change in order

A new Indian Medical Service needs doctors as administrators of public health

Public health management needs expertise in all key health systems, which is beyond the scope of officers of the IAS.

The union government has expressed an interest in creating an Indian Medical Service along the lines of the Indian Administrative Service and Indian Police Services. The health ministry recently sent a circular to the states asking for their views on such a move. There is a strong case for an Indian Medical Service – but one that is based on new foundational principles appropriate for present times.

An Indian Medical Service existed in pre-Independence India. In 1763-’64 medical services were first set up in the Bengal, Madras and Bombay administrations largely to recruit and deploy a relatively modest number of physicians and assistants to take care of the health of the military force, and officers posted in civil lines and in select factories. In 1857, after the first war of Independence, the British government took over direct control these three medical services and united them into a single Indian Medical Service.

During its long history, there was an ongoing debate about whether military surgeons and civil surgeons should be separate or in a single cadre. For the most part, the Indian Medical Service was a military service with medical officers being sometimes being sent to play modest roles as civil surgeons put in charge of certain districts. But their focus was on clinical care in the barracks and the civil lines. They had a very limited role in public health and a limited vision of organisation of healthcare services for the general population.

Ronald Ross (left) who discovered the mode of transmission of the malaria parasite and Charles Donovan who found the pathogen causing kala azar were both members of the Indian Medical Service. Photo credit: Wikimedia Commons)
Ronald Ross (left) who discovered the mode of transmission of the malaria parasite and Charles Donovan who found the pathogen causing kala azar were both members of the Indian Medical Service. Photo credit: Wikimedia Commons)

Not surprisingly, this was a time when the country was wracked with epidemics. Healthcare services were rudimentary and reached only a small part of the urban elite. The old Indian Medical Service operated on the simplistic top-down approach to healthcare rather than as a general administrator of healthcare across the country.

India needs a new Indian Medical Service as a cadre of public health managers at the national level. Such a service should be established parallel to and in synergy with the establishment of state public health management cadres.

Where present systems fall short

Public health management means not only addressing preventive and promotive measures of health, but also organising of primary, secondary and tertiary healthcare services. This, in turn, needs expertise in all key health systems components – human resources for health, community participation, health informatics, technologies and technology choice for health, governance and management, financing of health care and above all the organisation of healthcare services. It also needs a sound grounding in epidemiology and an understanding of clinical care.

Officers of the Indian Administrative Service, even those with medical degrees, are not equipped to understand and organise comprehensive nationwide healthcare. This requires formal qualification or training in public health management as well as experience of managing health systems at the state and district levels. Senior leadership positions in an Indian Medical Service should further require experience in policy making bodies at national and international levels.

India currently has a cadre of medical officers under the Central Health Services, which was constituted in 1963. There are four types of officers under the Central Health Services – teaching specialist, non-teaching specialist, public health officer and general duty medical officer. The current cadre is more than 3,000 strong but only about 50 members have anything resembling public health experience. Many of them have worked in dispensaries that render basic ambulatory care to central government employees, requiring very minimal levels of clinical and administrative skills. Others are specialists working in the central government-managed hospitals who have good clinical skills but in very limited areas of specialisation and their management and administrative experience.

Towards the end of their careers, members of the Central Health Services may get promoted into policy making and leadership roles in the union health ministry. For instance, the Director General of Medical Services is a Secretary level officer of the Central Health Services. However, few officers are able to assert their presence among general administrators from the IAS. This is often attributed to the myth that doctors make poor managers. However, the runaway success of doctors as leaders in private healthcare industry belies such a characterisation. Members of the Central Health Services underperform because they are recruited and trained to play entirely different roles than what is required of health administrators and policy makers.

A primary health centre in Goa. Photo credit: RubyGoes/Flickr
A primary health centre in Goa. Photo credit: RubyGoes/Flickr

A general administrator from the IAS does have a role to play in health services but this should be more in terms of shaping the institutional framework than in running the show – more in governance than in management. Even though IAS officers gain some health experience in their tenures as district collectors, when they supervise district health matters, they do not have domain knowledge in this knowledge-intensive sector. Moreover, officers from other services like secretariat services, economic services, railways, customs and forests, are increasingly being posted as health administrators.

Two parallel health cadres

One of the main arguments against an Indian Medical Service is that it could encroach on the federal nature of governance and make healthcare more of a central subject. To avert this, state public health management cadres should also be created. Both the state health cadre and officers of the Indian Medical Service can learn from each other. To be effective, the Indian Medical Service officers should complete district-level and state-level stints and the state cadre structure must allow this. Similarly, state officers should work on deputation for some years in the Indian Medical Service to get national experience, which is valuable to build state systems.

There is enough work in policy and programme management and in providing technical support to health systems development in the states and in providing leadership to the many apex public health institutions under the central government to merit the creation of a small but effective Indian Medical Service.

