The Congress on Public Health took place in Kolkata in February 2015. Hundreds of public health leaders and experts from around the world and across India attended. We took this opportunity to present the most challenging public health problems we face in India in sessions called ‘global consultations’. Participants helped elaborate the problems and discuss how to address them. We report here on one of several topics discussed.

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Challenges of Public Health Education in India

Public health is ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals’.1

For a long time, public health education has been expected to find solutions for a multitude of public health problems through building the capacity of the public health workforce – cutting across all categories from grassroot to managerial levels.2

The focus on public health education came into consideration as early as the formation of the Bhore Committee in the 1940s. The report of the Health Survey and Development Committee, chaired by Sir Joseph Bhore, emphasised the inadequate teaching of preventive medicine and public health in medical students’ undergraduate training – highlighting the need and importance of public health education.3

Later, in 1961, the Mudaliar Committee4 sought to strengthen public health education in the country by recommending schools of public health in every state to train medical officers, public health nurses, maternity and child welfare workers, public health engineers and sanitarians, dieticians, epidemiologists, nutrition workers, malariologists, and field workers.

The extent to which we are able to improve public health depends largely upon the quality of the public health workforce, which in turn depends upon the relevance and quality of its education and training. Realizing this, in 1985, an expert committee for Health Manpower Planning, Production and Management under the chairmanship of Dr JS Bajaj5 recommended that a National Policy on Education in Health Sciences be developed.

The urgency of the need to reinforce the public health education system in India by strengthening the existing schools of public health was expressed also by two other bodies: the Expert Committee on Public Health Systems (constituted by the Ministry of Health and Family Welfare, Government of India in 19966) and Voluntary Health Association of India Independent Commission on Health in India in 1997.7

In 1999, World Health Organization convened a ‘Regional Conference on Public Health Education and Practice in the South East Asia Region in the 21st Century’ in Kolkata. Participants undertook a critical review of the public health situation, including public health education and practice in this region, and to identify effective ways and means to improve and strengthen public health education and practice. The conference developed the ‘Calcutta Declaration’ providing a broad strategy and framework of action for strengthening public health education in the South East Asia Region including India.8

Calcutta Declaration on Public Health

The following declaration, based on the deliberations and recommendations of the Conference, was unanimously adopted by the delegates at a special session on the concluding day presided over by Mr Jyoti Basu, Honorable Chief Minister of West Bengal, India.

We, the participants in this Regional Conference on Public Health in South-East Asia in the 21st Century , appreciate the substantial achievements made in improving the health status of the people in the countries of the South-East Asia Region during the past decades. However, we enter the 21 st century with an unfinished agenda of existing health concerns, and new and complex challenges that demand innovative solutions. We uphold the centrality of meeting the health needs of the community and our responsibility to preserve, protect and promote the health of the people. We commit ourselves to the goals of poverty alleviation, equity and social justice, gender equality and universal primary education, which are all essential elements in the pursuit of health for all . We recognize that expertise and experience in Public Health and capacity-building are essential for sustaining partnerships in designing, developing and providing health for the community. And we emphasize the importance of Public Health as a multidisciplinary endeavor to meet the health needs of people.

Having noted the progress in public health practice, education, training, and research in the countries of the South-East Asia Region, and having reviewed the lessons from Public Health-related policies and programs, we endorse the following strategies and directions for enhancing health development in the South-East Asia Region in the 21st Century:

  1. 1)

    Promote Public Health as a discipline and as an essential requirement for health development in the Region. In addition to addressing the challenges posed by ill-health and promoting positive health, Public Health should also address issues related to poverty, equity, ethics, quality, social justice, environment, community development and globalization;

  2. 2)

    Recognize the leadership role of public health in formulating and implementing evidence-based healthy public policies; creating supportive environments; enhancing social responsibility by involving communities, and increasing the allocations of human and financial resources;

  3. 3)

    Strengthen Public Health by creating career structures at national, state, provincial and district levels, and by establishing policies to mandate competent background and relevant expertise for persons responsible for the health of populations; and

  4. 4)

    Strengthen and reform Public Health education, training, and research , as supported by the networking of institutions and the use of information technology, for improving human resources development.

We urge all Member Countries as well as WHO to continue to provide leadership and technical cooperation in building partnerships between governments and UN and bilateral development agencies; the academia; NGOs; the private sector; the media, and other organs of civil society, and to jointly advocate and actively follow-up on all aspects of this Calcutta Declaration on public health .

