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SCATTERED PUBLIC HEALTH SERVICES, FRAGMENTED GOVERNANCE: THE FAULT LINES IN PUBLIC HEALTH AND ITS EDUCATION IN INDIA
SCATTERED PUBLIC HEALTH SERVICES, FRAGMENTED GOVERNANCE: THE FAULT LINES IN PUBLIC HEALTH AND ITS EDUCATION IN INDIA
Why in the News?
- World Health Day 2025 was observed on April 7 with the theme ‘Healthy Beginnings, Hopeful Future’, promoting a message of optimism and progress in global health.
- However, India faces significant structural gaps in public health preparedness, highlighting a disconnect between vision and reality.
- A critical yet under-discussed issue is the state of public health education in the country.
- The design and delivery of Master of Public Health (MPH) programmes remain inconsistent and fragmented across institutions.
- These educational deficiencies directly impact India’s ability to proactively strengthen its public health infrastructure, much like how national security requires continuous investment and attention.
Understanding Public Health: A Broader Perspective
- Common Misconception: Public health is often wrongly perceived as a subset of medicine, mainly involving doctors and hospitals.
- In reality, public health is a distinct field that blends multiple disciplines.
Scientific Foundation:
- Rooted in medical sciences (e.g., germ theory of disease).
- Applies engineering solutions (e.g., water purification, sewage systems).
- Informed by social sciences (e.g., understanding how poverty affects health outcomes).
Art of Public Health:
- Involves persuasion and communication.
- Requires creative problem-solving to address community health challenges.
- Focuses on designing effective campaigns, influencing behaviour, and building trust.
Independent Field: The integration of these varied elements makes public health a unique and standalone domain.
How Public Health Works in India
Fragmented Constitutional Framework
- Public health is commonly seen as a State subject, as per the 7th Schedule of the Indian Constitution.
- However, responsibilities are scattered across all three lists:
- Concurrent List: Drug safety, pollution control, family planning, food safety (both Centre and States can legislate).
- Union List: Quarantine, international health regulations, Census, and vital statistics.
- State List: Primary care, health education, and local health services.
- This dispersion leads to confusion and fragmented governance without a unified command structure.
Colonial Legacy and Structural Misfit
- India inherited a unitary health system from British colonial rule, poorly adapted to the federal structure of independent India.
- Public health was never institutionalised within a single executive arm in most States.
Intra-State Departmental Silos
- Responsibilities are split across multiple departments:
- Health Ministry: Immunisation, disease control.
- Water Resources/Public Works: Sanitation and clean water.
- Food Safety Authorities: Oversight of food standards.
- Municipal Bodies: Local sanitation, health inspections.
- This leads to low synergy and poor interdepartmental coordination.
- Limited accountability arises due to blurred lines of responsibility.
Lack of a National Public Health Vision
- Public health has never been positioned as a cohesive national agenda.
- Fragmentation leads to reactive policies, not proactive prevention.
Contradictory Policies Undermine Public Health
- Examples of policy contradiction:
- India fights tobacco-related diseases through ICMR.
- Simultaneously, it promotes tobacco farming via ICAR’s Central Tobacco Research Institute.
- This reflects a disjointed vision, where health and economic interests clash.
Need for Coherent Governance and Education
- India requires unified public health governance.
- A revamp of public health education and inter-sectoral alignment is critical to address current inefficiencies.
Public Health Education in India
Fragmentation in Public Health Education
- Master of Public Health (MPH) curricula in India are fragmented, mirroring the disjointed public health governance structure.
- MPH programmes lack national coherence and standardisation across institutions, resulting in inconsistent training.
- The MPH is essential for training future public health professionals, such as epidemiologists, food safety officers, and health economists, but the current system doesn’t meet the interdisciplinary needs of these roles.
Inconsistent Eligibility and Curriculum
- Eligibility criteria for MPH programmes are inconsistent: Some universities restrict entry to medical, dental, or allied health graduates.
- Others are more inclusive, admitting graduates from various disciplines, but lack a standard baseline curriculum.
- This leads to diverse student backgrounds but no common foundation, making curriculum standardisation essential.
- The courses are inconsistent:
- Some focus on theory, others on management, with limited hands-on experience or technical depth.
- This results in wide disparities in student knowledge and capabilities, even among those with the same degree.
Gaps in Key Public Health Domains
- Several crucial domains of public health are either underrepresented or absent:
- Public health engineering, essential for disease prevention through systems like water purification and waste disposal, is given minimal attention.
- Nutrition is taught in a static manner, missing the practical aspects of food safety, handling practices, and food technology.
- Although food safety is governed by the Food Safety and Standards Authority of India (FSSAI), the skills to implement its policies are not adequately addressed in MPH curricula.
Lack of Focus on Behavioural Sciences
- Understanding and changing human behaviour is key to many public health efforts (e.g., vaccine uptake, tobacco reduction, sanitation improvement).
- Few institutions offer comprehensive training in behavioural change theories, psychology, or social marketing—fields that are essential for large-scale public health interventions.
Limited Focus on Health Technology Assessment
- Health technology assessment (HTA), which evaluates the cost-effectiveness and impact of health interventions, is taught in only a few institutions.
- This limits India’s ability to make evidence-informed policy decisions at scale.
Unrealistic Programme Structure
- The two-year MPH programme tries to cover a wide range of topics—epidemiology, health policy, behavioural science, health economics, and operational research—within a limited timeframe.
- This compressed format often results in superficial coverage, especially with thesis requirements and field postings.
- The programme might need to be restructured to include modular training with flexible entry and exit points.
Need for a National Overhaul
- Coherent and standardised public health education is essential to produce professionals capable of addressing the diverse public health challenges in India.
- The MPH programme must be made more interdisciplinary, practical, and aligned with the current needs of the public health sector.
Systemic Invisibility of MPH Graduates in India
Lack of Structured Public Health Cadre
- Despite their training, MPH graduates remain largely invisible within India’s public health system.
- Most States lack a structured public health cadre that formally recognises and employs these professionals.
- This is a missed opportunity, especially given the National Health Policy 2017, which envisions a skilled public health workforce.
Underemployment of MPH Graduates
- Many MPH holders end up in: Short-term projects, NGOs, Data-entry or clerical roles in government health departments
- These roles do not leverage their technical expertise, nor do they provide a long-term career trajectory.
National Implications
- The absence of a robust public health workforce has serious consequences:
- India’s response to antimicrobial resistance, climate-driven health threats, and future pandemics remains reactionary.
- Without qualified public health experts, evidence-based planning and resilience in the system remain weak.
Way Forward
- Public health must be treated with the same strategic importance as national security—as a field requiring continuous investment and foresight.
- India must begin by revamping the public health education system, which includes:
- A nationally coordinated MPH curriculum with:
- Minimum national standards
- Flexibility for regional adaptation
- Training professionals to:
- Interpret and use epidemiological data
- Conduct health technology assessments
- Lead disease surveillance units
- Advise on environmental and occupational health risks
- Call to Action: A system-wide transformation is needed
- Recognise and institutionalise public health roles within government frameworks.
- Align MPH training with current and future public health demands.
- Create career pathways and incentives for skilled public health professionals.
Mains Question (250 words):
“Discuss the challenges facing public health education in India and evaluate how systemic fragmentation in training and governance impacts the country’s preparedness for emerging health threats.”
