evolved a s,x m0J!th
E career / vocation. This initiative entitled the
graduates, to strengthen public health as choice o care’
project, which has just been
WOrkSh°P °f PUb'iC
Sate^
hea,th
trainers in July 2006 at Bangalore.
tZ: SZXX’Xt
aesotib.d in CHC sMi.s
a''1993 aTbeao3urses199perimeatedn0wrthdane allerna^a
»'
i.
participatory, experiential, learner centred and action oriented.
ii.
iii.
?h ? y
R et
“ ”a
«"aa community based
iv.
SX^S^X^X’S'jXants givinp teadPa* and .vdiaing ihe
v.
vi. There was a greater
SS SEKTaa^g*. and a«ed«.e aspeeis p< Paining and on »»rK .«d
evolved inno.aiiv. caee siudiee. si—n games and p— solving
viii.
ix.
While the orienlailon of the courses were ,s,y
mee™c" p™lde?s « programme
^a^mTXS1’^
a^Ceres of .0.’ eommonit, or precess
managers.
A very fmportanf and slgnlAcant eharactertsdc of dirs group
degrees along the way.
The current anxiety that somehow a foreign e^^°r!cin
a creative adaptor to a different soci •
’ ..
had relumed Io
^n^poht^al^ealhy "is a highly
voluntary sector of health in India is to
then their local counter parts. This may
.
opposed to the more hierarchical and didactic
dialogue environment of academic centres abroad as opposeo io
academic environment locally.
C) OTHER DEVELOPMENTS
While the earlier sections focused on coursesi andbegmning to have an important
-- - -—Eafl Asaa
Health Education Institution Network (SEAPHEIN)
i.
People’s Health Nlovement (PHNI) - Global and India
28
i
A Global Peoples Health Movement and a People's Charter for Health arose out of an important
People's Health Assembly, held at Gonoshasthya Kendra, Savar, Bangladesh, in December
2000. when over 1454 people from 75 countries gathered to reflect on why 'Health for AH’ had
not been reached by 2000 AD. This had been the goal of the famous Alma Ata declaration of
1978 committed to primary health care. This global assembly was preceded by the First National
People’s Health Assembly in Kolkata, which also resulted in an Indian People’s Charter for
Health. Both these documents have led to the emergence of a growing People's Health
Movement in India, known as Jana Swasthya Abhiyan (JSA), which brings together over 18
national networks committed to strengthening the Right to Health and Health Care in the country.
The leadership of this Movement includes a wide variety of public health / community health
oriented professionals and activists from all over the country and are slowly becoming a force to
reckon with in public health policy and system development. The Charters both global and
national have a series of recommendations of great significance to public health, public health
system development and public health education in India and abroad. (PHM 2000 and JSA 2000)
Members of the JSA are now actively involved with advocacy initiatives with the Ministry of Health
and Family Welfare, Planning Commission, and other national bodies and also participating on
task forces of the National Rural Health Mission and other schemes.
ii.
The South East Asia Public Health Education Institutes Network (SEAPHEIN) is an initiative
that has evolved as an outcome of the regional conference of ‘Public Health in South-East Asia in
the 21st century’ in 1999, hosted by the IPHA which led to the 'Kolkata Declaration’. The
Declaration had four major strategic directions relevant to India as well:
a) Promoting public health as a discipline and as an essential requirement for health
development in the region;
b) Recognizing the leadership role of public health in formulating and implementing
evidence-based healthy public policies;
c) Strengthening public health by creating career structures at national, state, provincial and
district levels; and
d) Strengthening and reforming public health education and training and research.
Five consultations have followed in the South East Asia Region in which some of the existing
public health institutes in India have participated especially CMC-Vellore,; Sri Chitra,
Trivandrum; AIIHPH-Kolkata; IHMR- Jaipur; and NIE-ICMR- Chennai; and more recently CHC
and PHFI. These consultations have focused on:
a) Accreditation Guidelines; (b) Curriculum structure (c) Networking (d) Future Directions; (e)
Regional Guidelines for Public health education standards and accreditation (WHO-SEARO
2000, 2005 and 2006). (See Annexure -2)
This over view of development in public health/ community health education in the main stream
and alternative sectors and related developments of key networks would be an eye -opener for
many of us in mfc, who may have been unaware of all these diverse, plural and anarchic nature
of development of public health and community health courses in India. Very few reviews or
overviews are available on them except those undertaken by CHC and mentioned in this paper
earlier. There is need for a more evidence based and standardized assessment of the content,
methodology and relevance of all these ongoing experiments and initiatives even as we focus on
the newer developments like the PHFI. Many institutions like AIIHPH, NIHFW JNU-CSM CH,
CHAD-CMCV, NIE-Chennai, IRHM-Jaipur and Sri Chitra - Trivandrum - have contributed to the
challenge of public health education in India. By focusing on the practitioners who have been
trained by these institutions and feedback from them on the relevance of the training, we can help
build an evidence based national consensus on what works and what doesn't from a people’s
health and a Health for All perspective. This is an urgent imperative and the MFC dialogue could
be the initiator of such a process especially if we want to move from being a 'thought current’ to
also being an ‘action current’
D) POLICY RECOGNITION OF THE ‘ALTERNATIVE SECTOR’ :
In 2004, CHC was invited to the First National Consultation on Schools of Public Health organized by
the Ministry of Health & Family Welfare, in New Delhi, to reflect on the contributions of the alternative
sector of public health / community heailth education in India. Taking an overview of the sector and
building on all the previous studies amd reports , Narayan, R (2004) identified some of the key
. challenges faced by the alternative sedtor, which included: the experience of building capacity from
grass-roots workers up to reorientation and skill development of health professionals: community
29
t
capacity building including strategies for system development and demand creation; the evolution of
the concept of a ‘new public health’ with strong focus on community dynamics, social and
development determinants and alternative pedagogy: and various efforts through campaigns and
movements to counter distortions and market deviations in public health policy and action.
■*”
'
'I
Three recommendations were made to the policy makers and public health professionals gathered at
this consultation:
5. “Recognize alternative sector as strong public health resource in the country for
training, policy action, system development and demand creation (not as
'appendage' or 'after thought');
6. Involve alternative sector in development of relevant / creative learning modules
which could be included in the mainstream courses. The themes would include (a)
social and developmental determinants (including social, economic, political,
cultural and environmental factors; (b) public health policy and action; (c) public
health and social science research ethics; (d) public health and community process
management, etc.
7. Include some alternative training centres in evolving networks to strengthen public
health capacity in the country, which would be offering MPH and shorter courses”.
There were some interesting outcomes of this strong plea by CHC on behalf of the alternative sector
at the National Consultation:
i. In the strategic framework evolved for strengthening public health education in WHO-SEARO
region entitled ‘South East Asia Public Health Initiative 2004-2008 (WHO-SEARO, 2004), the
following significant inclusion in the section on Partnerships shows that the demand has been
taken seriously. (See box item)
Partnerships with Alternative Sector
“Many alternative institutions, both organized and informal, have been actively involved in
public health work as well as public health capacity building. Sometimes, they have been
termed as alternative sectors. For example, in India, the following organizations, among others
have been active In public health education and training - some since the 1980s and others
more recently:
•
VHAI Educational Council (diploma in community health management);
•
Network off community health trainers: with inputs ffrom many voluntary organizations, they
have conducted short courses in community health development and management;
•
People’s Health Movement;
•
Society for Community Health Awareness, Research and Action (CHC);
•
Centre for Enquiry into Health and Alternatives (CEHAT)
The list can be enriched by examples from other countries, as well as with more examples from
India.
These organizations have become active in public health development due to
dissatisfaction with existing governmentowned PH institutions, usually run by conventional
Preventive and Social Medicine Departments, and also having low status for public health and
increasing inequity and social exclusion. A wave of community health NGO movements have
taken place to try alternative experiments and actions, and to build capacity from communities
and grass root workers. Unless the national apex Institutions or schools of public health
recognize these alternative sectors as strong resources and involve them in training and
research, a large portion of creative energy in public health will remain untapped”
Source:
South-East Asia Public Health Initiative 2004-2008. WHO-SEARO
30
3
ii. When the Public Health Foundation of India was set up in consultation with the Ministry of
Health and Family Welfare, the Planning Commission and the PMC’s office, in February
2004, a representative of the alternative sector of public health / community health was
included as a stakeholder in the Governing Board and it is in that capacity that CHC is
represented on the Governing Board. This is therefore, an opportunity for all of us in the
alternative sector to engage with the initiative and make its academic, research and policy
endeavours more India relevant and pro-people oriented. By this active engagement we
may be successful in countering other agendas that any such multi stake holder initiative is
bound to be subjected to. This opportunity rather than threat is described in the next
section.
In conclusion, as we dialogue and debate on public health education In India at our mfc
meeting, we should recognize the large plurality and diversity of ongoing initiatives and not
Just focus on one of them - however high profile. We need to identify trends including
externalities and agendas and also recognize both opportunities for engagements with a wide
Variety of on going initiatives while at the same time evolving our own initiatives to counter
•/market oriented and other trends. A great challenge would be to build up as soon as possible
the India relevant pro-people public health capacity building curriculum that many centres and
initiatives are talking about today.
References :
1. CHC (1991), Proceedings of the Community Health Trainers Dialogue, Bangalore.
2. Narayan, R, Narayan, T and Tekur, S.P. (1993), Strategies for Social Relevance and Community Orientation
in Medical Education - Building on the Indian Experience, A CHC/CMAI/CHAI Medical Education Project
Report, Community Health Cell, Bangalore.
3. Narayan, R (1993), the Primary Health Course at Jamkhed - Building the framework further - some issues
and perspectives based on an overview and experience of training in India’ (Jamkhed Conference handout)
4. Kasturi A (1993), A checklist of ideas options and alternatives : an overview of fifteen community health
training programmes in India (A short term CHC project) Appendix A to 2.
5. VHAI (1997), Perspectives in Medical, Nursing and Paramedical Training and Education, Chapter 3, Report
of the Independent Commission on Health in India (by CHC).
6. Narayan, R (2001), Perspectives in Medical Education, Health Policy series, Independent Health
Commission in India, VHAI, New Delhi.
7. WHO- SEARO (2002) Accreditation Guidelines for Educational /Training Institutions and Programmes in
Public Health , Report of Regional Consultation , Chennai, Jan-Feb 2002, WHO-SEARO, New Delhi. (SEA HMD 213)
8. Dutta, G.P. and Narayan, R (2004), Perspective in Health Human Power Development in India - Medical,
Nursing and Paramedical Education, The Independent Commission on Development on Health in India,
VHAI, New Delhi.
9. Narayan, R (2004), Public Health Capacity Building - Initiatives by the Alternative Sector, National
Consultation on Schools of Public Health, New Delhi, September 2004 (Power Point presentation).
10. Gupte, M.D. (2004), Public Health Education in India : Status and Key Challenges, National Consultation on
Schools of Public Health, New Delhi, September 2004.
11. Thankappan, K.R. (2004), Public Health Education in India : Status and Key Challenges, National
Consultation on Schools of Public Health, New Delhi, September 2004.
12. WHO-SEARO, (2005), South East Asia Public Health Initiative 2004-2008 - Strategic Framework for
Strengthening Public Health Education, WHO SEARO, (SEA-HSD 282).
13. SEAPHEIN, (2006), Regional Guidelines for Public Health Education Standard and Accreditation, 2nd
SEAPHEIN Annual Meeting, South East Asia Public Health Education Institutes Network
4.3 Reflections on 'public health teaching, learning and competency building*
For over three decades, we have facilitated teaching, learning experiences in public health, preventive
and social medicine, occupational health and community health. Since the 1970s, we have had 'real
life’ experience and engagement with all aspects and dimensions of the topic being discussed. This
includes being students of post-graduate courses in India and abroad: teaching in India for a decade
in St. John’s Medical College as faculty members of the department of Community Health; Ravi has
been an overseas lecturer of the London School of Hygiene and Tropical Medicine (LSHTM); a
visiting professor for a year each at the School in mid 80s and mid 90s; during the years in CHC
evolving the 'alternative paradigm’ of Community Health (the new public health) we have been
involved through praxis and engagement with movements and health systems - both alternative and
mainstream; and have lectured and facilitated teaching sessions in public health schools in India, and
several countries. More recently, we have taught modules on public health policy and public health
31
1
system management at the National Institute of Epidemiology, Chennai and interacted with public
health faculty, students and colleagues in the PHM from all over the world at conferences, the
International People’s Health University (IPHU) and at the annual Global Forum for Health Research
(GFHR). From this more global and ’praxis’ perspective, we wish to highlight issues that may be
relevant for discussion.
1) Public health with a community health perspective (the new public health) is not only an attitude of
mind and a perspective - but also a discipline. While an undergraduate, clinician, general
practitioner or allied health professional can develop attitudes and perspectives, the discipline
needs periods of discipleship to develop skills and competencies based on public health
principles and methods. Public health practice requires academic rigour, the capacity to analyze a
public health problem not only bio-medically and techno-managerially, but also to consider the
social, economic, political, cultural, and environmental roots of the problem, and thereby evolve
responses and systems that address this complexity with the involvement of the public or the
community.