The declaration provided strategic directions for strengthening and reforming public health practice, education, and training in South East Asia. After one and half decades, India shows a slow but perceptible change with persisting gaps. This underscores our collective failure to address the challenges of public health education that cut across all levels of public health systems and all categories of public health workers.

After the Declaration

Even after the Declaration, India’s curricula for professional public health education remain fragmented, outdated, and based on static curricula. This situation produces ill-equipped public health workers with inadequate competencies, not only from the medical and nursing disciplines, but also public health engineers, veterinarians specializing in public health, social scientists working in public health, statisticians working with public health related databases, health workers and ground level workers such as Accredited Social Health Activists (ASHAs), responsible for health promotion, health education, and many more who are involved in keeping people healthy in a healthy environment.

Some of the major problems in public health education in India today include:

  • Inadequate (quantitative and qualitative) training facilities

  • Mismatch of competencies to rapidly changing population need

  • Narrow technical focus without broader contextual understanding

  • Predominant curative orientation at the expense of primary care

  • Quantitative and qualitative imbalances in the professional market.9

Workforce shortages and maldistribution of public health workers

Every year, and all across India, schools or departments of public health, churn out thousands of public health professionals of different categories and levels. Even so shortages are exacerbated; maldistribution and the training opportunities do not align well with the needs, either in terms of population size or national burden of disease. A study, mapping courses relevant to building capacities for district health planning found 286 such courses in 15 states, of which 85 covered content that qualified them to be called ‘complete public health courses’ while 201 partially covered minimum public health content, but were relevant and related to public health.10

Need for a well functioning, evidence-based system of accreditation based

In India, public health education varies across institutes. India needs an accreditation system to ensure that public health education reaches the desired quality and sustains this standard. Accreditation systems are weak and unevenly practised, mostly by the respective professional councils, the Medical Council, Nursing Council, and others.11

There is scarcity of information and research about public health professional education, especially about the non-medical, non-nursing categories responsible for most delivery of the public health services at the ground level.

Strategic Directions for Professional Public Health Education

Initiatives from various parts of the world offer lessons. They point to needed reforms in professional public health education. The health care system in India is largely dependent on its public health workforce – a team of doctors, nurses, managerial staff, counsellors, laboratory staff, ground level health workers, ASHAs, Peoples’ representatives from the Panchayati Raj Institutions, and others. The need of the hour is development of adequate and appropriate public health competencies among them. This will vary according to public health workers’ main roles and responsibilities and should reflect the public health challenges and priorities of a particular setting.

Globally, the concept of public health competencies has evolved over time. Some direction emerged through the report of the Joint Learning Initiative on Human Resources for Health in 2004, followed by the Lancet report on Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World (2010),12 and the publication of World Health Organization (WHO) Transforming and Scaling up Health Professionals’ Education Guidelines (2013).13

In 2013 the Sixty-Sixth World Health Assembly passed a Resolution on Transforming Health Workforce Education in support of Universal Health Coverage (World Health Assembly Resolution 66.23).14 Subsequently core competencies in public health have been described by public health associations and professional bodies including the European region,15 WHO,16 the United States,17 Canada,18 and the United Kingdom.19

Health systems in India are having to cope with a changing environment:

  • Epidemiologically: in terms of changing age structures, the impact of pandemics, and the emergence of new threats;

  • Politically: in terms of changing perceptions about the role of the state;

  • Technically: in terms of the growing awareness that health systems are inequitable and constitute one of the rate limiting factors to achieving better development outcomes.20

Strengthening public health functions and services in India, now more than ever before, needs to be comprehensive in concept and approach, addressing the multiple determinants of health, with the help of competent multidisciplinary teams. Building such teams will require public health training in core competencies for a range of qualifications.

Public health education in India now needs to improve the performance of health systems by adapting core professional competencies to specific contexts to assure high-quality comprehensive public health services that are essential to advance health equity.

To transform and scale up public health education and training, only a revolution can bring about the necessary sea change.

The 14th World Congress on Public Health envisioned a global movement of all stakeholders – educators, students and health workers, professional bodies, universities, non-governmental organisations, international agencies, donors, and foundations. Such a movement can propel action in India to promote a new framework of transformative professional education. The result will benefit populations not only in India and South Asia but everywhere in our interdependent world.