Introduction:

Public Health is defined as "the science and art of preventing disease, prolonging life and improving quality of life through organized efforts and informed choices of society, organizations, communities, and individuals”. Public health can claim the credit for eradicating small-pox Guinea worm disease and near elimination of polio. The necessity of “Public Health” had never been felt so vital across the globe than during the times of COVID-19 pandemic. The Indian and global experience had underscored how important are the “organized efforts and informed choices of society, organizations, communities, and individuals” in halting COVID-19 pandemic destructive force. India witnessed a collective public health effort pivoted by the public, political leadership, health workforces, regulators, public and private sector partners, and media in addressing the dreaded pandemic [2]. Covid-19 had underscored the scopes and potentials of Public Health as a scientific discipline, and this would be the right moment for the public health professionals of the country to seize the opportunity to set their identity, not think of retirement and set agenda for the public health future of the country [2].

I recall many conversations I had at the end of my active service as a Senior Program Officer (Health) with UNICEF, India country Office, New Delhi by end January 2006, with many public health cadre officers of MOH &FW, in Government of India and State Government.  I am used to interact with officers approaching their tenure or retiring early (mutually agreed termination or Premature voluntary retirement) from Govt. service by 60 years or earlier. I was not so excited to retire myself after nearly 38 years of active service in 2006, and therefore was a bit shocked to hear that someone would voluntarily end a career.  I was still enjoying and had my own plans of being a freelance public health Consultant. After all, Public Health Profession (PHP) is a field where people can practice with flexibility, and do a private practice (consultancies, PH teaching, PH advocacy, National program data Analysis for PH program planning and implementation mentoring) is not an all-or-none endeavour.

Unlike many retired PHPs, I continued to work with the World Bank, New Delhi from March 2006 go to National Centre for Disease Control (NCDC) and States for monitoring the implementation of Integrated Disease Surveillance Program (IDSP) in its 3^rd year of implementation, dressed in simple attire, followed by lunch with young professional colleagues wherever I was. Simultaneously I used to take short consultancies for UNICEF and WHO in the areas of Routine Immunization, Polio eradication assessments, IMNCI and other child Health Interventions in Bhutan, Azerbaijan, Bihar, Odisha, UP, MP and Rajasthan. I also use to do family physicians practice with a focus on diabetes in Diabetes Foundation of India, Vasantkunj, New Delhi. I relocated to Bengaluru in April 2018, was prepared to lose consultancy opportunities, and was getting prepared mentally for retirement or family physician’s practice.  Fortunately, UN consultancies continued, and new opportunities came through from Private sectors like PwC and Amata’s India and my plan of retirement was put aside.  In August 2018 a new avenue opened in the state of Karnataka. I was invited to join as Visiting Professor (Adjunct Professor/ Honorary Processor) for master’s in public health (MPH) course in a newly started Government University. Under the department of Rural Development and Panchayat Raj, Govt. of Karnataka, Karnataka State Rural Development and Panchayat Raj University (KSRDPRU), had started in Gadag, Karnataka, India 582102. I continue to be involved in professional activities even now at the age of 76 years.

Another half a dozen contemporaries and senior colleagues (Drs K B Banerjee, Dutta, Shanti Ghosh, Chadha, Shiv Lal, Shivram, Jacob john, Suresh Joshi, Mathur) practiced Public Health (Being advisors, trainers in UIP, IDSP, and RI & PPI evaluations) after retiring from GOI/AFMC and New-Delhi Municipal Corporation (NDMC). The most influencing person was an IDSP consultant from USA Dr. Claire Broom (Disease Surveillance Consultant from CDC Atlanta) at the age of 65 years. I have also seen many others have whittled down their practices, hanging on to a few hours of patient care along with supervision, teaching, and involvement with professional organizations.

In discussing retirement with some of my peers, it's became clear over time that how each PHP approaches this decision — and how they choose to live after it's made — with a unique set of concerns and goals.

Case Studies:

1. Fatigued by Bureaucracy

Dr M. Datta in the process of "shrinking" his private consultancies said he is not retiring but planning to scale back to 3 days a week and 4 hours a day starting 1996. "I want to work less so I have more time for my grandchildren, friends, and travel, and to finally write more. He spoke. "I'm so tired of prior authorizations, and the 3 days a week of Public Health exchanges I've been committed to feels just about right." He spoke. During the Guinea worm eradication efforts, Datta relinquished his office, and he continued with a virtual guidance, which allowed him more flexibility in terms of where he is physically located. "The Guinea worm eradication didn't influence my decision to scale back, but it did play a role in deciding to give up my office," he said.

Similar was the story of Gen. Chadha in UIP between 1987-1999.Having retired from Armed forces and NDMC, he actively participated in UIP trainers training, National Immunization surveys in initial districts in early and mid-1990’s and finally with drew saying the travel involved and long hours of UIP training did influence his decision.