•
2) Knowledge of the discipline can be built to some extent through didactics and classroom teaching,
utilizing new pedagogical approaches like problem solving methods, case studies and
simulations, audio-visual aids and computer assisted learning. However what is more urgent as a
prerequisite is 'hands on’ learning by involvement in programmes/systems at field level. This
involvement should include.
• meeting, observing, interacting and working with the community supported by 'mentors’
involved in ‘public health system building’ or 'public health movement building*.
• Learning from practitioners of public health, at different levels of the system, tackling public
health problems in 'real life’ situations;
• listening to their sharing in a spirit of learning and identifying the strengths, weaknesses,
opportunities and threats of their action at community level, system level, or policy level.
Teaching programmes that only include theoretical analysis both quantitative and qualitative
without a live contact with the system as found in many mainstream and alternative public
health educational programmes in the country continue to be less inspiring and effective.
The Community Health Fellowship Scheme of CHC - which recently concluded its first four
year phase and was externally evaluated and reported In July 2006 was based on these
principles. We are confident that this method is capable of creating in young public health /
community health students, a passion for this discipline. Further work is progressing to
develop modules and frameworks of learning that can build further skills and capacities. CHC
now has nearly 40 young people who can share about this initiative from their own diverse
learning experiences.
3) The academic environment in which public health and community health skills and capacities are
best developed are also environments which foster a spirit of self learning and a capacity for
analysis by the student. To sharpen this skill, it is also necessary to expose students to different
streams of thought, different types of public health action, and new paradigms and new
approaches. This is important even if the trainers have a certain definitive point of view or
preference for a certain paradigm.
We have surprisingly discovered this more in academic environments and public health
schools abroad - rather than in teaching /training centers in India (both mainstream and
alternative). The culture of hierarchy together with dependency, part of our wider social
traditions, prevails greatly affecting the learning process. We need to actively encourage a
culture of interactive, participatory discussion; of student feedback completing the full loop
of educational planning; learning that challenges gender bias, caste and class hierarchies
even within our institutional ethos; and a culture that allows the teacher and taught to
discover and analyze perspectives together. All these need to be internalized in training
programmes, teaching methodologies, assessment and examination systems in order to
produce practitioners and personal and social transformation.
4) Too much emphasis has been on placed on basic training and post graduate courses. There is
need for an equal emphasis on continuing education, in-service training and distance learning
since the complexity of public health challenges is changing everyday. No course however well
planned or however long can cover everything that needs to be taught and every skill that needs
to be developed. All' public health educational institutions must build working links with public
health systems, and not be confined to over-utilized, over funded, over-studied and over staffed
field practice areas. The faculty can then prepare students for real life situations and not models.
32
f
This will also move faculty from theoretical analysis and / or unrealistic models to praxis based on
engagement wSh real life systems and situations. Institutions will discover opportunities for
offering short courses, distance learning modules and learning by doing.
5) We often hold on to some notions of reality based on past situation analysis and not necessarily
careers choice in India. While this may be true of the 70's or 80 s, the situationi has changed
dramatically. Many good students, keen and competent are now opting fo a pos 9^
in public health. While cynics may link this to increasing job opportunities in Internationa
health, or to a back door entry into the US medical system (since public health courses do not
require medical registration to begin with), close interaction with many students; in recent
years shows that this is not always true. Even if 25% of those who are starting| th s journey
are serious, we still have the prospect of a very large number of pubi c heatth Professionals
arriving on the scene, seeking training, research and work opportunities. Area^ 'n
schools abroad, Asians including Indians and not only NRIs are a substantial Percentage of
the student population. Similarly, there is the phenomena of NRIs increasing on the faculty of
these schools, Both these factors are also additional pull and push factors for initiatives such
aStheWeFhave been tracking interesting public health training programmes and research
1.
2
projects in many parts of the world - both North and South, developed and developing
countries - trying to learn from praxis everywhere. The older and new public health
institutes and departments of public health in India need to be open to a wide variety of
ideas which include initiatives such as the National School of Brazil; modular courses of
the University of Western Cape, South Africa, which starts with rural nurses and offer
credits and courses to health team members at different levels; distance learning
initiatives in many countries; special courses in socio-epidemiology, mequahties in
health and health care, social determinants and human rights in universities in the USA
In many parts of the world, alternative and mainstream public health professionals are •.
also much more in dialogue with each other through professional associations and
meetings unlike in India. If we, in the alternative sector feel we have evoived
knowledge or alternative skills and capacities, we need to share them with he
mainstream more proactively. Our recent experiences as part of the PHMteam, ini the
World Public Health Congress at Rio or in the Global Forum for Health Research
meetings since 2002 show that dialogue is possible and necessary (see report on
Research Priorities for Schools of Public Health in the Global South and the Social
Vaccine on the CHC and PHM website (www.sochara.org; www.phmovement.org)
for 3 P-e
»
j“™' “
supplement the People’s Health Movement that evolved in 2000 AD. The rationale is as follows.
a.
Public health capacity budding, including establishment of a stand alone public^health
practical skills and capacities to tackle challenges in health and the hea'th system
currently under further assault by neo-liberal economic policies. The issues are not of
tensionbetween generalst vs. specialists; doctors vs. health workers, primary heaKh
care vs. public health; clinicians vs. public health, communicable vs^ no
communicable diseases; bio medical vs social commun.ty mode s* J^se am old
debates and will continue, though they mask deeper more difficult soceta! conditions
that produce ill-health. The situation of public health and health systems is so bleak
that we need action on all fronts with a strong 'new public health I community health
33
public health system development policy initiative. It is only when this'Complexity s
understood in the context of today’s political economy of health that these debates
will lead to concrete action. Already many people’s health movement activists have
dual involvements - proactive watching as well as critical engagement.
b. Today's complexity also requires that the focus of attention is not just on PH
emerging institutions and initiatives however high profile they may be in the> med a
but on all the ongoing and evolving initiatives in educational, strategies for pubic
health and community health in India - subjecting them to the same questons and
scrutiny, reviewing their relevance, contribution,
lessons earnt trough their
experience, and their potential contribution or continued irrelevance to the new
The quesfonTweare asking of PHFI are also questions that we should be asking o^elv^s
in the context of the pre-PHFI developments in HRD in India in both the mainstream and the
alternative sector. Have any of our initiatives made a significant difference?
c. In the current market place that, prevails in policy and ^‘em dev^opmeJ a"d
the dialectics of medial tourism vs the National Rural Health Mission, this debate
needs to move from radical spaces to critical engagement. This engagemen _could
be through a public health watch and a public health movement that tackles the
continuing lacunae of human resources for Health for All in the country.
.
d. A few years before the national and global people’s health assemblies and the
adoption of the Indian and Global People’s Charter for Health, CHC identified a 12
point agenda for action to strengthen health human resource development in the
country to counter the disturbing and distorting trends evident in the 1990s. These
included:
Banning medical college expansion;
Strengthening MCI - making it more professional and socially oriented;
Setting up a National Human Power Development Commission with a strong multidisciplinary focus to evolve need based and evidence based change,
Strengthening existing medical education efforts including medical education cells and
•
•
.
.
.
social and community orientation;
Examination reforms towards rational and ethical systems,
Promoting creative autonomy for experimentation towards primary health care,
community health and general practice;
.
.
Strengthening continuing education of health and allied professions involving IGNOU
.
StrenX^nTpubS
.
Research in health human power development including implications of privatization,
•
•
brain-drain and new economic policies;
Regulation of privatization and commercialization of medical education and health,
Promoting training of health worker training ; and finally,
•
.
capacity building and development of public health cadre;
strengthening the movement dimension of health which in 1997, we had defined as follows. “What is
needed is altrong countervailing movement initiated by health and devel°pm^^
and people's organizations that will bring health care and medical education (including public health
education) and their right orientation high on the political agenda of the country
Since 2000 AD, the People's Health Movement in India (Jan Swasthya Abhiyan) \h®s de^op®^
this emerging countervailing movement in which we all are actively involved. What 'S a sc. needed
urgently is an alternative public health network that brings together a!l those united in theirconarns
for public health capacity building - both civil society networks like JSA MFC. or Professional
associations like the Indian Association of Preventive and Social Medicine ('APSM), Indian' Publie
Health Association (IPHA), INCLEN and other alternative training groups. An active engagement with
initiatives such as NRHM, PHFI, SEAPHEIN as well as with social movements are part of the
challenges and opportunities ahead.
Can the mfc meeting in December 2006 or the second National Health AssemblyJn Marchi 2007
be the starting point for such a network - the Public Health Movement of Ind a to complement
and strengthen the people’s health movement? Our inaction or failure to move beyond
discussion in radical spaces to offer concrete, well defined alternatives may be the greatest
threat of all. This is the imperative before us.
34
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Reddy, K S (2006) Boosting Public Health Capacity in India, NMJI, Vol. 19, No.3, 2006 p122-125.
Qadeer, I (2006) Whither Public Health, Letters, EPW, May 20, 2006
Sathyamala. C (2006) Public Health Foundation of India - Redifming Pubic Health, EPW, July 29, 2006,
P3280-3284.
Banerji, D (2006) Personal communication to Dr. Sathyamala, mfc yahoogroup.com, August 24, 2006.
Reddy, K S & Sivaramakrishnan.K (2006) Unmet National Health Needs - Visions of Public Health
Foundation of India, EPW, September 16, 2006, p3927-3933.
Rao, M & Nayar K.R. (2006) Public Health in Private Hands? A note on the Public Health Foundation of
India, Speaking for Ourselves, NMJI, Vol.19, No.4, 2006, p221-224.
Reddy, K S (2006) Public Health needs a Boost, not Bickering, Speaking in spite of Myself, NMJI, Vol. 19,
No.4, 2006, p224-226.
Shukla, Abhay (2006) Public Health Foundation of India - Will the Public be placed at the Center? Indian
Journal of Community Medicine, Vol 31, No.2, April-June 2006.
Prakash, P (2006) Manushi article.
'
_x.
Narayan, R (2001), Perspectives in Medical Education, Health Policy series, Independent Health
Commission in India, VHAI, New Delhi.
*
WHO- SEARO (2002) Accreditation Guidelines for Educational /Training Institutions and Programmes in
Public Health, Report of Regional Consultation, Chennai, Jan-Feb 2002, WHO-SEARO, New Delhi. (SEA HMD 213)
Dutta, G.P. and Narayan, R (2004), Perspective in Health Human Power Development in India - Medical,
Nursing and Paramedical Education, The Independent Commission on Development on Health in India,
VHAI, New Delhi.
Narayan, R (2004), Public Health Capacity Building - Initiatives by the Alternative Sector, National
Consultation on Schools of Public Health, New Delhi, September 2004 (Power Point presentation).
Narayan, T (2005), Capacity building for public health in the Asia pacific region - A policy reflection for
Economic and Social Commission for Asia and the Pacific, (UNESCAP), Bangkok.
Narayan, R & George, S (2006), PHFI Inaugural Workshops - summary of key suggestions, July 2006, A
compilation.
Task Force on Medical Education for the National Rural Health Mission (2006), A report from Ministry of
Health and Family Welfare, GOI.
35
*
CHLP NW 02092016
Background Paper - 5
PUBLIC HEALTH IN INDIA SCORE (WWW.COMMUNITY.IN)
5.
PUBLIC HEALTH IN INDIA-SCORE
SOCHARA-SOPHEA
What is your PHIN - SCORE?
Note: This compilation of key documents, reports, publications, experiments, events and
initiatives covers most of the important aspects of Public Health Policy ancj System
Development In India since Independence.
O'- •. ■
As a staff / faculty member of a school of public health and or ngo/ institution / network
involved in public health education, research, system development, policy advocacy and
community health action, it is necessary to be aware of all these important and historical
■
contributions to India relevant public health.
The list covers ten groups of resources and ten key items in each. Together they form a list
in India should be
of hundred resources that every public health professionals or <activist
---------------
■
aware of.
You are invited to tick these hundred items and find your PHIN Score (Public Health in
India score). You should tick this item only if you feel you can actually share the key
features or describe the significance / content of the document / item to another
colleague or to your students. Just knowing the name or having heard vaguely about it is
not enough.
If you cannot tick some of the items then write to us for another complementary
document that gives you web reference for each of these items, (cphe@sochara.org, or
■
clic@sochara.org)
■
This effort is not to find out whether you have a high or low score but to encourage you to
improve your score so that your team member, students, fellows and others will be
oriented to India relevant Public Health through your informed writings, reflections,
teaching and learning facilitation.
■
This self assessment score sheet has been tested out on a series of postgraduates in public
health, preventive and social medicine, and fellows and ngo staff members from various
of this
organizations. We thank them for their participation in the test run u
:'..L document and
for all the suggestions given.
We hope you have enjoyed participating in this small self assessment score sheet that we
are releasing to support team/ faculty / institutional development in Public Health in
India.
