A case for Community Health Officer and Nation's Health !

Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Doctors treat individual patients. Public Health takes into account the health concerns of the entire community. Health cannot be ensured without addressing the environmental factors - socio-political-economic-physical-psychological. Thus, community health interacts with many variables in the periphery, and a public health specialist needs to be far more equipped than a doctor is.

The Great Plague of London, from 1665-66, and the Cholera outbreak in 1832, forced officials to realize, that London had to create a new sewer system. The 1848 Public Health Act was passed to help individual cities improve the sanitary conditions of their towns. Vaccination became a requirement for all by the mid-1850s. In the early 1900s  many acts were passed and the England's public health, was being structured.

In India, under the British rule, Bhore committee was formed in 1943, known as the Health Survey and Development Committee, and it submitted its report in 1946. Some of its major recommendations were -

1.Integration of preventive and curative services of all administrative levels.

2. Development of Primary Health Centres in 2 stages :

Short-term measure – One primary health centre as suggested for a population of 40,000. Each PHC was to have 2 doctors, 1 nurse, 4 public health nurses, 4 midwives, 4 trained dais, 2 sanitary inspectors, 2 health assistants, 1 pharmacist and 15 other class IV employees. Secondary health centre was also envisaged to provide support to PHC, and to coordinate and supervise their functioning.

Long-term program (also called the 3 million plan) of setting up primary health units with 75 – bedded hospitals for each 10,000 to 20,000 population and secondary units with 650 – bedded hospital, again regionalised around district hospitals with 2500 beds.

3. Major changes in medical education which includes 3 - month training in preventive and social medicine to prepare “social physicians”.

While Britain made efforts to develop public health in its own country, as early as early 1800s, it was not done in the colonies. The Indian Medical System was developed for the sole purpose of keeping the army healthy. In 1952, the proposal of the Bhore Committee was accepted by the newly elected government of independent India, but it was only partially implemented. Preventive and Promotive care primarily took a back seat, the 'social physicians' were never recruited. No concious efforts were made to develop a public health cadre in India, until 2017, when for the first time the health policy talked about -

'The policy proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria. The policy also advocates an appropriate career structure and recruitment policy to attract young and talented multidisciplinary professionals. Medical and health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as sociology, economics, anthropology, nursing, hospital management, communications, etc. who have since undergone public health management training would also be considered. States could decide to locate these public health managers, with medical and non-medical qualifications, into same or different cadre streams belonging to Directorates of Health. Further, the policy recognizes the need to continuously nurture certain specialized skills like entomology, housekeeping, bio-medical waste management, bio medical engineering, communication skills, management of call centers and even ambulance services' (Health Policy 2017)

The Mukherjee Committee in 1966 prescribed a system of targets and incentives and identified ANMs( Auxiliary Nursing Midwifery) and other village-level workers as agents for the populizing  health programs in the community. In the 1950s and 1960s, training of ANMs mainly focused on midwifery and mother and child health.

In 1973, the Kartar Singh Committee of the Government of India combined the functions of the health services and changed the role of ANMs. The committee recommended that there should be 1 ANM available per 10,000-12,000 people.

In 1975, the Srivastava Committee recommended expansion in the role of ANM. Recommended expansion included the role of an ANM as a multipurpose health worker. Along with maternity care, the committee recommended that ANM's work should include child health (immunization) and primary curative care of villagers. The Indian Nursing Council (INC) accepted the recommendations of the committee and included them in the syllabus in 1977. This decision also reduced the training period of the ANM from 24 months to 18 months.

In 1986, the National Education Policy gave the ANM program a status of Vocational Education. However, only a few states of India have made the ANM course a vocational course at the higher secondary level of schooling. According to the latest guidelines by INC, the minimum age for admission to ANM course should be 17 years while the maximum age limit is 35 years.