2. A Decision Precipitated by Medical Reasons

Another highly experienced PHP retired as director of NCDC and for a brief period as advisor (PH) to MOH&FW GOI and fully retired from professional activities in June 2011. He started scaling back a few years ago, when he had to give up his NCDC office because the building was undergoing renovations. It was a setting he had never worked in and retired as Additional Director (PH) General and continued to work for another 3 years as advisor (PH) in MOH &FW. His decision to retire was propelled by the diagnosis of Parkinson's disease at the end of 2010. "Till then he had only a resting tremor, but this is an illness in which cognitive decline is a possibility."

3. A decision motivated by keeping occupied and supplement income:

Dr K B Banerjee retiring as deputy Commissioner (MCH) in MOH&FW, started doing private practice as family health care practitioner to be active and support his income form the pension.

What Do PHPs have to do to Retire from individual PH Practice?

I. Financial Stability: What many financial planning professionals advise "What investment net worth do an individual need to be financially independent and make practicing medicine optional?" In my 52-year career, this "magic number of net worth" is by far the most common thing PHPs want to know. If you look online, articles may recommend having a portfolio valued at, INR 20 million if you own a house and 30 million if not.  A few Financial experts may recommend not uncommonly 50-100 million or more to retire. Really? Most of us might be thinking that surely not everyone needs that amount. Luckily, my own and our peers experience in the last 16 years of retirement says that's true.

There's no magic number your portfolio should be, just your number. It's human nature to want a simple, clear target to shoot for. But unfortunately, there's no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client's financial plan including insurance, investments, estate planning, and other items the most honest answer I can give is, "It depends." Not satisfying, I know.  If Bank FDs and Mutual funds can earn a minimum interest of 5% per year, to fetching about 10/15 lakh per year or roughly 1-1.5 Lakh per month for routine expenses is enough in the current time. But there are still too many holes to fill.

By far the most important factor in getting beyond "It depends" is having an accurate estimate of annual retirement expenses. I and most of my friends live comfortably on INR 50,000 a month (as many own their homes by the time of retirement. If not may have to add another 30-50 K for rental purposes in an upper-middle class localities in any metropolitan cities. That amounts to a maximum of INR 1 lakh per month. A district or sub-district life may cost around 50K in all. In retirement not many needs INR 50,000 or more. Knowing how much an individual needs depends on the individual's unique dream for retirement and calculating what that dream will cost. Form a Guesstimate Based on Savings and Anticipated Expenses, the total portfolio value needed to sustain a monthly expense of INR 50,000 a year in retirement spending, vs the portfolio size needed for INR 100,000 or more, blows apart the fiction of a universal "magic number.

It's hard to gauge exactly what you will need; the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence. In the end, it's up to you to determine your desired retirement lifestyle. Then, the only way to get there is to (1) calculate how much it will cost and (2) save up for it by following a well-informed financial plan. This plan shifts from the middle to the later stages of your career and into retirement [6]. The key strategies:

Option 1: Spend Less

The first bucket necessary expenses such as housing costs, food, and healthcare. The second holds discretionary expenses that are nice to have but aren't really that important to you.

The discretionary bucket:  

Driving more modest cars: Case study- One of my friends was set on retiring at age 60. One of his pleasures was driving late-model cars like Rolls Royce, Ferrari or at least a Tesla. Given the current cost of Fuel (Petrol INR 120/litter), when he looked at his use of car (hardly 50kms /week) and the battery going down due to under0utilization) and other priorities, the cars didn't matter as much as not working. So, he retired at 60, is content at 76, using Hyundai’s I-20 and he doesn't miss those cars that ate up so much of his income.

Supporting your children: Case (self) study. Many of my friends including me help our adult children from time to time. Despite out 34 years son, who has limited earning capacity (due to a genetic condition called Noonan Syndrome) with a potential to improve as a sport journalist. I and my spouse planned for his occupational rehabilitation and slowly eliminating this spending. We have made assets and cash balance to get them the requisite monthly expenses and communicated our plan clearly to this child and his elder sibling (for support, if needed, out of his share of parental assets) in USA.

Traveling.  I have not given up give up traveling but economized my travels. I travel by train where it involves overnight train and take flights only beyond 10 hours overnight journey. I have started travelling by II AC sleeper coach instead of travel by first class! I stay in the University guest house or three-star hotels instead of 5/6-star class hotels and dine out in the moderate expensive restaurants. Delhi, Mumbai, Pune, Chennai, Kolkata won't be any less spectacular whether you stay at a three-star or a five-star hotel. What I'm saying is that even modest changes in spending, such as a few thousand Rupees a month, can have a big impact [6].

