The Road Not Taken - Career Options In Public Health In India

The COVID-19 pandemic acquainted the ‘general public’ with terms like public health’ and ‘epidemiology’.  A largely neglected field in India, a lot more people now realize why there is a desperate need to ramp up action in public health. India has made considerable progress in several areas of public health like HIV/AIDS, Polio, immunization, maternal and child health etc. and yet, there is scope to do much more.

India has one of the largest public health programs in the world, the National Health Mission (NHM), but the vertical disease-specific programs under the NHM ail from lack of integration, inadequate administration and implementation. The country lacks a public health cadre in most states.

In this piece I share my understanding of the career options for public health professionals in India, while clarifying that in India; the terms ‘public health’ and ‘community medicine’ are used interchangeably.

Community medicine training in India

First, to understand what Community Medicine education entails in India, let’s take a peek at some of the objectives of learning this subject as an undergraduate medical student.

The erstwhile Medical Council of India (MCI) and now, the National Medical Council (NMC) of India states the goal of learning the subject for an ‘MBBS’ student is to “prepare them (medical graduates) to function as community and first level physicians”. A wide variety of disciplines are touched upon briefly, including epidemiology, biostatics, demography, health care delivery systems, health management, administration, health communication, epidemic control, diagnosis and management of common health problems in the community.

An M.D. in Community Medicine explores these disciplines, more in depth and detail. In addition to greater focus on health planning and management, the post-graduate (PG) course aims at a better understanding of the country’s health policies and programs. Other important areas in the PG course include Nutrition, Environmental and Occupational health, International health and Health economics.

Contrary to the popular notion that Community medicine, also referred to as ‘Preventive and Social Medicine’ is equivalent to the textbook by ‘Park’; the NMC syllabus for the postgraduate degree in Community Medicine, suggests 12 other textbooks; most by non-Indian authors.

The other group of people eligible to take jobs in public health are those who have done a ‘Masters in Public Health (MPH)’. Unlike MD community medicine, where an MBBS is a requisite eligibility criterion; MPH can be done by an undergraduate from any background. 

So, now Ms. K has an MD degree in community medicine or an MPH, what are the career paths/roads she can choose from? I have described six possible roads that one could take to grow as a public health professional in India.

The Journey After Completing MD/MPH

The first road - Medical college

The conventional road to join a medical college and go from being a lecturer/senior resident to professor in the Department of Community Medicine, in some colleges, still referred to as PSM or Preventive and Social Medicine.

This is an option only for the people who have completed MD Community Medicine and not for those with MPH. This path includes mainly teaching related activities and nil-to minimal clinical duties in most medical colleges. Involvement in meaningful public health research depends on self-interest. The work environment and culture here depend on the medical college in question.

Some medical colleges like All India Institute of Medical Sciences (AIIMS), New Delhi and Christian Medical College (CMC), Vellore have a significant proportion of clinical duties for PGs and faculty. They also have a competitive research milieu leading to the fact that less than 10 medical colleges out of the 500+ in India, contribute to the majority of biomedical research in India.

Some departments of community medicine are involved in overseeing vaccination programs or have tie-ups with the government, WHO/ UNICEF and other NGOs to provide school health, rural health, run various clinics etc. In most medical colleges however, the department activities are largely theoretical. 

The second road - Research organizations

To join research organizations either in the government or private sector. For a beginner  the posts are mainly contractual with low job-security and remuneration. There are posts like ‘program manager’ ‘project manager’, ‘research associate’ or ‘research officer’ etc. This route will entail work-related travel and program management.

A government research organization: Indian Council of Medical Research and its various daughter institutes in different cities in India have frequent contractual ‘Scientist’ posts and rarely ‘regular/permanent’  posts. Depending on the institute you join, the nature of work differs. For example, if you get a job in the Reproductive Health Institute at Mumbai, the projects would involve reproductive health topics. Some of the renowned non-governmental research organizations are: Public Health Foundation of India, Institute of Public Health etc. Jobs in research positions are available in the Pharmaceutical and allied health industry as well.

Depending on the research projects, a typical research position includes field work, mainly desktop-based research, report, proposal and manuscript writing. The ensuing results may or may not influence/ translate to health policy at the national, regional or local level.  

The third road - Public health cadre

To join state public health cadre (available in few states like Tamil Nadu, West Bengal) through state level exams or interviews or to join central government health services by giving exams like UPSC (Union Public Service Commission), medical stream. This includes posts in CGHS (Central Government Health Services) in railway hospitals and Ordinance factories. Most of these jobs are mainly clinical in nature.