From time
to
time we
hope to
update
this
list or add
supplementary/complementary lists to enhance the India relevant context and focus in all
our efforts.
36
Please note that all the documents/publications that we considered significant for
evolving the score were not available always on the internet. We have currently included
shortnotes/reviews in the list of web references prepared by us as supplementary
documents. We are making efforts to scan the originals with permission where required
and hope to constantly update the score and the reference list.
■
The score may be used freely by all crediting SOCHARA and ensuring that we receive
information about this use, to continue producing revised and updated scoring
instruments. These communications may be sent to clic@sochara.org or
cphe@sochara.org.
10/1/2013.
Team CPHE
-SOCHARA
~7'x'
(Ravi Narayan, Deepak Kumaraswamy, HRM Swamy, Lalit Narayan, Prashanth NS.)
A. POLICY DOCUMENTS
PHIN Score
1. National Health Policy (GOI-1983).
2. National Education Policy (GOI-1986).
3. National Education Policy for Health Sciences (GOI-1989).
4. National Population Policy (GOI-2000).
5. National Health Policy (GOI-2002).
6. National Policy and Programs on Ayurveda, Yoga and Naturopathy, Unani, Siddha
and Homeopathy (GOI-2002).
7. National Pharmaceutical Policy (GOI-2002).
8. Karnataka State Integrated Health Policy (GOI-2003).
9. National Rural Health Mission (GOI-2005 - 2012).
10. National Knowledge Commission Repot of Working group on Medical Education
and Community Health (GOI-2007).
B. EXPERT COMMITTEE REPORTS
PHIN Score
1. Health Survey and Development Committee (Bhore, 1946).
2. Health Survey and Planning Committee (Mudaliar, 1961).
37
3.Report on Multipurpose Workers (Kartar Singh, 1973).
4. Report on Medical Education and Support Manpower (Srivastava, 1974).
5. Report of the Committee on Drugs and Pharmaceutical Industry, Ministry of
Petroleum and Chemicals, GOI. - (HATHI committee, 1975).
6. Health For All: An alternative Strategy (ICSSR- ICMR, 1981).
7. Report of the Expert Committee on Public Health Systems (Draft-GOI-1996).
8. Report of the National Commission on Macroeconomic and Health (GOI-2005).
9 Annual Report to the People on Health (MOHFW - GOI, 2010).
10. High Level Expert Group Report on Universal Health Coverage for India- (GOI-
Planning Commission-2010).
PHIN Score
C. KEY MONOGRAPHS / REFERENCE BOOKS
1. Alternative Approaches to Health Care, (ICMR -1976).
2. Evaluation of Primary Health Care Programmes, (ICMR -1980).
3. Appropriate technology for primary health care, (ICMR-1981).
4. Health and Family Planning Services in India: An Epidemiological,SocioCultural and Political Analysis a Perspective, (Banerji, D. 1985).
5. Experiences in Community Health, (Anubhav Series) (VHAI / Ford Foundation
1987).
6. State of India's Health Report (VHAI -1992).
7. Report of the Independent Commission on Health in India, (VHAI -1997).
8. Towards Equity, Quality and Integrity in Health - Report of the Task Force on Health and
Family Welfare, (Govt, of Karnataka. 2001).
9. Review of Health care in India (CEHAT-2005)
10. Report: Task force on Medical education for The National Rural Health Mission, (MoHFW-
GOI-2006).
38
D. ALTERNATIVE SECTOR - KEY PUBLICATIONS
1. In Search of Diagnosis: Analysis of the Present System of Healthcare (Patel, A. 1977)
2. Poverty, class and health culture in India, (Banerji. D, 1982)
3. Health Care Which Way to go?: Examination of issues and alternatives, (Bang, A & Patel A, -1982).
4. Rakku's Story: Structures of ill-health and the source of change,(Zurbrigg, S, 1984).
5. Under the Lens - Health and Medicine, (Rao, Kamala. & Patel, Ashwin. 1985).
6. Taking Sides: Choices before health worker, (Sathyamala. C et al, -1986).
7. Medical Education Re-examined, (Mankad, Dhruv. 1991).
8.People s Health in People's Hands - A model for panchayati raj, (Antia, N.H. and Bhatia, K -1993).
9.Health for All Now!: The People's Health Source Book, (JSA 2000).
. 10. The Rights Approach to Health and Health Care — A compiled review- 2007.
E. GOVERNMENT /NATIONAL PROJECTS EXPERIMENTS
l.Narangwal Project.
2.Najafgarh Project.
3.Singur Project.
A.Gandhigram Insitute of Rural Health and Family Welfare.
S.Chittaranjan Mobile Hospitals.
6.ROME Scheme (Reorientation of Medical Education).
7.Expanded Program of Immunization.
8.Integrated Disease Surveillance Programme.
9Janswasthya Rakshak-Janata Scheme.
lO.State Health Systems Resource Centre- Mitanin
39
F. INSTITUTES OF PUBLIC HEALTH SIGNIFICANCE (NATIONAL)
1. All India Institute of Hygiene and Public Health, Kolkatta.
2. Centre for Social Medicine and Community Health, JNU, New Delhi.
3. Malaria Research Centre/ National Institute of Malaria Research.
4. National Health Systems Resource Centre (NHSRC), New Delhi.
5. National Institute of Communicable Diseases, New Delhi.
6. National Institute of Epidemiology -Chennai.
7. National Institute of Health and Family Welfare, New Delhi.
8. National Institute of Nutrition, Hyderabad.
9. National Institute of Occupational Health, Ahmadabad.
10. National Tuberculosis Institute, Bangalore.
G. PUBLIC HEALTH/COMMUNITY HEALTH RESOURCE CENTRES / NETWORKS (ALTERNATIVE
SECTOR)
1. Anusandhan Trust (
CEHAT, Mumbai; SATHI, Pune, and CSER, Mumbai).
2. All India Drug Action Network (AIDAN)
3. Catholic Health Association of India, Secunderabad, (CHAI).
4. Christian Medical Association of India, New Delhi, (CMAI).
5. Foundations for Research in Community Health, Mumbai, (FRCH).
6. Jan Swasthya Abhiyan, (People's Health Movement, India).
7. Medico friend circle, (mfc).
8. Public Health Resource Network, India, (PHRN).
9. Society for Community Health Awareness, Research and Action, Bangalore. (SOCHARA)
10. Voluntary Health Association of India, New Delhi. (VHAI).
40
H. EVENTS/DEVELOPMENT OF PUBLIC HEALTH SIGNIFICANCE (Mainstream)
l.The Calcutta Declaration —1999
2. South East Asia Public Health Education Information Network, SEARO - 2003, (SEAPEN)
3. National Consultation on Institutes of Public Health in India - 2004
4. NRHM
Advisory Group for Community Action (AGCA)-2005
5. Public Health Foundation of India (PHFI) - 2006
a’J
*
",HGNI New D'renlons'or p““ic H“"h
'
r^rengthenlng Epidemlolo6ical Principles for Poblic Health Action - SEAPO l„ltlati,es
8. Nahonal Consultation on Public Health Workforce -WHO India Office, 2009.
9. Indian Public Health Standards, NRHM - 2010.
“■
a"‘"n',“n Assotl,t'“ ■” p'™"'he “X
I. events/oevelopment of public HEALTH SIGNIFICANCE (Civil Sodely)
1. Indian People's Health Charter, 2000.
2. Community Health Environment Skill Shares (CHESS) -2002.
3. The Mumbai Declaration- 2004.
4. Pre Election Policy Briefs/ Health Manifestos for 2004 & 2009.
5‘ SXZ" Ri8htS COmmiSSi°n ^ight t0 Hea'th lnitiative
copies Heaith
6. The Second National Health Assembly-2007.
learmng Prp6rammes for Communit, Health and Public Health- Report of a National Workshop.
8. People's Rural Health Watch -2009.
9. South East Asia Regional Conference on Epidemiology-WHOSEARO/IEA-2010.
41
Q
10. Community health Wikipedia-2010.
J. GLOBAL EVENTS /DEVELOPMENTS THAT HAVE A NATIONAL CONNECTION /LINKAGE
l.Alma Ata Declaration - WHO UNICEF-(1978)
2.0ttawa Charter on Health Promotion - (1986)
3.World Development Report - Investing in Health (1993)
4.Millennium Development Goals - (1999)
5.People's Charter for Health of PHM -(2000)
6. Commission on Macro Economics and Health (CMH)-2003
7. Global Health Watches -I (2005) and II - (2008) and III- (2011)
8. International People's Health University (IPHU) - (2005)
9. The World Health Report,- Primary Health Care- Now More Than Ever-(2008)
10. WHO Commission on Social Determinants of Health (WHO CSDH) (2008)
Count the ticks to get your score
Date:
Total Score
? /100
Now check the list of internet references available on line from www.communityhealth.in and or
www.sochara.org
42
CHLPNW 02092016
Background Paper- 6
6. COMMUNITY HEALTH LEARNING PROGRAMME OF SOCHARA: 52 Week Curriculum
COLLECTIVE -1
(8 Weeks)Week:l-8
Week-1
THEMES
C01-BUILDING BLOCKS FOR FELLOWSHIP - LEARNING
TOGETHER
Understanding oneself - intra personal and Inter personal skills
Inside learning, outside learning, learning skills, social skills and self
teaming
i
<.“1
Week-2
Week-3
Week-4
Week-5
_____
What is Health? Physical, Mental, Social, Economic, Political, Cultural,
Ecological. Differentiating Health and Medical Paradigms____________
Values: Equity, rights, gender, social justice, inclusiveness, respect for local
health culture, solidarity, secularism
______________
Perspective on self-transformation white engaging in social action
C02-UNDERSTANDING COMMUNITY/ SOCIETY /
DEVELOPMENT AND HEALTH
What is community, society, family, collective, cooperative
Class, caste, gender, social exclusion, marginalization
Structures, stratification, power dynamics, conflicts, transitions
Understanding dalit issue; adivasi issue; agrarian distress;
Community dynamics, perceptions, mobilization, capacity building
C03-UNDERSTANDING COMMUNITY HEALTH/ PUBLIC
HEALTH - PRINCIPLES AND AXIOMS and Primary Health Care
Community Health, Public Health, Community Medicine, Preventive and
Social Medicine
Social, economic, political, cultural, ecological determinants of health and
their inter relationships and dynamics
Axioms and principles of Community Health
History and relevance of comprehensive primary health care and strategy /
approach towards health for all
_ ___________________
Learning from community health initiatives and action for health
C04-SITUATTON ANALYSIS OF HEALTH AND HEALTH CARE IN
INDIA_____________________ ___________________________
Situation Analysis of Health and Health Determinants in India_____
Regional Disparities and inequalities, trends______
Understanding Health care sectors - public, private, voluntary tradition,
people sector and local health tradition -- strengthens / weaknesses
COS-SOCIAL DETERMINANTS OF HEALTH AND SOCIAL
ACTION
____________________
Social Determinants of Health, action on determinants and social vaccine
Environmental Sanitation and Community led total sanitation
Environmental and Health
Culture and health and cross cultural dialogue
43
Week-6 CQ6-GLOBALIZATION AND HEALTH_________________________
Political economy of health and forces of liberalization, privatization and 7"
globalization________________________________________ ____________
What is Globalization and its impact and consequences and health and equity
Challenge of equity — geographical, gender, social exclusion and
marginalization_________________
_________ ________________
Challenges: Social Dimension, Health Equity, Health Policy, Access to
Health, Disease Risks, Patents, Trade and Health, Technology
Globalization Risks, Responses, Alternatives and solidarity from below
(PHM)_______ _ _____________ ____________ ______________________
C07-RESEARCH-1 - Measuring Health and Disease
Measuring Health and Disease - why and how__________________________
Basic Biostatics : Concepts and Tools_________________________
Summarizing data- tables, graphics, Pie-charts, Maps, Bar Charts, Line
!