The Indian Medical Service as well as the state public health cadre have to be structured as management cadres distinct from public healthcare providers like Auxiliary Nurse Midwives and primary health centre medical officers. But even these public healthcare providers should have opportunities to enter the Indian Medical Service and opt out of clinical work. Further, if the Indian Medical Service is re-imagined as a management cadre, then people with backgrounds in health economics, sociology, anthropology and so on may also be admitted into the service.

Finally, creating an Indian Medical Service will also require new designs of governance and knowledge management. Healthcare institutions will have to rethink how they network, how they manages knowledge, how their internal structures and work culture are defined, and how the balance between autonomy and accountability is achieved.

The writer teaches at school of health systems studies, TISS.

Support our journalism by subscribing to Scroll+ here. We welcome your comments at
Sponsored Content BY 

Why do our clothes fade, tear and lose their sheen?

From purchase to the back of the wardrobe – the life-cycle of a piece of clothing.

It’s an oft repeated story - shiny new dresses and smart blazers are bought with much enthusiasm, only to end up at the back of the wardrobe, frayed, faded or misshapen. From the moment of purchase, clothes are subject to wear and tear caused by nature, manmade chemicals and....human mishandling.

Just the act of wearing clothes is enough for gradual erosion. Some bodily functions aren’t too kind on certain fabrics. Sweat - made of trace amounts of minerals, lactic acid and urea - may seem harmless. But when combined with bacteria, it can weaken and discolour clothes over time. And if you think this is something you can remedy with an antiperspirant, you’ll just make matters worse. The chemical cocktail in deodorants and antiperspirants leads to those stubborn yellowish stains that don’t yield to multiple wash cycles or scrubbing sessions. Linen, rayon, cotton and synthetic blends are especially vulnerable.

Add to that, sun exposure. Though a reliable dryer and disinfectant, the UV radiation from the sun causes clothes to fade. You needn’t even dry your clothes out in the sun; walking outside on a sunny day is enough for your clothes to gradually fade.

And then there’s what we do to our clothes when we’re not wearing them - ignoring labels, forgetting to segregate while washing and maintaining improper storage habits. You think you know how to hang a sweater? Not if you hang it just like all your shirts - gravity stretches out the neck and shoulders of heavier clothing. Shielding your clothes by leaving them in the dry-cleaning bag? You just trapped them in humidity and foul odour. Fabrics need to breathe, so they shouldn’t be languishing in plastic bags. Tossing workout clothes into the laundry bag first thing after returning home? It’s why the odour stays. Excessive moisture boosts fungal growth, so these clothes need to be hung out to dry first. Every day, a whole host of such actions unleash immense wear and tear on our clothes.

Clothes encounter maximum resistance in the wash; it’s the biggest factor behind premature degeneration of clothes. Wash sessions that don’t adhere to the rules of fabric care have a harsh impact on clothes. For starters, extra effort often backfires. Using more detergent than is indicated may seem reasonable for a tub full of soiled clothes, but it actually adds to their erosion. Aggressive scrubbing, too, is counterproductive as it worsens stains. And most clothes can be worn a few times before being put in the wash, unless of course they are sweat-soaked gym clothes. Daily washing of regulars exposes them to too much friction, hastening their wear and tear.

Different fabrics react differently to these abrasive agents. Natural fabrics include cotton, wool, silk and linen and each has distinct care requirements. Synthetic fabrics, on the other hand, are sensitive to heat and oil.

A little bit of conscious effort will help your clothes survive for longer. You can start by lessening the forces acting on the clothes while washing. Sort your clothes by fabric instead of colour while loading them in the washing machine. This helps save lighter fabrics from the friction of rubbing against heavier ones. It’s best to wash denim materials separately as they are quite coarse. For the same reason, clothes should be unzipped and buttoned before being tossed in the washing machine. Turning jeans, printed clothes and shirts inside out while loading will also ensure any abrasion is limited to the inner layers only. Avoid overloading the washing machine to reduce friction between the clothes.

Your choice of washing tools also makes a huge difference. Invest in a gentler detergent, devoid of excessive dyes, perfumes and other unnecessary chemicals. If you prefer a washing machine for its convenience, you needn’t worry anymore. The latest washing machines are far gentler, and even equipped to handle delicate clothing with minimal wear and tear.

Bosch’s range of top loading washing machines, for example, care for your everyday wear to ensure they look as good as new over time. The machines make use of the PowerWave Wash System to retain the quality of the fabrics. The WaveDrum movement adds a top-down motion to the regular round action for a thorough cleaning, while the dynamic water flow reduces the friction and pulling forces on the clothes.


The intelligent system also creates water displacement for better movement of clothes, resulting in lesser tangles and clothes that retain their shape for longer. These wash cycles are also noiseless and more energy efficient as the motor is directly attached to the tub to reduce overall friction. Bosch’s top loading washing machines take the guesswork away from setting of controls by automatically choosing the right wash program based on the load. All that’s needed is a one-touch start for a wash cycle that’s free of human errors. Read more about the range here. You can also follow Bosch on Facebook, Twitter and Instagram.

This article was produced by the Scroll marketing team on behalf of Bosch and not by the Scroll editorial team.