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.

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Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the marketing team and not by the editorial staff.