Of the 59 institutions identified in our desk review, 45 cities across India were represented, with clusters in the North, Southwest and Northeast (Fig. 1). We identified 3 institutions with multiple locations, and the two cities with the highest concentration of public health training were New Delhi (6) and Bangalore (5).
MPH programs constituted the most common primary pathway for public health training opportunities in India with a total of 25, followed by Master of Science (MS) programs (20) and then diplomas (14) (Fig. 2). PhD programs and a range of workshops and other certification opportunities were also available.
We identified the broad knowledge, skills, abilities, and attitudes targeted by the different public health trainings offered, using a set of core competencies for public health professionals developed in Uttar Pradesh, India as a foundation.(8) We also adapted from a framework for the MPH programs that has been developed or India.(9) Of the eight core competencies considered necessary to deliver public health functions effectively in the Uttar Pradesh framework, leadership, communication, and financial management were the least represented in our desk review (Fig. 3).
Beyond the competencies specifically covered in public health education and training programs, career and post-graduate outcomes of students trained in public health varied across institutions, but a few themes emerged from the interviews. In particular, the careers of public health students often relate very closely to their previous backgrounds resulting in path-dependency (i.e. that once a student starts down one path of study, such as community medicine or another medical specialty, it is challenging to change to another one) in public health training. One faculty program coordinator at a private university described this common background for a successful public health career in India: “...doctors, nurses, or other management-trained graduates who are a part of the existing health system and have been nominated by the respective state governments to come in for the program.” The same interviewee further elaborated that these students differ from “... the students who come in who are absolutely fresh and have just completed their bachelor’s or their master’s and have enrolled into a public health program” in that the former are more likely to have a set career pathway and identified job opportunities for which specific public health skills can add value whereas the latter are still seeking out job opportunities and need an entire package of useful skills. Thus, career trajectories for many students undergoing public health training are pre-determined according to their academic or professional background rather than being informed by the education they receive during the course of their program.
II. Key Factors Influencing Public Health Students and Curricula in India
This section further describes key factors contributing to public health education and training curricula and students in India; these factors are summarized in Table 2 and the following sub-sections further describe and illustrate each of these themes in further detail. Factors related to institutional strengths and faculty capacity will be described elsewhere.
Table 2
Key themes related to student body and curricula for public health education in India
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Theme
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Strengths
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Weaknesses
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Collaborations to support student learning
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• Students commonly engage with local communities and partners during training
• These interactions are valuable for gaining skills and also informing longer-term career choices
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• Availability varies across institutions and states
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Mentorship
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• Mentors support thesis development and often become more general guides for students
• Backgrounds of mentors are rich and variable; represent key leadership roles in the public health system
• Impact of mentorship
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• Retention of mentors, particularly in rural areas
• Areas for expansion
• Formal structure or model can be lacking
• Incentives for mentors (balancing time commitment)
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Curriculum structure an standardization
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• Room for flexibility, innovation, adaptation
• ASPPH* competency framework has been utilized as reference in some programs; there is a Ministry-approved competency framework now
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• Lack of standards/accreditation,
• Competition for students and duplication of courses between institutions
• Challenge to ensure recognition or relevance of degree/diploma/certification
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Tuition and funding for students
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• Government funding supports a number of key programs
• Tuition fees for public sector programs in particular are affordable
• Students can often earn stipends as part of their degree or by working
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• In other cases where tuition is more expensive and scholarships are limited, students generally rely on loans (although this was not recognized to be a barrier for applications)
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Student demand for public health education and career pathways
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• Students can get promotions after completing specialized trainings
• MPH degrees are a positive feature for learners who want to go on an pursue a PhD
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• Lack of clear career pathways
• Lack of available job positions that focus on public health specialties particularly at the government level
• Lack of motivation and incentives
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|
*Association of Schools and Programs of Public Health
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Collaborations to Support Student Learning
Strengths
Institutions emphasized the need for and value of hands-on experience for students undertaking public health training. Specifically, many institutes used a practicum or field placement in collaboration with other organizations to provide field-based opportunities to students. One professor from a government institute explained that “the idea [is] that exposure to other institutions, their best practices… so that they can learn from, other institutions and their… experiences.” Further, some institutes engaged in preexisting collaborations for students to gain first-hand experience working on government programs at local and national level in order to provide “good insights of implementation of various national health programs with the help of the program manager.” Some institutions have a systematic approach to assisting students with placements and these can include “a placement team at the institution led by a faculty member supported by three faculty members and a program officer…” as expressed by an interviewee working in a private institute. This approach would source placement opportunities and aid in matching students with appropriate placements.
