A public health expert shares a ₹20,000 crore plan to improve India’s health infrastructure including a dedicated cadre

• An increase in the health and family welfare budget by at least 50% at the state and central level is imperative.
• We currently have only one Auxiliary Nurse Midwife for a population of 5,000 or five villages.
• India urgently needs a robust public health management cadre on the lines of IAS and IPS etc.

The dwindling number of COVID-19 cases per day is, undoubtedly, excellent news for India. Plus, the vaccination drive is on, which will aid in building herd immunity and protecting the most vulnerable. If we can expand the vaccination drive rapidly, there will be no chance of a second wave in India and COVID-19 will be finished by summer.

The question now is what can we learn from the pandemic and how can we consolidate these public health gains via this year's budget. An increase in the health and family welfare budget by at least 50% at the state and central level is imperative. Our aim should be to reach 3% of GDP for health from the current 1.2% or so in the next five years. Most of this money should strengthen primary care at the village level and improve public health services.

As a public health expert, here’s my wishlist for the budget 2021.


1. Government's commitment to one qualified primary care nurse per village
Currently, we have one Auxiliary Nurse Midwife for a population of 5,000 or five villages. We have recently added a Community Health Officer (CHO) at this level who is a nurse Ayurveda doctor trained for a further six months. India is producing enough nurses to staff all of its villages with at least one nurse.

Appointing one nurse per village will ensure around the clock presence of a primary healthcare provider in each village. For context, China did this in the 1970s, Bangladesh in the 1980s and Nepal also has a similar provision. An ASHA worker per village is not enough – she is a partly-paid volunteer. We desperately need preventive and curative care professionals at the village level.

The cost will be around ₹25,000 per nurse per month in 500,000 villages which come to ₹15,000 crore annually. The implementation can be phased, and the state and central govt can share the cost. But it is an essential move so that villagers can receive services of vital healthcare at their doorstep.

2. Strengthen primary care centres (PHC) and urban health centres with public health officers' appointment
Currently, we have medical officers with MBBS degrees for primary care centres. However, there are many places where MBBS doctors are not available, and the posts lay vacant.

More than half of the work of PHCs is to manage public health programs such as immunization, maternal and child health, environmental sanitation, malaria and other mosquito-borne diseases, surveillance and monitoring of diseases and epidemics etc. For such public health program management, a clinical doctor is not essential or desirable.

A public health officer with a Master of Public Health degree is sufficient. So the suggestion is to have a post of public health officers at each PHC besides a medical officer. For the whole of India, we will need 30,000 such public health officers.

At an average salary of ₹55,000 per month, this will cost the government about ₹1980 crore. The benefits will be immense. All national public health programs will be managed better – with better quality, coverage and outcomes.

Moreover, the MBBS medical officer can fully devote his or her time to clinical medical services to providing good quality clinical care that is currently unavailable since they spend more than half of their time in public health programs. This will also boost the medical officers' morale as they are not trained to do public health work that they have to do in a PHC.

3. Instituting a public health management central services cadre
To plan, organize and monitor our public health actions, including for diseases like COVID-19, India urgently needs a robust public health management cadre on the lines of IAS, IPS, IFS and other central services. Each district should have five to seven such centrally selected public health cadre post officers with similar posts at state and national level.

They should have pay and other facilities in lines with other central services. Currently, the district, taluka and city-level public health posts are filled variably by medical doctors, specialists and some non-doctors due to unclear recruitment and promotions rules in various public health departments of states and cities.

Even at the national level, there are very few public health officers. The entire pandemic was managed by generalist administrators and specialist medical doctors without much input from public health experts and infectious diseases or epidemiology experts.

For a national public health cadre, India will need a minimum of five officers per district, which will come to 3,695 officers for district level. We need to add about 1000 officers at the state and city level, and the total will come to 4,695 officers. At an average salary of ₹1,50,000 per month, such cadre at the national level will cost about ₹845 crore per year. Such cadre will improve public health management at ground level in each district and city.

4. Strengthen public health institutes that are not AIIMS
The All India Institute of Medical Sciences (AIIMS) is not a public health institute; it is a medical care apex institute, and their advice on how to care for coronavirus patients may be the best. However, we rarely heard the voices from experts from All Indian Institute of Hygiene and Public health (AIIHPH) or National Center for Communicable diseases (NCDC), or an additional director general of public health in India or any of the states during the pandemic. We also hear from cardiologists and pathologies from the private sector, but from very few public health experts.

There is no doubt that IAS officers are essential for inter-sectoral administrative actions on a large scale, which are needed during major catastrophes. But the technical strategies for controlling an epidemic is the job of epidemiologists and public health officers. We hope that through this budget the government will plan to improve our institutions dedicated to public health like NCDC, AIIHPH, Indian Institutes of Public Health and other schools of public health and public health divisions in the ministry of health.

A provision of ₹2000 crore to strengthen public health institutions and division in the country should be made in the budget. If implemented in this budget, these suggestions will go a long way to strengthen our medical care and public health system in the country. This will reduce the possibility of future pandemics and increase our ability to deal with it in a better manner. Due to the pandemic, the economic and social loss should make the policymakers willing to invest in public health in this and subsequent budgets.

*The author is the Director of Indian Institute of Public Health, Gandhinagar. Views expressed here are personal.

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