During 2001–2007, the programme established itself and grew, using standard competencies . If the second cohort is left aside (start-up years faced initial difficulties), the number of graduates increased from 9 to 26 between 2003 and 2007 (+288% in five years). In states such as West Bengal, Orissa and Himachal Pradesh, the graduates played a crucial role, advocating with state governments for them to nominate candidates. The programme continued to achieve its objectives despite the increase in students. In addition to the acquisition of competencies, public health service was delivered through the production of information for action, some of which was reflected in conference presentations and publications. An excessive focus on such products could send the wrong message to public health managers who might perceive the programme as excessively academic. However, the constant increase in scientific production indicated that the quality was compatible with international standards. Moreover, as per prior studies, such products represent a useful indicator of future career success . Senior State level health managers acknowledged the contribution of the students towards improvements in health services either to the faculty member during the field supervision (Himachal Pradesh, Orissa) or at national level meetings (West Bengal) . Finally, the Indian public health system managed to retain this trained workforce in field positions even after graduation. This is similar to the experience of the EIS programme, wherein EIS officers assigned to the field had a tendency to stay in the field after graduation [8, 9].
Aside from strengths, we identified areas for improvement. One weakness was the faculty-to-student ratio that dropped under the level of 0.25 per student initially pledged. While this did not affect the programme quality according to the indicators examined, it placed the faculty under a pressure that could have longer-term adverse effects. Conscious of this issue, the management decreased the number of admissions from 26 in 2007 to 15 from 2008 onwards. In 2009, the management also implemented a new system to screen state-nominated applicants through a selection process. This will (1) restrict admissions to the best applicants and (2) advocate for the quality of the programme. This, in turn, may generate higher quality applications. Laboratory support was another area identified for improvement. Institutionalization of the collaboration between epidemiologists and laboratory scientists is key to a functional disease prevention system . From 2005 onwards, an increased utilization of the laboratory network of the Indian Integrated Disease Surveillance Project (IDSP) provided additional opportunities of laboratory confirmations. Finally, the use of computer programs to analyze data deserved more attention. This component of the curriculum faced a number of challenges, including (1) the heterogeneity of the target audience in terms of baseline computer skills, (2) the need for computers and statistical software and (3) the need for substantial faculty/tutor time.
Our evaluation suffered from three main limitations. First, for the purpose of this evaluation, the students self-assessed their competencies in the on-line survey. This could have over-estimated the competency level actually achieved. Second, this evaluation was only internal. Hence, we may have been subjective. To address this issue, we selected indicators that were as objective as possible and used a generic framework proposed by the United States CDC for FETPs. We also added a survey of graduates. Overall, we may have overlooked some of our limitations or generated an overly optimistic picture. However, our internal evaluation allowed us to identify areas that need improvement, which was our main objective. Third, our evaluation mainly focussed on input, process and output indicators of the programme. It did not address longer term outcomes and impact such as changes brought to the health system. These aspects will require a longer term perspective, maybe in the context of an external evaluation that our programme is willing to conduct in the future.
The establishment of a first FETP in India constitutes a proof of concept documenting that this approach was possible. Key innovations that this FETP brought to India included (1) the learning-through-service principle by which students in training deliver public health service and (2) the use of field epidemiology methods to investigate outbreaks using a sequence of descriptive and analytical epidemiology. Future work will need to focus on continuing investments in human resources to ensure a sufficient faculty-to-student ratio and additional curriculum innovations in the area of the laboratory and the use of statistical software. Most importantly, the FETP needs to be scaled up as the current number of graduates barely reaches about 10% of all the districts of the country that need a qualified epidemiologist. To provisionally address this gap, a shorter, two-week course was developed in 2008 to build basic epidemiological capacity in a lower-tier of professionals. This approach was also used in Germany  and Central America . The National Centre for Disease Control (formerly National Institute of Communicable Disease) in Delhi scaled up this two-week course to train district epidemiologists in the country and also started a Master of Public Health in Field Epidemiology in 2006. However, to reach a critical mass of field epidemiologists and scale up the various initiatives successfully into a full-dimension national FETP, additional organizations and institutions must participate, possibly involving MD (Community Medicine) programmes that have always been a reference in terms of public health training in India. Such partnership will require quality assurance and possibly, an accreditation mechanism. In parallel to scaling up efforts, additional work is needed so that the competencies identified, developed and taught in the context of the FETP can become professional competencies recognized and sought in the public health workforce in India .