Graphs, Frequency distribution
_
Defining health, Measuring disease frequency_______ __________________
Summarising numbers: mean, mode, median, variances, standard deviation I
C08-HEALTH SYSTEMS AND HEALTH POLICY - (3 days)
|
Health systems and health policy in India - history and evolution
Health system at different levels — local, district, state, central
I
Week-7
Week-8
Issues of access acceptability, affordability, availability, quality |
CONSOLIDATING FELLOWSHIP PLAN - (3 days)
Planning the fellowship learning journey
_______________
Goal Setting objectives and learning framework |
Interaction with mentor and planning field work
_
——
A—
k
(8 Weeks) Week:9-16
COLLECTIVE-II
( 4 Weeks) Week: 17-20
I
Week-17
- w*
Week-18
Week-19
COMMUNITY
w
Ip
(Understanding and describing a community. Understanding community (
priorities, Understanding the field placement organisation and their projects
Social determinants of health and Intersectoral collaboration, Framework for |
a Situational Analysis, Health Care Providers and Medical Pluralism
Understanding NRHM and Communitization, Understanding Mental Health) '
THEMES |
C09-NUTRITIQN, and WOMEN and CHILDRENS HEALTH
Understanding Nutrition & Food Security ________ _____________
Understanding Women's Health (beyond RCH)
Understanding Child Health
_
_
Understanding Adolescent Health and Life Skill Education
_
CIO-COMMUNICABLE DISEASES- Community health responses
TB/Malaria/ HIV/AIDS_____________________________________
Water borne diseases_________________________ ______________
Vector borne diseases - Malaria, Dengue, Filaria and other diseases
Cll-RESEARCH-II - Epidemiology (data and responses)_______ _
Basic Epidemiology - What / Who/ When/ Where/ Why/ How
Epidemiological perspective and understanding data
Analysis of situation and data and response
44
.1
I
Understanding steps in research
- ----------^g^^MMlW^BLE DISEASES ■ Community heaiih---------
Week-20
Heart Disease/ Stroke/ Diabetes
Jvlental Health and Substance abuse
Cancer/ Accidents etc
~
Field Work-II
(8 Weeks) Week: 21- 28
-- ---------------------?--------------------- --------------------- -
prevention and promotion
eomm.ni.yheaUh axLT
' lean""g"U
“d L
re™
‘leC'"raoACHTO
ive
COLLECTIVE-III
THEMES
4 Weeks) Week: 29-32
Week-29
IglT-HEALTH TECHNOLOGY AND INNOVATION---------------------
—_PProPriate Technology and innovation
'
'
----- ------information and communication technology (TCT>
---------------_C14-EQUITYIN HEALTH
------------------- -----------
Week-30
health and intervention-------
People with Disability
-------------------------------------------------
Week-3
1 EARCH- III- DESIGN AND METHODS-------------------------JglS-RES
Qualitative Methods in research ----------------------- --------------------- ----Quantitative Methods in research"------------------ - -------------- —
Week-32 C-16OCCUPATIQNALHEALTH AND URBAN HEALTH------ -------_ orj^d^Tunorganized------------------
FIELD WORK-HI
£9 Weeks) Week:33-40
FINAL COLLECTIVE
_(10 Weeks)Week:41-49
Week-41
Urbanization and urban health challenges
----------------- National Urban Health Mission
~---------------- --------- -------------- ^g^WCTtNCFiEa STUDY/COMMUNITY HEALTH--------
THEMES
C17-HEALTH POLICY-----------------------Understanding health policy process
Lfojgjggnding health policy history and current situation
Primary Health Care and Health ForAh
--------Universal Health Coverage
------------------ ---------Week-42
j^lS-PUBLIC HEALTH MANAGEMENT
-----------
levels
anting partnerships with community and other sectors
Hgalthresearch project- planning basicsteps-------------------
45
Week-43
Week-44
C19-RESEARCH IV
Participatory Action Research
___________ _______
_________
___________
SOCIAL CHANGE
_
—-------------------------Community Health Movement in India and Networking----People’s Health Movement (Glob^N^l and State Levels), GHW and
Social Movements and Social Change (beyond PHM)
Community action for accountability including monitoring, health watches,
people’s tribunals (COPASAH)
_
Decentralization in health and panchayat raj
I
C21-SPECIAL
CHALLENGES
Week-45
Climate Change and Health
___
and Opportunities including LHTs j
AYUSH and Public Health - Challenges
War / conflict / disaster / displacement
Agrarian Distress and Farmers Suicide
C22-RIGHT TO HEALTH
Week-46
and fundamental human right
Right to Health and Health Care, entitlements
--------------------------------- 1
Constitutional and legal aspects of health
~ Ethics ofhealth and health care_____________ 1
~ C23-HEALTH ECONOMICS_________________ (
Week-47
” Health Equity and Universal Health Coverage______ ______ ______ —----~ Basics of Health Economics including H^itlrFi^^^
----- 1
Week-48
Week-49
Week-50-52
_ Community Financing and insurance
----------- ----------------------------- <
~ C24SPECIAL COMPETENCIES -1_______ —
Governance and Decentralization
—
Partnership and Advocacy
__
—-------------------~ C25SPECIAL COMPETENCIES-II
Communication including informatics----------------- ------------------------------Monitoring and Evaluation ------------- -— ■
Conflict Resolution
— —---------------- --FINAL ASSESSMENT AND PLAN FOR NEXT STEPS /
FINALIZATION OF REPORTS ( see FA-1, FA-2)------------------------— the BEGINNING OF COMMUNITY HEALTH JOURNEY----------
25 Week of collective teaching learning
24 weeks of field work
3 week final assessment and next steps
Total 52 Weeks
46
CHLP NW 02092016
Background Paper- 7
7.
COMMUNITY HEALTH ORIENTED, COMPETENCY BASED MODULES BY SOCHARA
FORTRAINING IN INDIA (RGIPH-MPH HONORS COURSE)
7.1 VALUES ORIENTATION IN PUBLIC HEALTH
7.2 SOCIO-CULTURAL AND COMMUNITY HEALTH
7.3 PLURAL HEALTH SYSTEMS
Community Health Oriented, Competency based Special Modules
for Community/Public Health/Social Work Training in India
Introduction
i
The Community Health Learning Programme (CHLP) of SOCHARA is an interactive,
participatory, person centric, field based programme which has evolved since 2003. It caters
to young people from multi-disciplinary backgrounds wanting to explore community health
and take-up practice of community health as a career.
The Rajiv Gandhi University of Health Sciences established the Rajiv Gandhi Institute of
Public Health and Centre for Disease Control (RGIPH&CDC), Bengaluru in 2013 and
SOCHARA was invited to be part of the Advisory Committee to evolve a three year Masters
of Public Health (Honors)’ course to be recognised by University Grants Commission and to
be an innovative, India relevant training with some special additional modules and features.
Two members of SOCHARA (Drs. Ravi Narayan and Rahul ASGR) were part of the
Advisory Committee and based on a review of syllabus of existing MPH courses in India
identified areas lacking in these and introduce some additional competency based modules
and re-orient some existing ones through a consultative process.
SOCHARA was then requested to develop the syllabus for some of these unique modules and
different team members contributed to evolving them in designated framework suggested by
RGIPH.
These modules were developed incorporating ideas and experiences of the ongoing
Community Health Learning Programme and were submitted to RGIPH for their use and
further modification/adaptation based on teaching-learning experience for different batches.
SOCHARA is uploading these modules to its website, www.SOCHARA.org. so that other
community/public health learning programmes and courses can use and adapt it according to
their needs and contexts:
1. Values Orientation in Public Health (Contributors - Ravi Narayan, Thelma
Narayan and Prasanna Saligram)
2. Socio-Cultural and Community Health
3. Universal Health Policy
4. Ecological Sensitivity
5.
Plural Health Systems
6. Global and International Health
7. Public Health Capacity Building
8. Research Competency
47
Each of these modules is available separately on the website.
1 Rajiv Gandhi Institute of Public Health and Centre for Disease Control. Ordinance
Governing Master of Public Health (Honors) Regulations and Curriculum. Karnataka.
Department of Public Health Rajiv Gandhi University of Health Sciences; 2014
SOCHARA
May 2016
48
7.1 COURSE ON VALUE ORIENTATION IN PUBLIC HEALTH
(5 Credits, 3 Weeks Teaching Learning with 14 days of sessions)
•
•
•
•
•
VALUE orientation IN PUBLIC HEALTH_________
Right to Health
• Lectures and lecture discussions
Equity and health
• Case scenarios
Gender and health
• Student presentations
• Journal Club
Ethics/integrity and health
Quality in health
Source: RGUHS - MPH (Hons)
Regulations and Curriculum (2014)
1. OBJECTIVES
a. To understand and appreciate the values dimension in public
health
b. To be able to apply these values
i. in the practice of public health
ii. Programmes related to achievement of Health for All
c. To appreciate the challenges in the application of these values
2. SPECIFIC OBJECTIVES
To explore, appreciate and apply the following value dimensions in Public
health practice:
a. Right to Health
b. Equity in Health
c. Gender equality
d. Ethics and Integrity
e. Quality in public health
3. ASSESSMENT
a. Formative Assessment- based on participation in group discussions and
critical reading sessions
b. Summative- Written test with short questions and case scenarios
4. EVALUATION
Participants will evaluate the sessions and programs of the above module,
especially regarding the topics, quality of content, delivery of content and
assessment
5. ORGANISATION
a. General introduction and exploration of documents- 2 days
b. Right to Health — 3 days
c. Equity and health- 3 days
d. Gender and health- 3 days
e. Ethics/integrity and health- 3 days
f Quality in health- 3 days
g. Assessment- 1 day
(Three days for each value includes lecture discussions. Critical reading, Student
presentations. Group discussions)
49
6. SCHEDULE based on experience of 2014-17 batch of RGIPH
which incorporated the 5th National Bio-ethics Conference
sessions into it as part of learning of Ethics/integrity in health —
(Can be adapted further according to context, situation and
available resource persons)
Day One
Theme
____ ____________________ I Method
Introduction to Values and their role in public
Time
health practice
_______________
Review key documents to identify values
10 am-1 pm
Interactive Discussion
•
Alma Ata Declaration
•
National Health Policy 2002
•
Peoples Health Charter 2000
•
NRHM Mission Statement 2005
3.15 pm-4.30
EQUITY AND HEALTH:
• Understanding equity and equality
• Inequalities in health status, access to
healthcare and services, and health
enhancing environments;
• Inequities due to geography, gender,
marginalization and social exclusion
Case studies on Equity Challenges in Bhopal,
pm
CHESS and Environmental Health
1.30 pm - 3.00
pm
Lecture
Discussion
Case Study
Day Two
EQUITY AND HEALTH(continued)
An introduction to Equity gauge:
•
10 am - 1 pm
Measuring equity, indices and equity
stratifiers
Lecture
Discussion
•
Equity lens, equity gauges, equity
assessment, equity oriented health
system and health equity audits
Case Study on Regional Disparities in Health in
1.30 pm -4.30
Karnataka (2001)
Planning Exercise on Equity and regional
pm
Inequalities in Health in Karnataka — Current
Presentation and
planning exercise
| (DLHS 2012-13)
Day Three
10 am to 5 pm
Field visit to Ayush Grama, Gollahalli, Devanahalli
Group discussions
Taluk (field practice area of l-AIM) to explore the
with the community -
community context of the values - Right to
Health, Equity in Health., Gender equality, Ethics
each student will
and Integrity, Quality in public health
(Or any other suitable community field practice
and two on quality
(Anganwadi Centre
area can be chosen)
Day Four, Five and Six
and Health Centre)
50
focus on one value
Attend National Bio-ethics Conference at St Johns
National Academy for Health Sciences. An
indicative list of public health oriented plenaries
and
parallel
sessions
(workshops
and
presentations) will be given to the students to
guide their participation. Workshops to attend:
1.
Corruption in healthcare- Working towards
solutions
2.
Professional and civil society
perspectives on challenges and
approaches in ethical practice of
occupational health in India
Refer to
3.
program- u
Accountability for Reasonableness:
Addressing Challenges in Public Health by
4.
Harmonizing Ethics, Economics & Evidence
Public Health Ethics
5.
Policy Ethics and Just Health Systems: The
Pursuit of People-Centred Care
6.
All students will be
allotted certain
sessions or
presentations to focus
on and present
summaries at
debriefing session
indicated later in the
schedule.
WHO session on integrity and corruption in
healthcare
Plenaries for later discussion:
1.
Day 1- PLENARY -1: Keynote address -2
2.
Day 2- PLENARY - III: Keynote address1,2 and 3
3.
Day 3- PLENARY-V: Keynote address 1
and 2
_______ _____
Day Seven
GENDER AND HEALTH:
•
Understanding gender, roles, unequal
social and economic variables and power
•
10 am -1 pm
Gender inequity including vulnerabilities,
nature-severity and symptoms of health
problems, health seeking behaviour and
long term health and social
Lecture
Discussion
consequences
2.00 pm-3.00
pm
-4!’
•
Global issues related to gender
•
Victoria Hospital - Burns report: Gender
-
Case study
and Epidemiological Perspective
•
Gender, Sanitation and Mental Health- A
study
3.15 pm - 5.00
pm
.J-
Case study
Group discussion on Gender and HealthChallenges in Public Health and Primary Health
Practice (From participants perspective)
10 am -1 pm
___________________ Day Eight__________
GENDER AND HEALTH (continued)
51
Lecture
■'
,
!•,
Discussion
Gender discrimination and violence
•
against women
•
Legal aspects related to gender
•
Developing gender sensitivity through a
Debriefing on Ethics and Integrity in Health
______________
Presentation of
(NBC)
student assignments
gender lens
1.30 pm -4.30
pm
and summaries
Day Nine
RIGHT TO HEALTH-1:
• The Right to Health and Health Care
lecture
including theoretical perspectives,
10 am -1 pm
Discussion
political economy of assault on health,
O'.