These collaborations are entirely for the benefit of the student and are meant to further their skills-based education and are cultivated to supplement in-class instruction with hands-on learning opportunities. Institutions also emphasized the unique need for collaborations for students who may not have had direct field experience of public health programs and to “attempt to train our students so that tomorrow in case they have a choice, they can serve at the primary health centers” as noted by a faculty working in a public-private institute.
Weaknesses: Collaborations for students vary for each institution and depending on whose perspective at a given institution is captured. Many students have opportunities to pursue placements in hospital settings or to engage in research, but experiences with public health practice and leadership are limited. One faculty member at a government institution explained these opportunities: “We interact with the department of community medicine in the medical colleges. We interact with their faculty and they have students undergoing…the MD in community medicine. Our students go and interact with them and they learn.”
Notably, international collaborations are often more highly valued or focused on than local collaborations with partners such as non-governmental organizations (NGOs) or public health offices. However, international opportunities for students are often unbalanced and create more opportunities for the international students to come have placement experiences in India than vice versa.
Mentorship for Students
Strengths
The two main functions of mentors were as course-coordinators and faculty mentors. The course coordinators were often identified as point persons who provided a range of problem-solving roles including dealing with logistics, administration, housing, and a range of other student needs. Faculty mentors were primarily identified as support for academic and professional guidance in order to help students develop their thesis as required by the MPH, PhD, or diploma curriculum. These faculty mentors were assigned based on topical knowledge and alignment with student interests. Students were expected to check in with their faculty mentors regularly as they develop their thesis, and one professor from a government university expressed
The mentor is the person whom they will contact almost every second day, third day, or at least weekly to update him or her on the progress.
Graduate alumni also served as mentors as expressed by an interviewee from a government research institute where they identified “...graduates who are nearer to the place of posting or district of posting of a student...” . An “open style of mentorship” was offered to doctoral students, to facilitate any additional guidance as one respondent from a government institute described, “those on the DAC, the doctoral advisory committee, are also people whom we pick and choose as possible mentors, in case the PhD student requires or feels the need to, expand their mentorship beyond the supervisor...”
The background of external mentors (those involved outside of the students’ university or organization) included government officers such as Indian Administrative Service (IAS) officials, public health policymakers, district and state health officers and faculty from other medical colleges and international universities. Having external mentors was seen as beneficial for student exposure and interest as one human resource management faculty from a private university said,
In fact, more recently, there has been a trend, in fact, of trying to get external mentors, you know, people who are completely external to the system, because, I think, at least for us, it’s actually an opportunity to learn different styles of mentorship... the latest [advances] in a particular field which I may not, for example be, necessarily an expert or be able to keep up with what is happening…it brings in new ways of thinking, it brings in, you know, new understandings, new perspectives.
