Abstract
The quality, accessibility and viability of health services depend primarily on the performance of those who deliver them. Given the strong correlation between the quality of health services and job satisfaction of the health personnel, this study evaluates the problems faced by primary health care providers in India. This cross-sectional study was conducted among middle-level primary care providers operating in the National Capital Region of Delhi, to assess their perception of various issues and challenges related to human resources for health (HRH). They identified gaps in human resource (HR) staffing, training, performance appraisal and compensation, including delays in recruitment, lack of probationary training and failure to link appraisal and compensation to performance. This study contributes to the limited literature on HRH from a broader policy reform perspective, underpinned by stakeholder perspective.
Keywords
Introduction
In India, where a predominant proportion of the population is uninsured, patients from lower income strata rely largely on government health facilities which provide free or highly subsidized health care. During the past six decades, a large network of publicly funded and managed, three-tiered health facilities were created based on population norms (Venkat Raman, 2014). Despite the existence of a large network of health facilities, the public health system in India continues to be plagued by many problems, most important of which are the shortage of staff, resources and non-availability of free drugs. The shortage of doctors and paramedical staff is more acute in primary care facilities in rural areas and urban slums. Against the sanctioned strength of 34,750 doctors at the primary health centres, 9,389 (i.e., 27%) posts are vacant. At community health centres, the shortage is even more staggering as 84 per cent of surgeons, 76 per cent of obstetricians and gynecologists, 83 per cent of physicians and 82 per cent of pediatrician posts are vacant (Ministry of Health and Family Welfare, 2015b). There is also a shortage of paramedical staff such as radiographers, lab technicians and pharmacists.
For several decades, the public health spending remained stagnant at around 1 per cent of the gross domestic product or about 20 per cent of the total health expenditure (Ministry of Health and Family Welfare, 2005). Much of the public health expenditure is on account of wages and salaries, leaving little for purchase of equipment and medicines and meeting maintenance costs. Due to the shortage of staff and medicines in public health facilities, a large segment of people from the lower socio-economic strata is forced to seek services from the private sector. Latest estimates suggest that more than 75 per cent of outpatient services and 60 per cent inpatient services in India are provided by the private sector (National Sample Survey Office, 2015). Nearly 80 per cent of health care spending by consumers in India is private and out-of-pocket leading to debilitating economic consequences on the poor households (Ministry of Health and Family Welfare, 2009).
For a long time, health experts and policy analysts have advocated for addressing this inequitable and anomalous situation confronting the public health system especially as India is committed to achieving Universal Health Coverage (UHC) and sustainable development goals (SDGs). A recent research study that carried out the first global analysis of countries’ progress towards achieving health-related SDG targets, by an overall SDG index, placed India at a low position of 143 out of 188 countries (SDG Collaborators, 2015). This finding indicates that in order to achieve SDGs, specifically in relation to maternal and child health, urgent reforms are required to strengthen the primary care service delivery mechanism.
The need for overall reforms in health system has been recognized and emphasized under key policy documents in recent years, namely, National Commission of Macroeconomics in Health (NCMH) (Ministry of Health and Family Welfare, 2005), the High Level Expert Group (HLEG) (Planning Commission of India, 2011) and Draft National Health Policy (Ministry of Health and Family Welfare, 2015a). Some key recommendations under these policy documents include a substantial increase in resource allocation for public health system, renewed emphasis on primary health care, promotion of universal access to health services and the need to address the HR crisis in public health system on a priority basis. The need to address HR challenges in health sector, more specifically in public health system on a priority basis, was emphasized by the World Health Organization (WHO, 2004, 2006). The WHO reports summarized that the quality of health services, their efficacy, efficiency, accessibility and viability depend primarily on the performance of those who deliver them.
The NCMH, while reviewing the health sector in India, highlighted the importance of HR as one of the key areas for radical reforms as below:
Human resources are the critical variable for the effective implementation of health programs and delivery of quality health care to achieve the national health policy goals in India. The availability of an adequate number of health personnel to effectively and efficiently manage and implement health programs cannot be overemphasized. (Ministry of Health and Family Welfare, 2005, p. 159)
The report concluded that ultimately it is the attitudes, practices, knowledge, skills and values of the health care providers, which influence the nature of the health system and determine how appropriate, rational, efficient and affordable the health care system is. Thus, attracting, deploying and retaining capable and motivated health staff in primary care facilities are essential for achieving these goals. Traditionally, the issues pertaining to HR management (HRM) in the health sector have looked predominantly from a micro level (i.e., a behavioural or organizational dimension in hospital settings) and not so much from the perspective of macro-level policy reforms. Reforms of the health care system may not be possible without taking into account the views and expectations of key stakeholders, which include inter alia the medical officers. This study attempts to address this gap by incorporating a stakeholder perspective.