•
paradigm shift from charity to rights,
RIGHT TO HEALTH-2:
•
Universal Declaration on Human Rights
Lecture
and the International Covenant on
Economic, Social and Cultural Rights and
1.30 pm-3.15
pm
Discussion
the emerging rights language in various
international declarations.
3.30 pm -4.30
pm
_
RIGHT TO HEALTH-3:
The Right to Health movement at national,
Lecture
regional and international level.
Discussion
Day Ten
10 am -1 pm
Reviewing the Universal Declaration on Human
Review
Rights and the International Covenant on
Economic, Social and Cultural Rights
QUALITY IN HEALTH-1:
•
1.30 pm-4.30
pm
•
Understanding dimensions of quality,
tools of quality assurance, standards
Lecture
Quality improvement programs, quality
Discussion
circle and accreditations
•
Balancing quality and equity_________
Day Eleven
I QUALITY IN HEALTH -2:
10 am -1 pm
•
X'
Understanding current standards Reviewing Indian Public Health Standards
(NHM) with exercises
-
___
National Accreditation Board for
1.30 pm -4.30
Hospital standards
pm
Understanding standards under
Review and exercises
Clinical Establishments Act
Day Twelve
10 am -1 pm
Case
Review and exercises
Discussion
of
sterilisation
deaths
in
Chhattisgarh and exploring the compromise in
52
all the five values- Right to Health, Equity
in
Health., Gender equality, Ethics and Integrity,
Quality in public health
_______________
Day Thirteen
Seminar based on journal articles on all the
10 am-4.30
pm
values. Each student will be allotted one article.
Session l(Values: Philosophy, relevance and
guidelines)
Presentation of one
paper each by the
students
Day Fourteen
10 am -1 pm
Summative Assessment- Written test with short
questions and case scenarios
7. LEARNING RESOURCE MATERIAL
I. Exercises and journal club
a. Values Exercise
i. World Health Organization. Alma Ata Declaration. Geneva World Health
Organ.
1978.
Available
at:
www.who.int/publications/almaata_declaration_en.pdf
ii. National Health Policy-2002. Government of India. Available at:
http://mohfw.nic. in/showfile.php?lid=2325
iii. People’s Charter for Health. Peoples Health Movement. Available at:
http://www.phmovement.org/en/resources
iv. A Promise of Better Healthcare Service for the Poor. National Rural
Health Mission. Ministry of Health and Family Welfare. Government of
IndiaAvailable
at:
Www.chsj.org/uploads/1/0/2/1/10215849/entitlement english.pdf
b. Review Exercise for Rights
i. The Universal Declaration of Human Rights. Available at:
http://www.un.org/en/documents/udhr/
ii. International Covenant on Economic, Social and Cultural Rights.
Available
at.
http://www.ohchr.org/en/professionalinterest/pages/cescr.aspx
c. Understanding current standards
i. Indian Public Health Standards. Available at:
J,
http://nrhm.gov.in/nhm/nrhm/guidelines/indian-public-healthstandards.html
ii. National Accreditation Board for Hospitals & Healthcare Providers - See
more • http://www.nabh.co/Index.aspx#sthash.MuMqHOFw.dpuf
iii. Draft Minimum Standards. The Clinical Establishments (Registration and
Regulation) Act, 2010. Available at:
http://clinicalestablishments.nic.in/cms/Home.aspx
d. For Journal Club
i. Session l(Values: Philosophy, relevance and guidelines)
53
1. Stewart KA, Keusch GT, Kleinman A. Values and moral experience in
global health: Bridging the local and the global. Glob Public Health.
2010;5(2):l 15-21.
2. Jesani A, Barai T. Ethical guidelines for social science research in health.
Mumbai Centre for Enquiry into Health and Allied Themes. 2000
3. Mann JM, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineberg HV.
Health and human rights. Health Hum Rights. 1994;6—23
ii. Session 2(Values: Evidence gathering and analysis)
4. Babu GR, TN S, Bhan A, Lakshmi JK, Kishore M. An appraisal of the
tuberculosis programme in India using an ethics framework. Indian J
Med Ethics.2014;ll(l):12-15
5. Subramanian S, Nandy S, Irving M, Gordon D, Lambert H, Smith GD.
The mortality divide in India: the differential contributions of gender,
caste, and standard of living abross the life course. Am J Public Health.
2006;96(5):818.
"
6. Roy T, Kulkami S, Vaidehi Y. Social inequalities in health and nutrition
in selected states. Econ Polit Wkly. 2004;677-83.
II. Basic Reading
a. Values(General)
i. Public Health Management at District Level - Concepts and Values. A
hand out from the project on “Integrated management of public health
programnles at district level. SOCHARA-SEARO
ii. Issues of concern and an agenda for action. Towards Equity, Quality
and Integrity in Health: Final Report of the Taskforce on Health &
Family Welfare. Government of Karnataka; 200T.xv-xxiv
iii. Macinko J, Montenegro H, Nebot Adell C, Etienne C. Renewing
primary health care in the Americas. Revista Panamericana de Salud
Publica. 2007
b. Right to Health
i. Shukla A. The Rights Approach to Health and Health Care- A
Compiled Review. MASUM Publications; 2007
ii. London L. What is a human rights-based approach to health and does it
matter? Health Hum Rights. 2008;10(l):65-80
c. Equity and health
i. Feachem RG. Poverty and inequity: a proper focus for the new century.
Bull World Health Organ. 2000;78(l):l-2.
ii. Anand S. The concern for equity in health. J Epidemiol Community
Health. 2002;56(7):485.
iii. Braveman P, Gruskin S. Defining equity in health. J Epidemiol
Community Health. 2003;57(4):254-8.
iv. Global Equity Gauge Alliance, Concepts and Definitions, Available
from http://www.gega.org.za/concepts.php
d. Gender and health
54
' Storgri9C98?en<ler
G'"»a World
heal,h: TeChnical
ISr? LG“to “d pow“issuesmedical education. Gender and
Material Ed^Je” ; R!port ,of National Consultation and Background
...
2^ “■ C“' f“
I
perepec,ives ” ,he
I
in“^
e.
Ethics/integrity and health
i.
ii.
SktZVCt
2»6
** E“‘°
iii.
Human Participants.
iv.
f.
Quality in health
i- Quality concepts and tools,
Quality and accreditation in health care
services: a global review.
World Health Organization, Geneva:
2003;51-102
ii. Gupta JP and Sood /”
AK. Quality of Care in Contemporary Public
Health: Policy, Planning, M;
Management. Apothecaries Foundation: New
Delhi, 2005: 2.57-2.61
iii- Richard KS. Quality Assurance and i
Quality Improvement in Public
Health and Preventive Medicine. T'
Eds: Rober Wallace. McGraw Hill
Medical: New York, 2008: 1277- 1280
HI. Additional Reading
a. Values(General)
i. Confronting Commercialization < ~ ’
of Health Care! Towards the Peoples
----- 1 Committee, Jan
s“sSron-5 Na,i”ai
*"■ - ««-
^^S^^T,dAlhVal
'!eiandGlobal
moral public health.C
2010;5(2):l 15-21.
b. Right to Health
'■ HeZ,M;
L' Grasldn s’ Brennan T-
Z. Ftarterg HV
Healthand human rights. Health Hum Rights. 1994'6-23
8
'
W°rking Group’ P^icims f” n™
Health Care DualY
SCh°01 °f Publ'C Health’ Primary
Care. Dua! |oyaity & llumm rjghts
J
55
practice: proposed guidelines & institutional mechanisms. Physicians for
Human Rights; 2002.
iii. The assessment of the Right to Health and Healthcare at the country
level. A People’s Health Movement Guide; 2006
c. Equity and health
1. Sen G, Iyer A, George A. Structural reforms and health equity: a
comparison of NSS surveys, 1986-87 and 1995-96. Econ Polit Wkly.
2002;1342-52.
ii. Sen A. Why health equity? Health Econ. 2002;! 1 (8):659-66.
iii. Gupta I, Datta A. Inequities in health and health care in India: can the
poor hope for a respite. Inst Econ Growth: Delhi Univ. 2003
iv. Schuftan C. Poverty and inequity in the era of globalization: our need to
change and to re-conceptualize. Int J Equity Health. 2003;2(l):4.
v. Roy T, Kulkami S, Vaidehi Y. Social inequalities in health and nutrition
in selected states. Econ Polit Wkly. 2004;677-83.
vi. Srinivasan K, Mohanty S. Deprivation of basic amenities by caste and
religion: Empirical study using NFHS data. Econ Polit Wkly. 2004;72835.
vii. Dilip T. Extent of inequity in access to health care services in India. Rev
Health Care India. 2005,247-68.
viii. Subramanian S, Nandy S, Irving M, Gordon D, Lambert H, Smith GD.
The mortality divide in India: the differential contributions of gender,
caste, and standard of living across the life course. Am J Public Health.
2006;96(5):818.
ix. Subramanian S, Kawachi 1, Smith GD. Income inequality and the double
burden of under-and overnutrition in India. J Epidemiol Community
Health. 2007;61(9):802-9.
x. Linares-Pereza N, Lopez-Arellano O. Health equity: conceptual models,
essential aspects and the perspective of collective health. Soc Med.
2008;3(3): 194-206.
d. Gender and health
i. Garcia-Moreno C. Gender and health: Technical Paper. Geneva World
Health Organ. 1998;
ii. Narayan T. Gender and power issues in medical education. Gender and
Medical Education : Report of National Consultation and Background
Material. Eds: Jesani A and Neha M. Centre for Enquiry into Health and
Allied Themes, Mumbai: 2002
iii. World Health Organization. Integrating gender perspectives in the work
of WHO: WHO Gender Policy. 2002;
iv. Gaitonde R. Community medicine: incorporating gender sensitivity.
Econ Polit Wkly. 2005; 1887-92
e. Ethics/integrity and health
i. Francis CM. Medical Ethics. New Delhi: Jaypee Publications; 1993
ii. Teaching of medical ethics in Undergraduate Medical Education.
Proceedings of Workshop. Bangalore: RGUHS; 1999
iii. Indian Journal of Medical Ethics
56
%
7.2 SOCIO-CULTURAL AND COMMUNITY HEALTH
COMPETENCY-1
(5 Credits, 3 Weeks Teaching Learning)
SOCIO-CULTURAL AND COMMUNITY HEALTH COMPETENCY^
• Lectures and lecture discussions
• Social Determinants of Health
• Social and behavioral sciences
• Case studies
• Health economics
• Visits */Postings/ Study /Internship
to district and community level
• Anthropological perspectives in health
centers to explore social determinants
• Political economy of health
• Community empowerment skill
training
' Source: RGUHS - MPH (Hons)
Regulations and Curriculum (2014)
1. GENERAL OBJECTIVES - (COURSE DESCRIPTION):
Students in this competency would be exposed to alternative paradigms in
addressing issues of health and health care. They would learn to appreciate how
health and ill health are produced at the intersections between biology, culture,
politics and society and why perspectives other than the biomedicine are needed'
to address the complexity of health, diseases and health system management.
They would learn core concepts and theories in community health and learn the
scope and challenges in building healthy communities.
2. SPECIFIC OBJECTIVES - (LEARNING OUTCOMES):
a. Develop sensitivity to the need for plural perspectives, more specifically
the contributions of social sciences to public health
b. Develop a critical and deeper understanding of notions of ‘culture’,
‘power’ and ‘actors’ as these shape the domain of health, health systems
and its management
c. Ability to examine the social, cultural, economic and political
determinants of health in order to develop strategies to improve the
health of communities and populations
d. Acquire skills in engaging with different kinds of data - visual text,
narratives, ethnography
i
3. CONTENT/LEARNING METHODS/ORGANISATION
(INTEGRATED):
i.
WEEK 1; SOCIAL AND CULTURAL CONTEXT OF HEALTH
AND ILLNESS
In this week, students would develop a deeper understanding of the contributions
of social sciences, more specifically, Sociology, Anthropology, Economics and
Political Science to understand the social, cultural, economic and political context
of health and health care. They would learn about how to approach the complex
reality of health and diseases in society. This would involve a discussion of what
57
ome of the analytical
* I
Community
Ecological
followed
the tiwil5 of a J “XC‘ *’ca/,- th■ e fhrn
. fife •V«^XSn/AIDS •X*’^Atrt
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•YestertoV m(“ ,a ,onth African m>ncs. B“'a
■»*•*
succinctly c P
. c« st"*
“nd
e workers, disease r
al to.usehold level,
slices at community
treatment and the role ot
future for the
SW' (ta<fa) 'n St"'la Z” ' E
I
SoMV OF HEALTH
ii.
•
„^a
tas this
s"“i’"'Sde °X S social and F0'1"'^““S” to understand
During lear” "t ?^ -old loam *■«
Je. education as
global level
■ lto such in«l>»M •™ ’
s like gender, cast ,
lhe
that
explain
rial
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natural nor
’h tr.me«ork <200 >
SOL-
determinants of health
Determinants o
contributed to
have ^n on
WHO Co""*7“ “Xtors and jesses that
«£
recent ,ack the role of dif
d locai level •. . The
& Vmcaf
and unp. . al global, nation
ally
social
would essenU
essentially
health inequities
social determman s
examine
exarnine actions
uunderstanding —-h Students would be ta u
Qf
;nter
nauonal,
studies at intern;
nUeaUhthroogbspeeirtc cases..
economy appmncl
determinants c.
local levels.