In 2005, the National Rural Health Mission (NRHM) was launched, which focused on improvising primary health care in villages and further increased the importance of the ANM as a link between health services and the community.

 Before the launch of NRHM in 2005, there was provision of one ANM per sub-centre. Later it was found that one ANM was not adequate to fulfill the health care requirements of a village. In 2005 NRHM made provision of two ANMs (one permanent and one contractual) for each sub-centre. The ANM is usually selected from the local village to increase accountability

The Accredited Social Health Activist (ASHA) is a community health worker. Depending on the area covered by the sub-centre, each ANM is supported by four or five ASHAs. ASHA brings pregnant women to the ANM for check-ups. She also brings married couples to the ANM for counseling on the family planning. ASHA brings children to immunization sessions held by the ANM. ASHA acts as bridge between the ANM and the village.

Ayushman Bharat operational guidelines gave a  key addition to the primary health team at the SHC-HWC, the Mid-level Health Provider (MLHP) who would be a Community Health Officer (CHO). The qualification of CHO, much in line with ANMs, is B.Sc Nursing or GNM. The rationale for introducing this new cadre of health provider is to:

1)Augment the capacity of the Health and Wellness Center to offer expanded range of services closer

to community, thus improving access and coverage with a commensurate reduction in OOPE.

2)Improve clinical management, care coordination and ensure continuity of care through regular

follow up, dispensing of medicines, early identification of complications, and undertaking basic

diagnostic tests.

3) Improve public health activities related to preventive and promotive health and the measurement

of health outcomes for the population served by the HWC (Health and Wellness Center).

In principle, the community health officer would be the nodal workforce to prepare a report on health status of the population served by HWC. This would be made possible by creating a digital health eco -system 'National Health Stack', where digital personal health records captured at the PHC level, will be stored in a national database, under a unique identity number (UIN). National Digital Health Blueprint (NDHB), 'which is more than an architectural document', as it provides an implementation plan of 'National Digital Health Eco-system' has been released on 15th of July, by Ministry of Health and Family Welfare, Government of India.

In future, there would be a wealth of local data, easily retrievable from a national database, to measure and monitor health outcomes. In principle, this looks like a perfect plan, but there is a missing link here, a very important one.

The missing link is the availability of qualified and skilled public health workforce at all levels of care, primary, secondary and tertiary, to work for preventing disease, prolonging life and promoting health through the organized efforts of society. As of now, ANM, ASHA and proposed CHOs, are the only public health cadres we have in India. They are not qualified or trained, they will join the work force, learn on job, and make a delivery. Their role will be further extended as and when required, and accordingly, they will be provided training for the job. The way we developed ANMs, we will develop CHOs. There is just one difference, the CHOs will be computer literate and will be trained to capture personal health data, digitally.

There is a long list of capabilities that a public health workforce should have in order to function effectively, but I will address that in a separate post.

Public health has had several success stories in India, smallpox, polio, TB, and HIV being some of them. Yet, season after season, we have instances of dengue and swine flu outbreaks, physical inactivity is increasing, stress levels are getting higher, pollution is becoming dangerous, malnutrition is rampant and tobacco abuse is increasing. Can a public health workforce possibly help that ? The answer is YES, for the simple reason that when a patient comes to a hospital with a problem, a doctor can diagnose a disease, but cannot scan his socio-economic-political-psychological environment, where usually the cause is.

Community Health Officer at HWC, should be made responsible to study such causes for a population of about 3000-5000, covered by one HWC, contribute in planning public health interventions and execute them. Community Health Officer will be the pivotal unit, in primary care, tilting the axis towards preventive and promoting care. Its historic. Many state governments have announced several positions for community health officers, which is a welcome move, but getting in a workforce whose roles and responsibilities are not very well defined, for such an important function is inapt and uneconomical.

Investing in public health brings better economic value, its just about time to do intense brainstorming about, what value should public health officials at various levels, can add to nation's healthcare.

The citizens deserve it.