Option 2: Work Longer

Even after lessened discretionary spending substantially it's still not enough, one can explore scenarios for working a few more years, at least part-time. Like making small adjustments in spending, working a little while longer (even at a lower income) can make a big difference. This can be a big relief if you want to retire sooner rather than later but you're behind in your savings.

What should a PHP in developing countries do? It depends. I can't tell you how to weigh cutting spending against working longer because it's a very individual choice. Economizing may be easier for one, whereas others are happier extending their careers like me. In the end, it's individual decision how to balance your current needs with what you want in the future.

Discussions:

Preparing for retirement poses challenges for many working adults, but for public health physicians, the concerns go beyond finances and planning how to fill their days. “The main challenge confronting physicians who are seeking to retire is the justified concern for the future wellbeing of their patients or the national health program they led. Majority PHPs expect to retire around age 60-62 but retire closer to age 70 -75 worldwide. According to a systematic review of 65 studies published on Nov. 15 in Human Resources for Health. Most of the studies examined were conducted in the United States, the United Kingdom, Canada, and Australia between 1978 and 2015. In many countries, a pattern has emerged over the past 40 years whereby a “disproportionate” number of physicians practise medicine beyond the traditional retirement age of 65 [4].

Retirement planning and transition strategies have “important implications for patients, hospitals and health care systems,” states the report. When physicians retire earlier than expected or, on the other end of the spectrum, hang onto their stethoscopes a little too long, it can have “dire consequences in terms of both patient safety and human resources allocations.

Reasons commonly cited for early retirement include burnout, a lost sense of autonomy and health concerns, such as psychological stress. Physicians who delay retirement reported doing so because of concern for their patients, a lack of interests outside medicine, financial obligations, and a fear of losing their sense of identity, among other reasons.

A recent survey in USA indicated that 60% of American workers surveyed nearing retirement or already retired are worried or do not believe income will cover expenses during retirement. More than half of near retirees believe they will need more than twice what Social Security provides to make ends meet and 66% of retirees surveyed would feel more retirement security with more guaranteed lifetime income [4].

4. National Interest- Indian Case Study:

The unmet need of public health professional cadre since Independence and Bhore committee report of 1952 and the recent alarm raised about the public health professionals demand in the wake of Covid 19 pandemic (2020-2022), re-emphasizes the urgency of consideration of PHPs not to hurry for retirement but continue to contribute if they are physically and mentally fit. It is not enough to think of one-self alone but look at the interest of the nation. PHPs from academic career can contribute directly as consultants in various national health programs starting from district to national level and more importantly working as adjunct faculty in MPH schools. PHPs from the field experience can contribute as adjunct faculty in MPH schools, in building requisite skills among MPH scholars in epidemiology, national health programs and their own area of subject expertise.

Case Report (Autobiography): I am an MBBS graduate, opted Public Health career by choice in late 1970’s and worked as a PH professional at all stages of the health system in India over last 54 years.

The most important consideration in developing countries is of the scarcity of the medical graduates with Public Health qualification and especially those associated with one or more national health programs {programming, capacity building, implementation, monitoring, and evaluation} experience. The recent Covid 19 Pandemic has increased the need for epidemiologists, and in response the Governments and many autonomous medical colleges, universities and allied health science institutions have started courses of master’s in public health, public health management, hospital, and health management etc. There are around 100 MPH Colleges in India and many more cropping up every year.  The minimum eligibility criteria for MPH course are that the candidates are required to pass a bachelor’s degree program in health science or relevant field from a recognized university [3]. MPH or Master of Public Health is a 2-year, full-time program in maintaining healthcare through public awareness and providing health solutions. MPH course imparts knowledge through variety of teaching/learning techniques, including lectures, case discussions, practical exercises, lab work, field visits, seminars, journal clubs, collaborative learning, group discussions, assignments, hands-on training, internship, and dissertation [4].

Most of the newly opened colleges outside of medical colleges or deemed universities run on 2-4 newly graduated MPH faculty with diverse (Dental, Ayurveda, or Homeopathy) background and MPH with very little experience. The country is churning out about 2500 MPH post-graduates every year in the last 5 years. Even the well-established autonomous medical universities have started these courses in their Allied sciences wing, but the pity is departments of community medicine of their own colleges are not involved in teaching and training of MPH scholars.

The scholars in these institutions come with diverse background like ISM (Ayurveda, Homeopathy), BDS, Nursing, Pharmacy, General Science and Social science), there is a big need of demystifying public health and medical terminologies to bring multi-disciplinary graduates on a common platform. Some of them are vernacular graduates with limited capacities of understanding English, the medium of instructions in these courses. Even where the teaching faculty in medical colleges are involved, they have very little exposure to health programs of the country and find it difficult to meet the practical skills empowering demand of MPH courses. The need to develop PHP cadre with requisite skills is demanding and continuation of experienced PHPs will be win-win situation for both the PHPs and country’s health System.