^esovtk^g/lea^ng
58
Field visits and writing health diaries. Students would be divided in groups.
They would visit different communities and prepare health diaries based on
household and community experiences of illness, seeking care, managing
chronic illness if any, barriers faced identifying these at different levels
(household, community, health system). These dairies would be presented in
the class for discussion.
• Field visits would also involve observations of Health and Nutrition Days as
part of inter-sectoral actions within the NRHM.
• Facilitating class debates on specific actions on social determinants of health
undertaken in key select sites.
• Group work based on case scenarios (eg: infant mortality, diabetes, maternal
health) identifying social determinants of health and possible actions (what,
whp, where) that could be taken to intervene in these determinants.
•
iii.
WEEK 3: HEALTH ECONOMICS AND HEALTH SYSTEM
FINANCING
During this week, students would learn about key principles of health economics
in terms of the role of the state, market and community in health care provision.
These will be discussed in the philosophical debates about theories of social
justice and health, health equity and role of the state. Topics on health spending in
India and other countries, out of pocket expenditure, need, demand and supply of
health care, economic rationale for government interventions, subsidies, public
provision, cash transfer schemes, performance based financing would be
discussed. Students would learn the larger economic and political context within
which provision of health care is placed. They would be equipped with skills to
evaluate different health financing measures as part of health systems reforms in
different countries.
MODES OF TEACHING
• Lectures followed by discussion
• Film ‘Sicko’ on insurance in US followed by discussion
4. ASSESSMENT
d. Formative Assessment- based on participation in group discussions and
critical reading sessions
e. Summative- Written test with short questions and case scenarios
5. EVALUATION
Participants will evaluate the sessions and programs of the above module,
especially regarding the topics, quality of content, delivery of content and assessment
6. LEARNING RESOURCES MATERIALS
•
i. WEEK ONE:
Cecil Helman Culture, Health and Illness (Fifth Edition). Chapters 5 and 15
59
Nichter, Mark (2003) Smoking: What does culture have to do with it?
Addiction, 98: 139-145
• Austin, La Toya T et al (2002) Breast and cervical cancer screening in
Hispanic Women; A literature review using a health belief model, Women s
Health Issues, Vol. 12(3): 1-7
• Arthur Kleinman, Leon Isenberg and Byron Good 1978 Culture, illness and
care: Lessons from Anthropologic and cross-cultural research, Ann Internal
Medicine 88 (2): 251-258
• Gilson, Lucy et al (2011) Building the field of health policy and systems
research: Social Science matters, PLoS Medicine, 8 (8)
• NIH (2005) Theory at a glance: A Guide for Health Promotion Practice (2n
•
edition) select chapters
*
ii. WEEKTWO^
• James Hargreaves et al (2011) The social determinants of tuberculosis: Fiom
Evidence to Action, American Journal of Public Health, 101: 654-662
• Iyer, Aditi, Asha George and Gita Sen (2007) Systematic hierarchies and
systematic failures. Economic and Political Weekly, Vol. XL1I (8)
• Marmot M. Social detenninants of health inequalities. Lancet 2005: 365:
1099-1014.
• WHO (2008) Closing the gap in a generation: Health equity through action
on social determinants of health. Geneva: World Health Organization
http:/www.who.int/social_determinants/the
commission/final
report/en/index.html (Executive Summary)
• Erik Blas et al (2008) Addressing social determinants of health inequities:
What can the state and civil society do? The Lancet 372: 1684-1689
• Paul Farmer et al (2006) Structural violence and clinical medicine, PLoS
Medicine, 3(10): 1-6
Sabrina T. Wong et al (2011) Enhancing measurement of primary health care
indicators using an equity lens: An Ethnographic study, International join nal
•
I
for equity in health, 10: 1-12
• Minkler, M., Wallace SP and McDonald, M (1994) The political economy of
health: A useful theoretical tool for health education practice. International
Quarterly for Community Health Education, 15(2): 111-126.
• Prasad, Amit Mohan et al (2013) Addressing the social determinants of health
through health system strengthening and social determinants of health: The
case of the Indian National Rural Health Mission, Global Health Action 6. 1-
•
11
The physician as public health professional in the 21st century. JAMA 2008,
300 (24):2916-2918.
iii. WEEK THREE
60
Culyer AJ and JP Newhouse (eds.) (2000): Handbook of Health Economics
(Volume 1), Elsevier Science. (Chapter 2: An overview of the normative
economics of the health sector by Jeremiah Herley, pp. 55-118.)
• Lagarde, Mylene, Haines Andy and Palmer, Natasha (2007) Conditional cash
transfers for improving uptake of health interventions in low and middle
income countries: A systematic Review, JAMA, Vol. 298 (8)
• Cutler, David M. and Jonathan Gruber (1996) ’’Does Public Insurance Crowd
Out Private Insurance?” The Quarterly Journal of Economics, 111 (2): 391430
• M. GovindaRao & Choudhury, Mita, (2012) Health Care Financing Reforms
in India, Working Paper, 12/100, National Institute of Public Finance and
Policy, New Delhi 1
:r..
• World Bank (1993)' World Development Report 1993: Investing in Health,
Oxford University Press. (Chapter 3: The roles of the government and market
in health).
•
SOCIO-CULTURAL AND COMMUNITY HEALTH
COMPETENCY-II
SOCIO-CULTURAL AND COMMUNITY HEALTH COMPETENCY-II
• Lectures and lecture discussions
• Communitisation: community needs
assessment, community participation
• Case studies
and working with community
• Visits */Postings/ Study to district
and community level centers to
• Social exclusion and Vulnerable
explore social determinants
groups- working child, elderly, people
with disabilities, Dalit and Adivasi,
• Community empowerment skill
sexual minorities
training (During internship)
• Community action on Social
Source: RGUHS - MPH (Hons)
determinants
Regulations and Curriculum (2014)
• Community mental health
• Foundations of Social Care Policy
(5 Credits, 3 Weeks Teaching Learning)
1. GENERAL OB JECTIVES
i
a. To understand the principles of Communitisation: community
needs assessment, community participation and working with
community
b. To understand the concept of social exclusion, marginalization and
vulnerability and health related challenges with focus on specific
groups
c. To be oriented towards community action on social determinants
including social exclusion and vulnerability'
d. To understand community mental health and community
responses
e. To be oriented towards Social Care Policy and its key component
as part of public health policy
61
2. SPECIFIC OBJECTIVES
a. To be able to perform community needs assessment and mobilise
communities for monitoring and action
b. To understand the concept of social exclusion, marginalization and
vulnerability and health related challenges with focus on
i. working child,
ii. elderly,
iii. people with disabilities,
iv. Dalit
v. Adivasi,
vi. sexual minorities
c. To explore the basic principles and axioms of community health
action with a focus on social determinants;
d. To explore the challenges of mental health at the community level
and evolve responses at both community and primary health care
system levels
e. To be conversant with all social care policies and actions that
affect health and well-being, and explore convergence health and
social policy
3. CONTENTS
•
CommunitisationCommunity needs assessment
Community monitoring
- Mobilising Community participation
- Community action for health
• Social exclusion and Vulnerable groups
Working child
Elderly
People with disabilities
- Dalit
Adivasi
Sexual minorities
• Community action on Social determinants
- Improving basic needs and living conditions
- Fair employment and decent work
Social protection across the life course
Tackling inequalities of power, money and resources
Political empowerment- inclusion and voice
Measurement of problems and measuring impacts of action
• Community mental health
Mental Health Situation in India: The Challenges
Recognition of The Rights of Persons with Mental Illness
National Responses to Mental Health Challenges
o National Mental Health Programme
o Community-Level Mental Health Services Including Family
Support
62
•
o Traditional Responses to Mental Health
Human Resource Development, Training And Resreach
- The Evolving new Mental Health Policy
Foundations of Social Care Policy
- Legislation
- Social Insurance
Social Care Policy and Support
- Community based action
4. LEARNING METHODS
a. Lecture discussions
b. Case Studies- ICMR Monographs, ANUBHAV Series and others
c. Community visits and interactions with NGO’s, PHC teams involved
in community action
d. Interactive visits to NGO’s and government programmes involved with
socially excluded and vulnerable groups
e. Interactive visits to NGO’s and government programmes involved with
mental health
f. Journal clubs and seminars
g. Simulation games like Monsoons and Chikkanahalli
5. ORGANISATION
a. Communitisation- 2 days
b. Social exclusion and Vulnerable groups- 5 days (including field visit)
c. Community action on Social determinants- 5 days (including field
visit)
d. Community mental health- 4 days (including field visit)
e. Foundations of Social Care Policy- 2 days
6. ASSESSMENT
a. Formative Assessment- based on participation in group discussions and
critical reading sessions
b. Summative- Written test with short questions and case scenarios
7. EVALUATION
Participants will evaluate the sessions and programs of the above module,
especially regarding the topics, quality of content, delivery of content and
assessment
8. RESOURCE MATERIALS (Being prepared)
63
7.3 PLURAL HEALTH SYSTEMS COMPETENCY
(5 CREDITS, 3 WEEKS TEACHING LEARNING)
______________ PLURAL HEALTH SYSTEMS COMPETENCY
• Lectures and lecture discussions
• Plural public health systems
• Visits */Postings/ Study
• Local health traditions
/Internship to district and
• Local healers and
community level centres where
• Alternative systems of healthcare
AYUSH staff are located
(AYUSH/TCAM)
• Interactions with local healers,
• Mainstreaming AYUSH in public health
AYUSH doctors and AYUSH
• Trans disciplinary research- an
institutions including department
introduction
of AYUSH and I-AIM ' .- f"
Source: RGUHS - MPH (Hons)
I Regulations and Curriculum (2014)
1. GENERAL OBJECTIVE
• To understand the potential of Plural Health systems
• To understand the plurality within the health systems and
approaches for community health/ public health through plural
health systems
2. SPECIFIC OBJECTIVES
To explore the plural options, and opportunities in the public
health systems and services in India(AYUSH), Japan, Sri Lanka,
•
China
To explore the availability, access, content and process of health
care through local health traditions (LHTs) and all other Indian
Systems of Medicine and Homeopathy in the country (AYUSH)
. To understand the role of LHTs and AYUSH in primary health
.
care and Universal health coverage
• To explore the Public Health policy development and challenges in
evolving and sustaining a plural health policy and systems
• To explore the intercultural aspects and challenges of health
seeking and health care in a pluralistic health system
3. CONTENTS
The contents of the above module are as follows:
i.
Introduction to Plural Health Systems
• Plural Health systems an overview
• Understanding Plurality within health systems
• Mapping Plural Health systems in India and selected othei
ii.
countries
Culture, health and disease/illncss
• Concepts of medical anthropology relating to pluralism and public
health such as
i. Intercultural aspects of knowledge systems
64
Epistemology
Inter/trans disciplinarily
Hierarchical pluralism
Medical absorption
Other concepts in pluralisms such as romanticism,
syncretism, co-evolution, complematarity, integration
Understanding the role of Local health traditions and Local healers
iii.
including traditional birth attendants
• Community based Oral Health traditions in rural India
• Contemporary History of community based oral health traditions
• Local Health traditions and AYUSH
• Mapping Local Health Traditions in India
• Our living Medical heritage; Examples of successful local healers
• Documenting Local health Traditions
• A participatory approach in assessing health traditions
• Community health registers
• Community role of Indigenous healers
• Validity of documentation and assessments
• Health at our door steps: Home herbal garden
iv.
Ecosystems and health
• Traditional medicine and efforts to medicinal plant conservation,
• Protection of traditional knowledge,
• Relevance biodiversity and ecosystem services in health and
wellbeing including therapeutic landscapes
v.
Understanding the principles and practice and public health
contributions of Alternative health care Systems (Ayurveda, Yoga,
Unani, Siddha, Sow-rigpa and Homeopathy)
• Introduction to Ayurveda: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Unani: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Siddha: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Sow- rigpa: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Yoga: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Naturopathy: History, Concepts, Principles, current
infrastructure and practice
• Introduction to Homeopathy: History, Concepts, Principles, current
infrastructure and practice
vi.
Policy options and challenges in regulating and mainstreaming LHT
and AYUSH in primary health care and public health systems
towards a national Integrated Health Mission
• Medical pluralism from a multilevel perspective including WHO
policies, national policies as well as policy practice linkages
ii.
iii.
iv.
v.
vi.
65
• What is Mainstreaming AYUSH in Public Health
• Integrating Traditional Medicine into Modern Health Care Systems
• The Indian Health Care System & the Diversity of Traditional
Medicine in India
• Status and Role of AYUSH in Public Health and local health
traditions Under NRHM
• Role of traditional medicines in primary health care
vii.
