Ideas
Why It's Time For An 'All India Health Service'
- This service will not only have specialised skills in public health but also the administrative and managerial skills of the civil services.
- The All India Services (Amendment) Act, 1963, already allows for such a service; no new legislation is needed for it.
People at hospital in India (Subir Halder/India Today Group/Getty Images)
The Rajya Sabha recently discussed the Right to Health Bill, 2021, a private members bill seeking to make health a fundamental right for all citizens and to ensure equitable access and maintenance of a standard of physical and mental health conducive for a life with dignity.
Similar legislations are under consideration in states like Tamil Nadu and Rajasthan. Under the leadership of PM Narendra Modi, the Government of India has launched various initiatives like Ayushman Bharat Yojana, PMJAY, AMRIT Deendayal outlets, Ayushman Bharat Digital Mission etc. in recent years to improve access, affordability and quality of health services.
However, to make Right to Health and Universal Health Coverage a reality there is an urgent need to reform state, district and local level management of public healthcare, its institutions and human resources in order to improve last-mile delivery of health services. During the COVID-19 pandemic as well, various states experienced major challenges in public healthcare administration.
India has a large network of Primary Health Centres, Urban Community Health Centres and District Hospitals, but they are marred with over-bureaucratisation, dysfunctional management structures, poor coordination of resources and an overall institutional apathy towards public health goals which is reflected in daily patient care, quality of health services and during the incidence of a health crisis.
This is further compounded by an ever growing shortage of skilled manpower in public health.
Despite the growing need for better public health services, the public sector provides only 18 per cent of the total outpatient care, 44 per cent of the inpatient care, 54 per cent of the institutional deliveries, 60 per cent of the prenatal care visits (2013) and a sizable population has to depend on private health providers that are largely unregulated, concentrated in urban areas and provide varying levels in quality of health services.
Due to lack of autonomy, authority and excessive bureaucratic intervention, public healthcare has failed to attract the best medical professionals of the country. More than three-quarters of registered doctors serve in the private healthcare industry.
This is further exacerbated by limited promotional avenues, sluggish career progression and negligible role in policy-making functions of medical professionals in the public health system.
To foster expert public health leadership at different levels of administration it is recommended that an All India Health Service which not only has the specialised skills in public health but also the administrative and managerial skills of the civil services is constituted. This new civil service needs to be established on a strong foundation of New Public Management.
NPM focuses on improvement of the public sector through greater emphasis on performance, preference for lean, small and specialised organisational forms and treating service users as ‘customers’ while moving towards ‘customer-oriented’ governance.
An Indian Medical Service existed in colonial India which started as a military medical service and civilian functions were added later on. However, the IMS was discontinued in 1947 when India became independent.
Subsequently, Mudaliar Committee (1962), fifteenth Finance Commission, High Level Empowered Group on Health all recommended the establishment of a new Health/Medical Service on the lines of Indian Administrative Service.
The Rajya Sabha has so far created the Indian Administrative Service and Indian Police Service through the All India Services Act, 1951. However, through the All India Services (Amendment) Act, 1963, the Parliament provided for the establishment of three more All India Services out of which only the Indian Forest Service has been notified and constituted.
Section 2A of the Act empowers the central government to constitute another All India Service namely, The Indian Medical and Health Service. Therefore, a fresh legislation is not needed to constitute it.
However, to make the Indian Health Service meaningful and accountable, complete administrative separation of the Health department at district level from the General Administration (District Administration) is essential. This is aimed at creating an autonomous institution in each district that is solely focused on public healthcare and has the requisite authority, autonomy and accountability to function.
District Administration in India plays a pivotal coordinating role in the governance structure. Since its inception in 1773, various roles have gradually and continually been added from time to time. This has led to an overburdened administration or in other words caused bureaucratic overload which has a detrimental effect on ground level implementation of government programs.
Furthermore, the district administration tends to prioritise general administration, law and order and revenue collection whilst public healthcare fails to garner adequate attention.
Also, the involvement of local bureaucracy with healthcare functions has led to over bureaucratisation, lethargy and severely impacted the morale of health professionals. To improve healthcare delivery mechanisms it is essential that the leadership at district level has the expertise and specialised knowledge and is exclusively focused on managing the health services.
Local bureaucracy has little to no expertise in medicine, public health or epidemiology which is essential for effective management of healthcare at the district level. There were various examples of mismanagement observed during the COVID pandemic when there seemed to be no distinction between Law and Order functions and disease/outbreak management functions.
Even the current Provincial Medical Services in states receive little to no training in public health or epidemiology or modern administrative and management techniques.
Similar reforms are needed at the state government level as well. The Seventh Schedule of the Indian Constitution places public health and sanitation; hospitals and dispensaries under State List which gives state governments the primary authority in all matters related to public health.
States currently have a separate secretariat (Health Department) which assists the Health Minister and is involved in formulation of policies, regulations and setting goals for the state government. Along with this, there exists one or multiple Directorates of Health Services which is an executive agency but also a subordinate office responsible for the execution of policies formulated by the Secretariat.
This secretariat-directorate dichotomy deprives the political executive (the Health Minister and the Chief Minister) of direct specialist advice on matters related to public health and vital information may get lost in the bureaucratic maze.
Proposals from the directorates have to go through several levels of generalist bureaucracy of the Secretariat, who may not have the expertise to properly scrutinise them. This not only dilutes the authority of directorate heads but is also detrimental to innovation and initiative taken by subject specialists.
The first Administrative Reforms Commission in its report “The Machinery of the Government of India and its Procedure of Work” has supported the integration of Secretariat as a policy-making body and executive agencies as the policy implementation bodies, thereby removing the undesirable distinctions between Secretariat and non-secretariat parts of the administration.
Therefore, amalgamation of Secretariat and directorates and reconstitution of State Health Departments as expert bodies led by public health professionals can drastically improve health outcomes in states.
As India embarks on the journey to provide Universal Health Coverage to its citizens, institutional, structural and managerial reforms become more and more pivotal.
It will leverage the vast medical professional talent that is already present in India but untrained, and unutilised for administration of public health. It will create a National Health System that is autonomous and exclusively accountable with a lean bureaucratic structure.
Finally, it will ensure suitable career progression and opportunities for the medical professionals and incentivise working in rural areas of the country that have failed to receive efficient and good quality healthcare services.
Siddhartha Verma is an officer of the Indian Railway Traffic Service and a Commonwealth Scholar in Public Policy at the University of Cambridge.
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