India's recent reformation in public health education: is it targeting the right people?

Recent attempts to increase the access to public health education in India are welcome developments. A previous estimate dated the year 2010 identified twenty three institutes in India offering masters level public health trainings (MPH) and over five hundred ^[1] graduates passing out through these institutes every year. Since then many new institutes have come up in various states in India. This is in addition to other formal training programmes in community medicine, community dentistry and community nursing that are offered in the medical, dental and nursing colleges. 

The challenges of the current approach to public health training The current expansion of public health

programmes is based on a model proposed in the 2005 McKinsey report. The report assumed that by increasing number of public health graduates with specialized skills along with creation of well-paid exclusive public health cadre would create better capacity of the system to manage public health functions. The report projected a need for about ten thousand public health professionals a year in India for the next ^[2] several years . Opening of new institutions has created better opportunities for professionals from different health and social science related disciplines to pursue public health education at the post graduate level. For example, a recent survey of students pursuing final year of Ayush programme in Odisha reported a ^[3] majority of the students aspire to pursue public health education. In many other institutions offering MPH programmes, a significant number of candidates who apply and join these courses are dental graduates. Even those with no background degree in health-related disciplines such as media, physics, and economics are now able to study public health programmes. They are expected to help in optimising the multi-disciplinary requirement of public health practice. 

However, the current model of expansion of MPHs is confronted with two major challenges, if better public health outcome and impact are expected merely by increasing availability of MPH graduates. The first and foremost challenge is that the current programmes are not targeting a major section of the public health workforce who by nature of their routine work handles the crucial affairs of public health practice. They include staff of government health services who are involved in range of activities including organising immunization service, providing health information, control of epidemic, ensuring delivery of health related welfare programmes and developing partnerships with households, community, panchayats, other government programmes like Integrated Child Development Schemes (ICDS) and private sectors in the delivery of public health services. They are the 'street level bureaucrats' and therefore play a crucial role in implementing and shaping all the regulatory and promotive policies and ^[4] programmes of public health. Equally important consideration is their potential to change the face of public sector in health, if they are provided with required knowledge, skills and right perspective to ignite a transformative power that they hold. These cadres of health workers which include medical officers, health inspectors and public health nurses rarely find a place in the current MPH programmes. Some of them hold leadership positions at the district and state level, while most others carry out day-today public health activities in the field. 

The employees of government health services who handle key public health related responsibilities are unable to undertake studies as they have to leave their workplace which is often impractical due to administrative and personal reasons. State governments are often reluctant to facilitate trainings of health workers by providing study leave or sponsorships as this has financial implications as well as affect the functioning of the departments. Moreover, among the current graduates, only a small section is currently entering into crucial public health roles within the government health services.^[8] Therefore, it is reasonable to assume that the formal public health trainings in India remain peripheral to the needs of the principal public health administrative systems.

The second challenge is the disconnect between the curriculum of post-graduate courses in public health and its direct application and relevance for the working professionals. Addressing this disconnect is crucial for an applied disciplinary fields such as public health. Creation of applied knowledge is a pedagogical ^[5] challenge for public health educators. In a recent evaluation of MPH programmes in India, experts have mentioned that the current MPH programmes did not adequately equip students to ^[1] plan and manage health programmes. A crucial competency required is the perspectives and skills to make local public health departments functional. Skills are required for facilitating effective intersectoral action at the implementation level which includes effective communication, mediation of differing interests and advocacy which are generally low in the department. Community engagement is the bedrock of public health practice and lessons from failed public health response to Ebola epidemic in East African countries point to the lack of these crucial skills in the health system. The skills required at this level are capacity for assessing the local burden of disease and health threats, engaging the local community to understand local health problems, devise collaborative solutions, and ensure that they are appropriately communicated and implemented^[6].

Scope of post-graduate education in public health through distance learning mode

Though there have been recent attempts to define core competencies of MPH programmes in India, they are unlikely to transcend the above mentioned challenges as long as the basic design and delivery of the programmes remain static. One possibility however, is to initiate trainings with a focus on functionaries of government health services that facilitate learning in their workplaces while they continue on the job. The modes of teaching and learning can vary from complete distance learning programmes in public health to courses which offer learning in 'blended mode'. Blended learning is realised by effective integration of different modes of learning and teaching facilitated by the use of technology for distance learning combined with occasional face to face interactions. Such mode of teaching can reduce the cost of study as well as sustain the health services.

Apart from the advantage of keeping health workers on job while training, the distance/or blended models can also offer pedagogical superiority for an applied discipline like public health as the trainees will be using their own work situations as practical arena in which to implement theoretical concepts that they ^[7] mastered. In such programmes, the challenge will be more for teaching than learning of the students and therefore requires innovative pedagogical approaches. The approach necessities relying on tacit knowledge of the learners and be sensitive to the needs of the students, and therefore let the workplace serve as a venue for problem oriented learning. Contextualising knowledge will be the key to curriculum design which needs to support learning and teaching strategies required for helping graduates to apply conceptual knowledge in complex real world practice situations.  

The common perception that the distance learning programmes are of lesser quality can only be addressed through sound curriculum development, rigorous teaching and learning methods and stringent, but meaningful course evaluation strategies. Wellfunctioning shorter term distance courses for government health workers offered by organizations such as Public Health Foundation of India, Institute of Public Health, Bengaluru and Public Health Resource Network have shown potential to bring in 'core' target (government staff) into public health training courses. The emerging online open source learning platforms such as Moodle offer new possibilities for creating interactive and reflective virtual class rooms for teachers and leaners. It has all the required features to manage an online learning by creating interactive and reflective virtual class rooms. These emerging technologies have potential to create appropriate learning activities for the students. Rather than being a passive recipient of information, students are empowered to try out and learn using various interactive tools. One of the biggest advantages of using elearning is its capacity to create a community of leaners rather than cost effectiveness or scalability. The recent advancements in open source tools have reduced the e-learning cost drastically and simplified the technology to help easier generation of good quality interactive learning material by anyone who has basic computer skills.

This paper briefly discussed the challenges before the Indian efforts to train more public health professionals. We attempted to argue that the future relevance and sustainability of public health programmes depend on its ability to focus on capacity development for public health practice at the local level. Much to be learned from the experience of African schools which shows that despite being offered as distance learning courses, their MPH programmes have achieved reasonably high course completion.^[8] rates Years of experience in training public health professionals through distant learning mode has helped them accrue invaluable knowledge to orient their courses to the personal and professional priorities of the working professionals. If India's current reformation in public health education has to contribute to its larger goal, it is important that the progress thus far ought to be reviewed and necessary path corrections are made at the earliest.