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.
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 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.