State program managers help in implementation of national health programs. Some of these jobs may be contractual in nature, while most are long-term/permanent. A few Public Health professionals join the Indian Administrative Services. However, this trend may change, as the Government of India has passed an act in 2022 that mandates all states in India to constitute a Public Health administrative cadre by the end of 2023 (This has not yet been implemented in reality as of November 2022). If and when implemented, this act may create a huge opportunity for public health professionals to work closely with NHM and improve health outcomes at the district and state level. 

The fourth road - International or national non-governmental organizations

The NGO-road may involve higher focus on humanitarian, socio-economic, anthropological and developmental aspects of Public Health. It could also involve community organization in rural, tribal and remote areas of the country. Depending on the area of focus of the NGO, a typical work day could vary from home-visits for palliative care to desk-jobs and data analysis in others. The nature of work may be project based or not and may/may not depend on the funding mechanisms. There are numerous NGOs doing phenomenal work at the grassroots level in India.

The fifth road - Private for-profit organizations

A few public health professionals also work for commercial (private) companies like Global Pharmaceuticals, Big Data Companies and other Health-affiliated start-ups as researchers and data scientists. This more of a desk job and involves working with data to produce results.

The sixth road - International health organizations

Lastly, public health professionals could choose to work for International Health organizations/ Global Health actors like United Nations, UNICEF, World Bank and the World Health Organization (WHO).

Here there is scope for great variety. WHO regularly calls for Surveillance Medical Officer (SMO) posts in several districts in India. International organizations are also looking for experts in Health policy, Health economics, Infectious diseases, Epidemic preparedness etc.  (One could do masters in these tracks from reputed universities abroad right after MBBS, to skip the traditional NEET-PG route in India). In these organizations the role of public health professionals could vary from Epidemiologists, Infectious disease expert, Health Economists, Surveillance Medical Officer Etc. based on their prior work experience and specialization.

Overall, the public health road is less commonly taken and less preferred by most medical graduates. As a follow-up to this exploration of the various career paths available for public health professionals in India, the author, with inputs from Community Medicine faculty at Christian Medical College, Vellore developed and circulated an online survey among people who have completed their MD in Community Medicine from India to get a feel of their career choices and their view on skills picked up during MD.

Findings from a survey

The online survey was circulated in the first quarter of 2022 and 65 public health professionals responded to the survey.

The age of the respondents ranged from 27 to 75 years with an average age of 38.5 years. Of the respondents 47.7% were female. It had been 0 to 44 years since the respondents had completed their MD in Community Medicine. The respondents had completed their MD Community Medicine from 43 different medical colleges in India, though a majority of the respondents (31.8%) were from Christian Medical College, Vellore.

The role in which the respondent reported to have worked the longest required the following top core skills: Teaching (68.2%), Program management (10.6%), Research (12.1%), Clinical (6.1%) and Administration, Community engagement (1.5% each). Of the 65 respondents, 48 (73.8%) had less than 10 years of work experience and a majority of 38 of these 48 respondents had switched jobs 1-3 times, with 4 of them having switched jobs 4-5 times.

Of the 65 respondents, 32.3% responded with a score of   </=6 on a scale of 1-10, with a score of 10 being most satisfied/fulfilled with their line of work. Of the 63 who responded, 16 (25.4%) reported a score of </=6 on a scale of 1-10, with 10 being ‘fully satisfied with the learning experience during MD’.

Respondents on exposure to various areas in Public Health during MD (n=65)

Suggestions by Respondents on Skill Sets Needed MD Community Medicine Graduates

• Administration
• Clinical skills
• Communication skills
• Community Engagement
• Health information technologies
• Networking
• One Health
• Politics in Health
• Risk taking
• Social Media skills
• Software- R, STATA
• Working with the government and pushing for policy change
• Writing skills (grants, manuscripts, blogs)

Each road has its pros and cons and is meant for different kinds of Public Health professionals. All these roads require a skill set that includes knowledge and application of the core areas of public health: Epidemiology and Research Methodology. Skills in communication and scientific writing are a must too. Another important requirement is a balanced and resilient attitude with a passion for the subject. Community Medicine is branded as ‘boring’ among most medical undergraduates in India and is likened to the textbook by Park and Park. This pandemic has shown us how important the field is. Moving forward, the world needs competent, motivated and grounded professionals in this field.