Weaknesses
Many institutions identified challenges with existing mentorship structures. Turnover and lack of commitment from mentors was a common challenge described for sustaining mentors at institutions. The main reasons given for these challenges were a lack of time “they are busy in their own jobs, ...the time is not really committed”, and a lack of incentives “mentorship is sort of voluntary, we don't pay anything to them.” as noted by a faculty in a government institute. Only a few institutes recognized a formal structure for mentorship, that includes as one private university faculty explained as “a written set of documents about what the role of that mentor is...there are clearly defined rules about dos and don’ts...” Most institutions however, recognized the need to expand on formal mechanisms for mentorship in their programs, and one interviewee from a government university made a general statement on his view of formal mentorship in India and said, “mentorship as such is not a very..., good concept in India, ...it is a very sweeping statement, ... we generally don’t have a very formal mechanism.” Interviewees also spoke about the need to focus on expanding faculty mentorship beyond a student’s thesis project and onto other academic areas, and on improving delivery of mentorship during COVID-19, particularly through building on online mentorship platforms as one private university faculty said, “with technology that has improved now, ...we will improve upon that [for] providing mentorship over distance, ...and through online media.”
Curriculum Structure and Standardization
Strengths
Enhancing curriculum structure and innovation through exposing students to experiences and opportunities abroad was mainly described for dual PhD programs where students spend their time abroad or where institutions expand their course modules with international universities. This curriculum exchange was expressed by a government institute faculty who said, “we were exploring..., doing a dual PhD program, or... having an exchange with, say, a couple of modules in their MPH that we don’t teach, and in our MPH that they don’t teach.”
Weaknesses
One challenge related to public health training in India was the lack of standardization in the curriculum and oversight across institutions offering public health education (PHE). A lack of having a structured curriculum was identified to affect the quality and value of public health education that students obtain in certain institutions as expressed by a government institute professor as, “...in India unfortunately, there are small institutions who have started their own MPH because there is no regulation, and nobody really knows what they are churning out.”
In the absence of a centralized framework or oversight of public health education, curriculums were sometimes identified as to be lacking necessary high-quality components, for example from disciplines like social sciences. As one interviewee from a private university said, “the academic rigor that needs to come… into a public health program is usually a little lower in India from every single program ... and it stems from a historical neglect of the social sciences by medicine.” Other faculty also pointed to an overly focused medical lens to public health training as well, indicating this was not particular to their own institution but across the field of public health. Standardization was deemed necessary to address the broad nature of public health and overcome the extensive medicalized view as pointed out by a private institute faculty who said, “I’m a doctor myself, but we have a very medicalized point of view towards addressing public health… There is a standardization of what should be covered...to get that multidisciplinary pool who can appropriately deliver the content is also going to be immensely important here in this setting.”
Others also expressed concern that the scope of training was not necessarily representative of the skills or knowledge necessary to address real-world scenarios and there was a need to identify a standard framework to address this translation of public health skills as one from a government university said, “The focus has been about, ...developing technologies to make health accessible. But to really understand, ...what this means...to really see how the potential for how all this works, a public health framework is really needed.”
Tuition and Funding for Students
Strengths
Almost all institutes made note of how funding impacts students and public health training as on interviewee from a government-affiliated institution noted, “[for public institutes] the grant is from the government. So, there is no problem, as far as the funding is concerned to our institute.”. In particular for many institutes funding was not a notable barrier specifically for public universities and government affiliated institutions as noted by one faculty, “the MPH course, we used to offer till this year it's free of cost to all the students.… All the students who are sponsored by the state health departments”. Tuition fees are often nominal as opposed to private institutes where tuition rates are higher. There are also other forms of support from public institutions. As a respondent from a government institution said, “the fees here [are] very, very nominal…there are no scholarships, rather to your surprise you will find that we actually pay our students a stipend because they are residents, so they get junior residency, which is a substantial amount…one-month junior residency can take care of their whole year’s fees.”
Weaknesses
In general, funding was not recognized to be a barrier to student entry, even in the case of private institutions where tuition is considered to be higher, as the draw for highly reputable institutions and post-education opportunities outweigh higher tuition rates in student program selection. One respondent from a private institution explained,
Our fee structure for courses in health in hospital is on the higher side… compared to all other universities or institutions or schools offering similar programs in the country. But still, we are able to attract people. Usually, our stake is almost 100% full every time and the reason for this is our reputation.'