For the academic from medical colleges, there are many constancy opportunities with multiple development partners for applying their academic and research knowledge in training, program implementation and monitoring. 

Case Report: India wakes up to the nations’ need: Professor of Practice:

In the light of National Education Policy 2020 expectation of a greater collaboration between academia and industries for promoting holistic and multidisciplinary education with a focus on creativity, innovation, and employability Government of India’s set up a committee in 2020, that has recommended to institute the ‘associate professor of practice’ and ‘professor of practice’ at all Higher Education Institutes (HEI) to attract mid-career and senior professionals in service at industry and research institutions. These recruitments will be distinct from regular faculty appointments and are capped at 5-10% of the total faculty strength. The panel also suggested a three-year contract for candidates with 10-15 years of professional experience, including at a senior management position.

A professor of practice is expected to design and develop new practice-oriented courses, advise students in their projects, and link them with appropriate external stakeholders, besides engaging in department building activities, enhanced industry collaboration and mentorship in innovation projects. The professors of practice apart, the committee also called for bringing in industry experts as “adjunct faculty” for holding lectures or practical for a maximum of 32 hours a month at a rate of INR 1500/per hour. The only anomaly is 2 hours of practical being considered equal to one hour of lecture diluting the basic principle of skill /capacity building.

Public Health Course as a part of Rural development - a unique opportunity:

Bhore committee had recommended primary health care as a component of overall community development, but country had lost the track in programming. For the first time in the history of Public Health in India, the ministry of Rural development and Panchayat Raj, Government of Karnataka started n MPH course since 2018 in the Karnataka State Rural Development and Panchayat Raj University (KSRDPRU), Gadag, Karnataka – 582101.

Vision and Mission of Karnataka State Rural Development and Panchayat Raj University

The Vision is to act as a centre of excellence to transform rural society by the creation of a dedicated, committed human resource which participates in the comprehensive rural development process to ensure sustainable rural development and broad-based improvement in the quality of life of rural population.

The mission of the university is to impart education and training to various stake holders for rapid economic growth and sustainable development that reduces poverty and creates employment opportunities, access to essential services in health, education, and skill development, leading to inclusive growth through the democratic mechanism of Panchayat Raj institutions, where people decide their own welfare and economic and socio-political development.

As a visiting professor for MPH course from the first batch in 2018, I was requested to design and develop MPH course, advise students in their projects, and link them with appropriate external stakeholders, besides engaging in department building activities, enhanced industry collaboration and mentorship of the faculty and in innovation projects. Having been a visiting professor from the first batch and seen two batches coming over with about 50 graduates, I vouch this will be the way to go about for Rural Public Health in India the city bred and taught medical graduates or MPH professionals will not reach the remote rural India in another 50 years.  All the graduates in KSRDPRU for different PG courses {MBA in rural management, M.Sc. (Food Science), M.A Social Work, Public Administration, Economics, Rural Development & master’s in public health)} of 2 years duration, are exposed intensively to their own subject of own and other subjects mentioned for about 30 hours in each semester for build capacities of overall rural development [7].

 
KSRDPRU Brochure of 2022

Conclusion:

Medical graduates with public health training are under-valued human resource in India and other developing countries.

Young PHPs come from diverse background and need some time to rise to the occasion. Even when experience their canvas can’t be as big as the Medically qualified PHPs.

There is huge demand for experienced subject experts

PHPs in India must strike a “delicate balance between encouraging preparation for retirement and delaying the timing and eventual transitions of its most experienced staff.

If PHPs do decide to Close their PH Practice: What they Need to Know?

If you have made that tough decision and have ruled out other options, such as joining with a larger group, an autonomous university or an NGO or development partner or there are government regulations and other obstacles to address to ensure a smooth exit, it should not be a hasty process. You will need at least a year to do it correctly, because there is a lot to do.

Once you have settled on a closing date:

1. Review all your contracts and leases. Contracts with Organizations, NGOs, Universities, and others such as answering services and website managers, should be reviewed to determine what sort of advance notice you will need to give.
2. Many organizations include tail coverage at no charge if you are retiring completely, but if you expect to do part-time, locum tenens, or volunteer medical work, you will need to negotiate payments.
3. Once you have the basics nailed down, notify your employees. You will want them to hear the news from you, not through the grapevine, and certainly not from your scholars or other people.  Keeping the current employers in the dark will not prevent that, as they will find out soon enough. Besides, if you help them by assisting in finding them new faculty or professionals, they will most likely help you by staying to the end.
4. At this point, you should also begin thinking about disposition of your official files and other records. You can't just shred them, much as you might be tempted. Your attorney may guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer.  You may have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.
5. Then you must notify your clients or patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it.
6. This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well.
7. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.
8. As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Each state has requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well.
9. Once the office is closed, don't forget to shred any blank prescription pads, and dissolve your corporation, if you have one [5,6].