Perspectives and principles of Trans-Disciplinary Research in the
context of pluralistic health systems
4. LEARNING METHODS
The learning-teaching methods shall include lectures/ presentations, lecture
discussions, demonstrations, case studies, visits, interactions with local
healers, AYUSH doctors, AYUSH institutions including Department of
AYUSH and Institute of Ayurveda and Integrative Medicine and postings,
internship to district arid community level AYUSH clinics and health centres
and NGOs Integrating AYUSH in their services:
1. Lectures
2. Case studies
3. Journal clubs
4. Group work: Plural health systems and Public Health - Check Lists.
5. Panel Discussion: Public Health Systemic Challenges to integrate local
health traditions and AYUSH (practitioners and Policy makers)
6. Visit to AYUSH Directorate, 1-AIM- (A short report to be submitted about
the learnings from the visit)
...
7. Visit to a AYUSH co-located PHCs- (A short report to be submitted about
the learnings from the visit)
8. Internship to district and community level AYUSH clinics and health
centres and NGOs Integrating AYUSH in their services (during internship
phase)
5. ORGANISATION
Day 1; Introduction to Plural Health Systems,
Days 2: Culture, Health and Disease___________ __________ ___________ _____
Day3 - day 5: Understanding the role of Herbal medicines, Local health
traditions and Local healers including traditional birth attendants.----------------Day 6 Visit to I-AIM/Any
7th day - Weekend
Day 8 to Day 13:_Alternative health care Systems
14th day - Weekend____________
Day 15 to Day 16: Mainstreaming AYUSH in Public Health
I Day 17:_Trans-Disciplinary Research
------------ ------Day 18 to Day 19: Visits, Interactions with local healers, AYUSH doctors,
AYUSH institutions including Department of AYUSH and community level
AYUSH clinics and health centres
_
66
7•
Day 20: Evaluation
21st day-Weekend
6. ASSESSMENT
i.
ii.
iii.
Multiple choice questionnaire at the end of topics
Weekly assignments in topics covered under syllabus to be submitted by
the 4th day of every week.
At the end of the module, a written examination and viva voce will be
conducted on the 20th day of the module.
7. EVALUATION
The participants will evaluate the sessions and programs of the above module,
especially regarding the topics, quality of content, delivery of content and,- .assessment.
«
8. LEARNING RESOURCE MATERIAL
Must read:
1. Darshan Shankar, Unnikrishnan PM, (ed); Challenging the Indian
Medical Heritage , New Delhi, foundation Books, 2004.
2. Lokhare, M., Davar, BV., The community role of Indigenous Healers In
Sheikh, K, George, A.,Health providers in India on the front lines of
Change, New Delhi, Routledge, 161-181.2010
3. Unnikrishnan PM, lokesh kuamr HP, Darshan Shankar. Traditional
Orthopedic practitioners in Contemporary Health In Sheikh, K,
George, A.,Health providers in India on the front lines of Change, New
Delhi, Routledge, 182-199. 2010
4. Robert H. Bannerman, John Bruton, Ch’en Wen -Chieh, Traditional
Medicine and Health care Coverage A reader for Health
Administrators and practitioners, Geneva, World Heallth Organization,
1983.
Narayan
R, Mankad D, Medical Pluralism A case for Critical
5.
Attention, Medico Friend Circle Bulletin 155-156.
on traditional
6. Consensus statement -South Asian regional conference
medicine, 2006
7. Priya R, conceptualizing UAHC Bottom UP: implications for
Provisioning and financing. Medico Friend Circle Bulletin 2011; 345347; 15-27.
National
Health systems Resource Centre, Mainstreaming AYUSH and
8.
Revitalizing local health traditions under NRHM- a health systems
perspective.
9. Report by Shailaja Chandra on AYUSH and LHTs
10. Wujastyk, Dominik, Evolution Traditional Medicine Policy in India
11. AIFO Bangalore Seminar
12. Planning Commission 12th Plan AYUSH Steering Group
67
Additional Reading:
1. Introduction to Ayurveda by C. Dwarakanath and selected books, articles
from Amruth Heritage, Ancient Science of Life and journals i.e. Journal of
Ayurveda and Integrative Medicine
-J-'
68
t
CHLP NW 02092016
Background Paper-8
8. PUBLIC HEALTH SYSTEM IN KARNATAKA
8.1
A STATE PUBLIC HEALTH CHARTER
8.2
STRENGTHENING STATE PUBLIC HEALTH CAPACITY AND HRD (2013)
Towards a Community Oriented
Public Health System
in Karnataka
A
Mission Group on Public Health
Karnataka Jnana Aayoga
(Karnataka Knowledge Commission)
Government of Karnataka
www.jnanaayoga.in
...
<24 C A STATE PUBLIC HEALTH CHARTER
he Karnataka State Task Force on Health and Family Welfare considered the
following definition by the Association of Epidemiologists as the frame work
for public health system development.
"Public Health is one of the efforts organised by society to protect, promote and
restore people's health. It is the combination of services, skills and beliefs that are
directed to the maintenance and improvement of the health of all people through
collective or social actions. The programs, services and institutions involved
7'x'
emphasize the prevention of disease and the health needs of the population on the
whole. Public Health activities change with changing technology and social values,
but the goals remain the same; to reduce the amount of disease, premature death
and discomfort of diseases in the population"
The Task Force also emphasized the following principles when considering Public
Health System development in the State. These included:
1. State's primary responsibility for Health and Health Care
2. Recognizing the political economy of public health system development and
the challenge of access and universality
3. The challenge of Inter-sectoral action including safe water supply, sanitation
and nutrition
4. The
Primary
Health
Care
approach
to
infectious
disease
and
non-
communicable disease control
5. The focus on Equity and Social Justice in health and health care
6. The convergence of AYUSH, LHTs and the Public Health System
The Mission Group on Public Health endorsed the above definition and principles and
held many deliberations to evolve the following Public Health Charter:
The Public Health Charter for Karnataka
Building on the historic Public Health consciousness in the State which has been
neglected and distorted in recent years, the State has to evolve policies and
programs based on recommendations of the taskforce to cover the following
challenges and system development issues outlined in this Public Health Charter.
Through the Public Health Charter, the Karnataka State will continue to develop a
comprehensive, integrated Public Health System that will be committed to the
following values: Equity, Quality and Integrity emphasized by the earlier Taskforce
no
and Communitization, Pluralism, Gender Sensitivity and Accountability added by
the current Mission Group.
The existing system will be further strengthened by initiatives in the following six
dimensions:
1. Public Health - Capacity building
• The State will evolve and establish a Public Health Cadre to strengthen the
capacity of the health system particularly focusing on the district and
beyond.
03
ru
03
c
• The state will develop a HRD unit in Health Department which will
rationalize the functions, salaries, promotions and transfers and also focus
on capacity development and continuing education of all cadres.
k—
03
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4—>
• The State will promote a School of Public Health to strengthen public health
capacity and skills at all levels from district level health administrators to
ANM s and ASHA s. This will enhance the development of evidence based
policies, strengthen institutional capacities and human resources, promote
to
ro
health promotion, public health regulations and research towards the goal
for Health for All.
GJ
X
2. Public Health - Governance
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T3
(b
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o
• The State will evolve mechanisms of Accountability and Transparency in all
its public health programs and campaigns.
• The State will enhance governance and supervision of peripheral Public
Health care systems with a special focus on decentralization and partnership
with Panchayat Raj Institutions.
c:
3
E
E
o
o
ro
T5
i_
ro
• The State will promote community participation in all its programs and also
enhance the role of community in monitoring and providing feedback
through the Communitization process now evolved by the National Rural
Health Mission.
■
• To enhance outreach and access, within the public health system the State
in partnership with NGOs and private sector will promote values of equity,
social justice and strengthen the government's role towards 'Health for All'
without compromising the constitutional mandate and taking care to
prevent market distortions of such partnerships.
3. Public Health — Inter-sectoral action
• z-
• Nutrition: The State will tackle the increasing malnutrition challenges using
inter-sectoral and multi-disciplinary approaches that address the problem
from grass root level upwards by strengthening the public distribution
systems and food security, food and agricultural policy, anganwadi and
school feeding programs, individual and community nutrition education and
health promotion campaigns.
Safe water supply: The State will promoting safe water supply and
mechanisms to apply standards for water quality at all levels using
appropriate technology to enhance access and purification of water, while
preventing commercialization and commodification of water.
• Sanitation Campaigns:
> The State will support the recently announced Total Sanitation Abhiyan
and enhance promotion of sanitation with the focus on schools, meeting
halls, bus stands and public places even as individual house and
communities are encouraged to adapt sanitation systems.
> While promoting sanitation, the State will also take steps to:
* Abolish manual scavenging
- Strengthen measures to enhance the Health of Pourakarmikas
4. Public Health-Response to some current health system challenges
• The State will enhance access to Free Medicines for Primary Health Care
throughout the State by adopting an essential medicines list, rationalizing
logistics of medicine warehousing and distribution mechanisms, promoting
rational medicine prescribing and policy initiatives and tackling some of the
obstacles to universalizing access to medicines.
• The State will evolve an urban primary health charter that will focus on
multi-sectoral services integrated through a primary health care approach
focusing on women and children's health, violence against women. The
Charter should include access to basic health services, mental health and
other emerging urban health challenges.
• The State will adopt the newly announced national program for non-
communicable diseases and enhance the primary health care approach to
chronic diseases with focus on management and re-orientation of personnel,
providing support and upgrading services, improving HMIS, building new
partnerships and strengthening operational research.
-.7a'
• The State will enhance healthy life style promotion as part of the youth
ru
oriented policies of the State while simultaneously linking it to health
03
promotion and education against substance abuse.
CO
C2
i_
CO
c
5. Public Health - Promoting pluralism and Integration
• The State will evolve Accreditation and Certification System for local Health
Practitioners and Knowledgeable Women involving Universities such as
E
<!■
co
IGNOU to support Traditional /Community Knowledge Systems.
• The State will promote Public Health Orientation and Training for all AYUSH
X2
Health Personnel starting with government sector and later offering it to
ro
CD
X
private registered medical practitioners as well as including community
supported LH practitioners on voluntary basis.
• The State will strengthen Swasthya Vritta Programme presently being
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experimented in five districts and enlarge this program to cover the whole
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other system as well.
State gradually. It will also draw upon the health promoting traditions of
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• The State will strengthen Yoga awareness and skills through Health
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Promotion in School and college curriculum.
• The State will strengthen community health and knowledge practices
related to food and dietary practices using traditional knowledge and
practices for promoting healthy nutritional status.
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• The State will strengthen documentation of clinical outcomes in AYUSH
sector including LHTs at all levels by introducing a standardized system.
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6. Public health - Strengthening HMIS and Knowledge translation
• The State will further strengthen the Health Information system by
providing universal access to available information to all categories of users
by removing the present imbalance between providers and users.
• The State will adopt and enhance e-governance within public health system
at all levels.
• The State in collaboration of the Health Department and the evolving State
GIS platform Will enhance the development of an effective health GIS.
In conclusion, through the adoption of this six point. Public Health Charter,
committed to the above values, the State will enhance the capacity of the Public
Health System to handle the emerging health problems and challenges; enhance the
commitment
to
human
resource
development;
enhance
accountability,
decentralised government, communitization and strengthen the ability of the
existing system to deal with the new emerging challenges.
STRENGTHENING STATE PUBLIC HEALTH CAPACITY
AND HRD
Strengthening Public Health Capacity
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I uman Resource Development in Health and their public health orientation
1"“^ and capacity remain the biggest challenge of public health system
1 development in the State. The four major challenges of HRD are coverage,
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competence, motivation and governance. These challenges operate at all levels from
primary health centre to taluk hospitals and upwards and need responses that are
both standard management practice and out of the box solutions.
The three most important recommendations that the Mission Group would like to
propose the following:
> A Human Resource Development unit in the Health Department
> The formation of a Public Health Cadre and its expansion, continuing education
and sustainability
> Strengthening public health capacity and training at all levels including the
development of a State School of Public Health that will spearhead the capacity
building at all levels
The
first
two
recommendations
had
been
deliberated
upon
and
detail
recommendations had been made to the Health Department in the earlier phase of
the KJA.
The present Mission Group has focused specifically on public health capacity building
and recommends the following:
> A State School of Public Health
> Some general steps to strengthen public health capacity
A State School of Public health - A capacity building policy imperative
Karnataka State urgently needs a
path
breaking initiative to strengthen Primary
health
care
and
Public
Health
system
development in the State to address equity,
quality and integrity of health and health
care. Karnataka had a good practice of
appointing Public Health trained individuals
for Government Health Services. But oyer a
period of time, this mandatory requirement
was
dropped.
Health
professional
and
health officers must have a public health
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skills and capacities and for this all those in
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public health positions need to undergo a
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formal training in public health to get an
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insight and skills in the practice of public
health and
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capacity to strengthen the
systems and improve outcomes.
It is only
then that health services will be manned by
appropriately trained health professionals.