Scholarships at such an institution were described as “not very substantial” and students seeking financial support are expected to rely on private loans from banks and, in some cases, foundations.
Student Demand for Public Health Education and Career Pathways
Strengths
For students who already have work experience in the health system in India, they often have a given position in mind prior to entering the program including being nominated by the government to participate in particular programs. One respondent described an example of this saying, “They [a particular group of students] are basically the health educators… So, after, you know, joining this course, they get a promotion also. So, more than 50% of our students, they are the in-service candidates.”
Other common targets for graduates aside from the health system were other government agencies, non-profit organizations, think tanks, industry-oriented companies, and further education. One private institute noted that demand changes depending on where in your career you are:
Almost immediately, after MPH, most individuals take on, you know, research officer course, research associate, you know, that could be one important group of people. And then, there are a few who directly join, you know, program officer type implementation posts, in government programs at the district level, at the state level, and so on.
Some students moved forward to pursue their PhDs not only in public health but in other fields of science as one interviewee at a private institute said, “there are others who’ve gone on to do PhDs in the basic sciences, and the engineering sciences and in public health and then there are others who have become very leading figures in government.” Students also used their public health degree to branch out to other areas such as healthcare technology in large companies. The same respondent also described how this works: “…lots of people who have gone to, you know, industries like Siemens, and GE, and Philips and Centricity... that work on different technologies in the health sector…” Finally, another private institute respondent recognized that the MPH degree was a significant value for students who would want to pursue public health careers internationally: “...MPH as we know, one of the programs that they find a very useful as a steppingstone to further employment opportunities abroad.”
Weaknesses
In order to pursue public health, a government institute faculty member noted that students need to be assured that they will have “a regular job” and “[a] basic education qualification through which I [student] can seek an employment…” once they graduate. Experts interviewed also identified the current lack of job positions and career growth opportunities in the Indian public health sector which needs to be improved to trigger greater demand and increase student enrollment in public health training programs.
One interviewee from a private institution, while speaking on the value of public health degrees in India said, “the promotion or the career advancement doesn't happen automatically ... even if you get [an] additional degree, in many states it really doesn't matter” indicating the apprehension for students to enroll in public health training without proper career incentives and clear pathways to additional opportunities once earning their qualifications.
While speaking about the lack of public health job postings in India, interviewees also expressed the clinical dominance of the field in India, such as this faculty program coordinator from a private institute who stated that in order to secure placements and be eligible for more career avenues and to increase demand for public health students. Particularly, one interviewee from a private institute spoke about the need to expand current postings in the government sector onto public health specialties in order to create demand: “[governments]have not...expanded into the specialty in... public health… And that’s why the demand for the post is also not there.”
Going beyond creating demand among students to enrolled in public health programs, there was a need to target the existing workforce that performs public health functions and offer a basic level of education as well as continuing education and training opportunities. As one interviewee from a private institute explained, “At the level of the other rungs of the ... public health cadre... ASHA, CNM’s, nurses ... there has to be a planned strategy for ...their basic education, but also for their continuing education.” This need to strengthen the existing workforce also relates to another challenge of making public health training programs equitably accessible to students who can benefit from them and contribute to the Indian health system. Another private institute respondent described this challenge as, “the idea was to open up opportunities in a way that is equitable, and there have been challenges to doing this. But they have really tried to figure out how to do this across the history of these institutions.”
There was an identified need to provide more provisions for students to go abroad “as a part of their elective program or the clerkship program” (private institute faculty member). The rationale for these opportunities is to expand on and enhance training offerings that were currently identified to be unstructured or limited, and to provide students with more opportunities for careers and diverse field work experiences so that they are prepared to work directly with communities. Other than the lack of available career growth opportunities, one interviewee identified a lack of amenities in their institution as a deterrent to student enrollment, “being in the rural area is a weakness also; people don’t want to come [for training] because we have minimum physical amenities, facilities” (private institute faculty member).