Four types of structures and frameworks are only suggestive, and the states have flexibility to modify the structures according to the local situation and context. Medical and Health professionals would form a major part, but professionals from diverse backgrounds like sociology, economics, anthropology, hospital management, communications, etc., who have undergone public health management training would also be considered. States could decide to locate public health managers (medical/non-medical) into same or different cadre streams belonging to Directorates of Health. In states like Bihar where there is lack of Directorates of Health the situation is very worse indicated by NITI Aayog Health Index reports. In such states the researcher found that untrained persons are posted on key public health management posts while the public health trained doctors are not posted for public health management. This may be related to corruption/scam etc. as shouted by media in such states and vigilance department reports [9].To encourage specialized skills like entomology, housekeeping, bio-medical waste management, biomedical engineering, communication skills, management of call centers, and ambulance services. The national green tribunal had recently found that a lot of public health facilities have violated bio-medical waste management rules and health department Bihar was on the top which have been imposed with a fine of rupee 1, 00, 00,000 / month for damaging environment and the fine for spreading covid-19 to humans by improper covid-19 generated waste management, which may have killed several thousand is still pending [10, 11]. Posting untrained personals for management can be so dangerous for life of people and environment is clearly indicated by above example. There may be ignorance/ posting scam and unscrupulous loot of government funds behind such acts which is a matter of investigation.
Setting / Framework of PHMC
The PHMC structures at state, district and block level will be guided by the following principles: see figure-1
Essential core principles:
1. Specialists- clinical specialists with PG degree/ diploma/MD/MS in streams like Medicine, Surgery, Orthopaedics, Eye, ENT, Obs/Gyn, Dermatology, Psychiatry, etc. [8]
2. Public Health Cadre - public health professionals with MBBS degree having MD (PSM) or PG (Public Health) Degree/ Masters/ Diploma. All new MBBS doctors will be required to acquire public health qualification within certain time (3-5 years) if not already achieved [8].
3. Health Management Cadre - health and other professionals PG qualification in Public Health (70%) and MBA (HR), MBA (Procurement/ Supply Chain), MBA (Finance), MBA (Operations), MBA (Hospital/ Health Management) or with a relevant qualification, etc., (30%). States will have the flexibility to change the percentage as per the local context and requirement [8].
4. teaching cadre will be as per the NMC guidelines, as revised from time to time [8].
5. The career progression for each cadre will be distinctive in their own respective streams with flexibility for inter-cadre deputation wherever necessary, if criteria for qualification are met. Existing GDMOs in Public Health Cadre with certain years (3-5 years) of seniority will be required to do a one/two/threeyear master’s course in public health for advancement in Public Health Cadre [8]. In states like Bihar it seems that the MBBS doctors are not given preference as well as there is lack of transparency in selection process as well as postings after successful completion of the PG course in public health management [5]. The researcher found that the selection seems too biased and the PG seats may be sold out to anyone and others for personal benefit/ corruption which are a matter of investigation. The state program officer posted in states like Bihar seems to be untrained and most of them may not operate computer or laptop etc. as found by the researcher [5]. This may be one of the reasons why such states are not improving in health sector.
6. For new recruitment to Public Health Cadre, MBBS doctors with MD PSM/Community Medicine, PG degree/ diploma in Public Health can be given preference [8].
7. Increments/special pay for acquired qualification should be encouraged for in-service doctors [8]. In states like Bihar there is wastage of government revenue on PHM training as the selection process is questionable as well as competency of candidates after training are also doubted [5]. The researcher have found that a candidate is present at the same time on government duty and also doing PGDPHM course from IIPH-Delhi and this seems to be some big scam of selling out diploma qualification. The researcher asked IIPH (PHFI) about this but they denied disclosing the facts. With such acts the future of public health will be limited to degree and diploma only and a big zero on real grounds. Even what kind of training such IIPH institutes are providing that candidates from Bihar after training except a few are unable to do a simple research or analysis? It may be possible that with government funds candidates are going for enjoyment at Delhi and institute is passing all the candidates due to government pressure, which is a matter of investigation? How many research publications came from IIPH trained candidates of Bihar and what works they have done in the field of public health management is a matter of investigation to stop corruption and loot of government revenue in the name of public health management. This may be some big conspiracy to grab the government revenue coming from taxes levied upon the citizens of India.
8. The head of the district/ block i.e., Chief/Block Medical Officer, shall be from a Public Health Cadre, however, if so desired by the state Specialist Cadre may also be considered for district level positions, and the ratio for which may be decided by the State. In states like Bihar it is found by the researcher that there is total violation of such rules by concerned authorities and this may be due to personal benefit/corruption etc, which is a matter of investigation [12].
9. Specialists and super-specialists will join at a higher scale in Specialist Cadre, to attract them in government sectors. Specialists will work in public health facilities as per Indian Public Health Standards (IPHS)[8].
Figure -2- shows the timeline for developing PHMC.
Desirable principles
1. Incentive schemes may be proposed for motivating the existing workforce to take up public health courses for their professional growth and continuing education [8]. In states like Bihar it seems that corruption have superseded motivation. In Bihar if a candidates applies for public health management work after successful completion of training the candidate is harassed badly and this may be due to getting unscrupulous profit in posting unsuitable / untrained candidates [5]?
2. District Health Society shall serve as a platform of convergence between public health and clinical functions [8].
3. The convergence of functions of public health cadre and specialist cadre at various levels needs to be established by the State [8].
4. For all cadres, method of recruitment, number of posts at various health locations and career progression needs to be clearly defined. States will take initiatives in scaling up and expanding public health courses identify relevant institutions to support the states with qualified professionals. Various types of professionals which may support public health functions are also broadly defined in NHP 2017.
5. Initiate urgent and time bound actions for creation of Public Health Cadre, Health Management Cadre, and Specialist Cadre [8].
Bias in PHMC
The specialists are not involved in PHM and it may be due to the fact that there is shortage of specialist at country and state levels. The public health cadre is a misnomer if they will also work for clinical treatments and the key goal of PHMC will be affected particularly in states like Bihar. Added to this the public health management is a very broad field and very high level of competency is required to control the explosion of public health problems in states and at country level. Already the public health management goal is shattered by unscrupulous selection and posting scams in states like Bihar. Without a dedicated public health cadre again the situation can be worsened in states like Bihar where it seems that there is complete violation of merit in postings and selection. The health management cadre selection should be made transparent. The teaching cadre must incorporate doctors from public health cadre to teach future doctors about PHM which is not available in current curriculum.
Stepwise implementation plans
1. Mapping of existing GDMOs and specialists in the present health cadre and their positions at various facilities [8].
2. Making a structure both in Public Health and Specialist Cadre based on IPHS norms in existing facilities [8].
3. Impart Public Health training to the in-service candidates [8].
4. Recruitment of doctors as per the sanctioned positions [8].
5. Making Health Management Cadre with public health professionals and other postgraduates such as MBA etc. [8]
6. Action plan for cadre strength and fill up vacant posts preferably over next six months to one year. [8]
Limitations
This is the first ever decision at national level for establishing PHMC and the details of pay structure , transparency etc. are not available and although the objectives are quite clear; the PHMC cadre may be affected in states like Bihar where it seems that lack of Directorate and unscrupulous management have grabbed the health system.