The Covid-19 crisis, has shown more than ever before the need of a robust and efficient public health system. While India has thus far dealt fairly well with the crisis, it has had its own share of hiccups- with doctors at the forefront complaining of the lack of Personal Protective Equipment, harassment by neighbours and police authorities in times of lockdown. Moreover, India’s response to the Covid-19 crisis has also been a sobering realisation, that though we have risen to the task when the pandemic struck, we have been turning a blind eye to several more preventable deaths that occur every day in what we consider ‘normal’ times (be it road accidents, malnutrition or vaccine preventable illnesses).
Another regular feature of the Covid-19 times across the world have been daily briefings by government authorities of different nations. In US the face of the briefings has been Dr. Anthony S. Fauci, a widely acclaimed name in the medical fraternity and one of the editors of Harrison’s Principle of Internal Medicine, considered as the Bible of Modern Medicine. In contrast, the Ministry of Health and Family Welfare in India has been represented by Mr. Lav Agarwal, an affable IAS Officer who is the Joint Secretary in the MoHFW. Mr. Agarwal, is not a doctor or related to the medical fraternity in any manner; he in fact is an engineer from IIT Delhi, who joined the prestigious Indian Administrative Service after cracking the UPSC (Union Public Services Commission) exam in 1996. Similarly, the Secretary in the MoHFW, Ms. Preeti Sudan, is also not from the medical fraternity, but an economics graduate, who among other postings has also served in the Ministry of Defence.
Defence and Health, sound as disparate as chalk and cheese isn’t it? Well, for that you can thank the Indian Administrative Services. Never mind your academic background or aptitude, once you crack the tough UPSC exam and get allotted the IAS cadre, you start of with managing a district and then as you rise through the ranks, you can be posted in almost any field, from archives to fisheries, agriculture to industries and as we have seen defence to health. IAS, often called the steel frame of India, prioritises the generalist bureaucrat over the expertise of a specialist. While it is not without its plus points, it has glaring limitations as well. For starters, there is little incentive to delve deep into a particular field and gather latest domain knowledge, when you have every possibility of being shunted to an entirely different field within a matter of days and there is every incentive to continue the mundane affairs of moving files from one desk to another and squat on matters.
The field of medicine and healthcare is today based on evidence and that evidence is generated through research and studies, thousands of which are ongoing in every part of the world. As a result, medicine is a dynamic and rapidly evolving field, in which new frontiers are being scaled all the time; in 2020 medical knowledge is estimated to double every 73 days. This makes health and its planning a particularly challenging field which could do much better with those people at the helm, who have the necessary knowhow and can keep updating themselves. The way a nation manages its health system, impacts each and every one of its citizens at some point of time or another and by extension, it plays a very fundamental role in the trajectory of the nation as a whole. Moreover, as the Covid-19 pandemic has shown, in the world of the future, a robust healthcare system will play the same role in furthering the interests of a nation (and humanity as a whole) as played by its army or industrial base in the past. Just like the government has given an expert from the armed forces a seat at the high-table of defence planning by setting up the office of the Chief-of-Defence staff, now is the time to radically reform the way India manages its health system.
It is in this background, that the long pending demand (more than 40 years old) of creation of an All India Medical Service (AIMS) on the lines of Administrative, Police or Revenue Services assumes more importance than it has ever had in the past. An AIMS will place the levers of the health system in the hands of those who have a basic knowledge of medicine (MBBS lets suppose) and are then trained in the administrative and managerial aspects, with particular focus on issues relevant to health system management. They can begin their careers from the hinterland (much like an IAS officer starts as a Sub Divisional Magistrate) and then as they pick up experience, be gradually promoted higher up in the ladder at state or central level, right up to the Secretary MoHFW. This also solves to a great extent the pressing issue of lack of doctors in the rural areas as compared to the urban areas. One particular aspect which dissuades doctors from taking up rural assignments is the perceived lack of growth opportunity in their careers. An AIMS would solve that problem and motivate young and talented doctors to start their careers in the most far-flung and underserved of areas and then once they rise through the ranks and become responsible for laying out the further path for healthcare of the country as a whole, they can put the experience gained from the field to use.
What is also true is the fact that most doctors have little, if any, exposure to the domains of economics, management, resource allocation etc., as none of these topics are taught in medical schools. For any AIMS framework to be successful, it would need to bridge these lacunae in knowledge through adequate training before posting the newly recruited candidates. IAS/IRS/IPS officers have a foundation training programme followed by a probationary period to train the future officers in their respective domains and a similar health system-oriented programme would have to be formulated. Looking at various health models across the world, for example the NHS (National Health Services) in United Kingdom (which is one of the largest employers in UK) and the lessons we can learn from them, apart from experience of our medical personnel and health system administrators gathered over the past several years, could be instrumental in formulating not only the curriculum of this programme, but also deciding on the nitty-gritties of how the AIMS framework is to be laid out.
A major barrier in creation of the AIMS, would prove to be the fact that health is under the State List of the Constitution, and any overarching framework laid by the Centre can only be through approval by an overwhelming majority (if not total consensus) of the state governments. This would require a lot of deliberations between all the stakeholders at the state and centre. Though this would make the process more tedious, it also provides the benefit of gaining a broad variety of perspectives and then incorporating the most feasible among them. As the GST council (Goods and Services Tax) has shown, with the necessary political willpower, such co-operation between the centre and states is indeed possible.
With a doctor himself as the Union Health and Family Welfare Minister, there could not be a better time to bring this long pending issue of an All India Medical Services out of the cold storage and make it a reality.
