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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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.