Recently on the recommendation of
the Knowledge Commission an
expert group has already reported
on the need for public health cadre
development and this welcome
development now needs an
important complimentary initiative
for urgent state intervention and
investment. This initiative is to focus
on the evolution and sustained
development of a range of Public
Health courses and educational
initiatives to strengthen the
capacities and public health skills of
the relevant health human power in
the State. A State School of Public
Health is therefore an urgent policy
imperative.
1. Towards multidisciplinary and multi-sectoral Public Health
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The
2001 and Integrated State Health Policy, 2003
disciplinary, and multi-sectoral
proposed to have a State School of Public Health
nature and challenges of public
in Karnataka. On the similar lines, Karnataka
health
Jnana Aayoga had already recommended a
collaborate
School of Public Health in Karnataka in its first
and
phase to cater to the needs of human resources
professional
development. The re-consitituted commission
bodies to make the school a
now wishes to re-endorse this path breaking
comprehensive learning centre
initiative for a "State School of Public Health" to
drawing upon the state's rich
address the specific public health training needs
institutional
of Karnataka.
resource network.
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inter
multi-disciplinary,
The Task Force on Health and Family Welfare,
this
other
School
with
should
Universities
multidisciplinary
institutions
and
and
educational
2. Structure
In addition to All India Institute of
Hygiene and Public Health which was
started before Indepedence and the
Achutha Menon Centre of Sri Chitra
which started in 1996, there has been
recently a new revival
of public
health education. In other states well
known educational institutional like
Since 2006 the Public Health Foundation
of India (PHFl) has already started four
Schools of Public Health one each at
Delhi, Hyderabad. Gandhinagar, and
Bhubaneshwar. Other schools have
been started by Indian Council of
Medical Research at NIC Chennai, NiCD
Delhi, and other centres.
TISS- Mumbai, CMC- Vellore etc have
also introduced public health courses. As part of this revival there is urgent need
for a
School of Public Health in Karnataka which
could be a governmental
initiative with a strong core public purpose supported by a network of partner
institutions and networks, but similar in focus and framework to these other
schools.
This School of Public Health would interact and build further on the State Institute
of Health and Family Welfare and the more recently created State Health Systems
Resource Centre, both of which are mandated to strengthen public health skills
and capacities and resources including policy research in the state. Based on the
Magadi Road Campus, these institutions already form a strong core of state
resources that can be creatively upgraded into a more well resourced and
comprehensive multidisciplinary School of Public Health.
3. Additional Features
• Campus: One alternative would be to creatively evolve the SOPH in the Magadi
road campus which has adequate land for the purpose. This has often been the
main constraining factor in many states.
Departments: Keeping in mind the core multidisciplinary nature of public
health, the school will need to develop core expertise in:
> Public health planning and management,
> Epidemiology & bio statistics,
> Social and
population sciences (Sociology, Social Work, Anthropology,
Demography)
Health information and communication systems including IT for health
> Environmental and occupational health,
> Health policy and health systems (including economics)
This core expertise will be in-house resource and will also draw upon additional
human resources from a supportive network of institutions already available in
the city of Bangalore.
• University affiliations & Accreditation of courses: To be negotiated with
RGUHS and or later with any National autonomous University or accrediting
body. RGUHS has recently created a new unit of Public Health in the University
campus.
• Financial Support:
An initial Corpus fund should7 be provided by the State
supplemented by funds for training from all existing national and state health
programs. In addition, in keeping with the importance of public health systems
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research the State should also consider a basic core research endowment to
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enhance this evidence gathering and policy development aspect of the SOPH.
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4. Governance
A governing body of Advisory and Resource persons drawn from multi disciplinary
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and multi-sectoral backgrounds who are already contributing to Public Health
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system development in the State and/or Country should be formed to support the
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growth and development of the institution.
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5. Bench Marking
An Academic Research Council to set benchmarks for SOPH at all levels and
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resource network that can be brought in to enhance the training/teaching
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resources. This should include mission and objectives; curriculum models and
competencies;
instructional
methods;
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composition
and
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methodology, admission policy; student support and counseling; pedagogy
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public
duration;
health
faculty
position
and
curriculum
recruitment,
structure,
assessment
expertise; exchange with other educational institutions; student performance;
interaction of health sector and continuous renewal of the school.
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6. Technical Resources
The State including Bengaluru already has the stronger cluster of Public Health
Institutions and multi-disciplinary hubs that are already involved on State and
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National level in public health system development and policy advocacy. These
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include NIMHANS, KACH, SOCHARA, IPH, IHMRJIM, NLSUI, ISEC and so many
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others already supporting national activities like NRHM, NHSRC, PHFI and NIHFW.
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Drawing upon these resources through a network would be the most cost
effective and realistic way to evolve this SOPH.
7. Educational and IT Technology
In keeping with the latest developments in educational and IT technology a
planned continuing medical education program for all cadres of public health staff
at all levels should be operational using distant learning, methods and modules,
and supplemented by contact workshops and telemedicine so that all parts of the
State can be reached through a decentralized and disperse network, enhancing
accessibility of training and human resource development.
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8. Courses and Training Programmes
WHO has recommended that Schools of Public Health in the region should focus
on the following:
• Post -basic and post graduate training for public health professionals
• Pre-service training for public health workers
• Public health content in pre-service training of other health workers
• In service training of health workers
• Continuing education of public health workers and
• Public health content in the training of workers in related sectors.
Based on the recommendations of the Task force and various expert groups over the
years, the School of Public Health would be involved in:
> Public Health (Short certificate course)
A 3 month induction course in Public Health for PHC Medical Officers, Dental
Surgeons, Public Health Nurses and AYUSH Physicians posted in co-located
Public Health Services in the State
> Public Health Management (PG Diploma)
A one year or 6 months crash Public Health program and induction training for
existing and or newly appointed District Level Medical Officers on the lines of
the present NRHM linked PG Diploma in Public Health Management
(PGDPHM). Already the State is sending such candidates to different
institutions in other states but the SOPH could start a similar course and
greatly enhance learning opportunities and career development in the State.
> Public Health Masters programe
A Two year MPH Program for Doctors, Nurses, Dental Surgeons and AYUSH
Physicians before they are appointed as District MOs or even at CHCs or
before promotion to higher levels of public health technical /administrative
responsibilities.
> Public Health: Special Courses
Focused Public Health Training programmes for special groups that can
supplement the public health cadre derived from bio-medical backgrounds. To
begin with this could include the following:
„
a. Public Health Engineers-Young engineers trained for a Masters in Public
health engineering
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b. Health Promoters-Young social scientist trained for a Masters in Health
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promotion and advocacy
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> Public Health : Induction orientation courses
Shorter Public Health Oriented capacity building courses for PHC team
members including Public Health Nurses, ANM's, Aanganwadi workers and
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ASHAs and operationalised through TOTs for staff of the numerous Health
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Training centres in the State. If this is based on incremental modules then they
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can also be linked into a step ladder type, career enhancement initiative.
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> Strengthening Public Health Consciousness: Public Health modules in other
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disciplines
.
...
The SOPH would ultimately also dialogue with other academic d.sciplmes like
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social and behavioral sciences, social work, law, management, engineering
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agriculture, environment, journalism, and evolve Public Health oriente
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modules to supplement the teachings in those disciplines and enhance the
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overall Public health consciousness in the State and in academia and researc
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Simultaneously the SOPH would also work closely with the PSM/ com™r"'tY
medicine departments of medical colleges, nursing,
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dentistry, AYUSH
institutions and enhance the multidisciplinary public health competence o
the under graduates from this institutions which will ultimately feed into
many considering post graduate opportunities in public health. A modu e is
also required for clinicians to orient them in all public health aspects.
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9. Competency based Skill Development
Public Health capacity building is increasingly becoming competency based skill
development with increasing focus on how to do rather than only what and why.
Last year the Ministry of Health along with IPHA, WHO India Office and many
other public health resource groups evolved a set of 24 competencies relevant to
the Indian situation and evolved a table of the level of this competency to be
taught at DPH; MPH; MHA; and MD levels. The State school of public health could
use this frame work as a background and evolve training needs and frame work
for each category of public health worker. The competencies are outlined below.
BOX-1
COMPETENCIES IN PUBLIC HEALTH RELEVANT TO THE INDIAN SCENARIO:
CORE
1. Health Planning
2. Epidemiological Skills,
3. Family and Community diagnosis
4. Health Management including Financial Management
5. Managing and Implementing Health Programmes
6. Monitoring and Evaluation including health surveillance
7. Health Promotion including prevention and protection.
8. Training and Capacity Building
9. Research including Bio Statistics and demography
10. Working with community including communitization.
11. Building Partnership and Network
12. Public Health Law and Ethics
13. Public Health Biology
14. Environmental Health.
15. Socio cultural competency including SEPC analysis
16. Health Policy and advocacy
CROSS CUTTING:
17. Critical analysis and systems thinking including problem solving
18. Leadership
19. Communications including informatics.
20. Lifelong learning
21. Equity
22. Human Resources Development
23. Governance and decentralization
24. Conflict resolution.
10.
Research
There is an urgent need to support the public health policy and system
development in the state through multidisciplinary research that should include
focus on:
• Socio epidemiological research
• Health system research
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• Health policy research
• Health economics
• Health impact assessment
• Health policy advocacy and knowledge translation
This will enhance public health policy and system development in the State based
on evidence rather than just expert opinion. This is a major lacuna in public health
system development in the Country and the State School of Public Health should
invest strongly in this dimension of learning activity to enhance sustainable and
relevant public health development in the State. Research projects could be
introduced to enhance partnership with other research and training institutions
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interested and involved in public health.
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Strengthening Public Health Capacity: some additional initiatives
At the stakeholders' consultation a small sub-group deliberated on public health
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capacity building focusing on additional initiatives other than the school of public
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health.
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1. Basic orientation and exposure to public health: All persons involved in the
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delivery of health care and health services at various levels (right from ASHAs to
Medical Officers) should at least have a basic orientation to and awareness of the
concept and practice of public health. They must be made aware of their place in
the public health system and the specific role they are expected to execute.
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2. Training and capacity building: Apart from the basic orientation, all personnel
within the health system must be equipped with the necessary knowledge and
skills to handle the public health functions at their respective levels and make
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them fit for purpose. We need a knowledge (formal/informal, accredited/non-
accredited) skills matrix to define these competencies and assist in the training
and capacity building of the public health cadre.
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3. Infusion of trained public health professionals: Public health must be made more
broad-based. The public health cadre should include the existing health workforce
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(equipped with public health training) as well as the emerging class of qualified
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and trained public health professionals to fill in the current deficit in capacity for
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planning and execution of public health activities. A major challenge in this regard
will be to overcome the inherent tensions between the entrenched medical
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fraternity within the establishment and new public health professionals entering
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the system, especially when the latter may be better equipped for certain public
health roles. Ways to bridge traditional boundaries and promote joint efforts will
have to be found.
4. Interdepartmental convergence: Current approaches to public health are
disjointed and lack functional linkages between the relevant government
departments concerned with public health, viz. between the Departments of
Health and Family Welfare Services, Women and Child Development, Medical
Education, Public Works etc. This is a major issue since public health is essentially
interdisciplinary.
Interdepartmental
convergence
is
essential
for
comprehensive approach to public health.
a ; more
. .
The following recommendations were made:
> Develop a separate training cadre for building public health capacity in the
state. Set up a faculty development programme to upgrade the training skills in
both the state and regional training institutes
> Training needs assessment and curriculum development for all health cadres
(especially for frontline health workers)
> Clear policies for graded capacity building and career advancement
> Develop district public health cadres to facilitate faster promotions and better
career advancement.
> Health supervisor training, mentoring and supportive supervision for frontline
health workers (particularly LHVs)
> Short term (one month) management training courses for Taluka Health
Officers
> Clearly define and establish operational roles and responsibilities for AYUSH
doctors in the health system.
> Capacity building for AYUSH doctors for public health roles with a strong focus
on national health programmes (possibly a three month training at induction
and continual in-service training)
> Public health training for at least one faculty member in each AYUSH medical
institute with relevant job roles, incentives and career opportunities
> Develop the
public health curriculum in medical (AYUSH/non-AYUSH)/
paramedical education (e.g. a one month NRHM module)
> Cross-pollination between persons involved with medical education and those
providing health services:
a. Compulsory postings for postgraduate medical trainees in preventive and
social medicine (six months) and those in other specialities like obstetrics
and gynaecology, surgery and general medicine (three months) in PHCs,
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CHCs and District Health Offices
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b. Systematically involve persons engaged in the delivery of public health
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services at various levels as resource persons or faculty in medical education
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programmes
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> Public health capacity building for private family/general practitioners and their
involvement in public health programmes/activities
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A healthy human resource policy must continually balance the need
for functional health teams at primary, secondary and tertiary levels
of health care and also facilitate a judicious mix of public health
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practitioners and clinical practitioners and specialists. The problem
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of non-availability and uneven distribution of skilled health care
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providers is the central challenge to meeting our health goals
Source: Annual Report to the People on Health, Gol, September, 2010
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