Review of Literature
There is a general consensus that HRH has been a neglected component of health systems development in low- and middle-income countries (Hongoro & McPake, 2004). In the developing world, particularly in the South Asian region, the public health system is plagued with severe challenges with respect to managing HR in the health sector. More than the shortage of trained health personnel, the public health system in India is confronted with archaic management systems, including traditional civil service rules, poor working conditions, prolonged postings/transfers to remote areas, insufficient pay or incentives for better performance, political interference, lack of career progression and opportunities for upgrading professional skills. This has led to high absenteeism, low morale, indiscipline, unionization, indifference and corrupt practices among health personnel (Venkat Raman, 2002). The high absenteeism and poor service delivery in turn result in an increased dependence of a large portion of the population on private health care, a trend that has also been reported in Bangladesh (Khan, Grubner, & Kramer, 2012).
Since independence, the Government of India constituted several committees to review the functioning of health sector in the country. The Bajaj Committee (1987) indicated that the genesis of HR problems in India’s health sector seems to be due to a the dichotomous growth of health services (delivery) and HR, each developing in isolation, without a proper synergy between temporal and spatial dimensions. The committee observed that there has been a major emphasis on the development of physical, technical and technological facilities rather than on managing the manpower or their development. According to Venkat Raman (2002), issues pertaining to the management of health personnel in the public health system are rarely viewed from a broader civil service (administrative) reform perspective, which is seen to be more complex having wider ramifications, and thus no attempts are made to address them. However, evidence shows that HR drives health system performances (Chen et al., 2004) and that addressing HR challenges enables the development of health care systems, which would be more responsive to the expectations and needs of population in the long term (Dussault & Dubois, 2003; WHO, 2006). Accordingly, developing capable and motivated health workers may be considered essential for overcoming bottlenecks to achieve national and global health goals. The importance given to HR cannot be disregarded in the strategic planning and implementation of the health sector reform process (Rigoli & Dussault, 2003).
Call for reforms in the management of HR in the public sector (i.e., civil services) has been ongoing for several years both in India and around the world. However, advocacy for HR reforms in the public health system gained momentum only in the recent past (Bhat & Maheshwari, 2005; Buchan, 2000; International Labour Organization (ILO), 1998; Martinez, Collini, & Martineau, 1999; WHO, 2006). While substantial efforts were made in planning and production (training and medical education) of HR in the health sector, very little efforts were made to introduce modern tools for managing health personnel in the public health system. As a result, despite an increased supply of trained health personnel, public health facilities in India are unable to fill vacancies or retain staff. This bolsters the argument that there is a need for urgent reforms in the management of HR in the public health system and the first step in this process will be to identify the kind of managerial reforms required.
Though measuring the effectiveness of HRM practices through employee perceptions has been considered to be a crucial factor (Wright, Gardner, & Moynihan, 2003), the number of studies focused on reviewing the perception of clinical care providers on management practices in public health system, more specifically on HRM, is limited.
In 2002, Venkat Raman conducted a survey among primary care physicians from government health facilities from rural areas of one district, each in two Indian states. The study identified several HRM issues, related to recruitment, probation, posting, promotion and transfers, training opportunities, rewards and incentives, etc. The study found most rural primary care physicians seeking radical reforms in the civil service rules. In 2007, an attempt was made to review the HRM practices prevailing at the government health establishments across two states in India (Gujarat and Madhya Pradesh; Central Bureau of Health Intelligence, 2007). The study did not make any attempt to document the perception of medical officers working in the public health system.
Awareness and suggestions about the HR practices were studied among health workers in Vietnam (Marjolein, Pham, Le, & Martineau, 2003) where health workers felt that the appraisal process should be more appropriate and training process be more transparent. However, this study was limited in the context of job satisfaction. In another study in Malawi, health workers considered training and career progression strategies to be inadequate and also felt that they were inadequately supervised, with no feedback on their performance (Manafa, McAuliffe, Maseko, Bowie, Maclachlari, & Normand, 2009). A study from Israel reported that employees who invest in their jobs expect feedback and recognition from their managers and there is a likelihood that the employees will produce a better quality of services if they understand that the ways in which they are evaluated and rewarded are procedurally fair (Tzafrir & Gur, 2007). Almost all the above-mentioned studies looked at the perception of care providers in rural settings. In this article, an attempt has been made to study the perception of primary care physicians in urban, government facilities.
Research Methodology
The overall objective of the study was to identify and highlight the issues and challenges in the HRM system, policies and practices as perceived by the physicians (General Duty Medical Officers or, GDMOs) employed in different government health facilities, in an urban area. The study was carried out through a survey of physicians in different primary care facilities (dispensaries) managed by four different government agencies: the Government of National Capital Territory of Delhi (Delhi government), Municipal Corporation of Delhi (MCD), Employee State Insurance Corporation (ESI) and Indian Railways (railways). While the health facilities under Delhi government and MCD are managed as government departments, the ESI and railways are autonomous government organizations. However, ESI is managed as a corporation. The respondents, that is, the GDMOs, are primary caregivers who, besides providing clinical services (outpatient consultations), also hold administrative responsibilities. They are permanent employees, who have been in service for few years in their respective organizations and are therefore expected to be familiar with the service rules, HR policies and practices of their organizations. For the purpose of the survey, the selection of facilities and respondents was through a purposive sampling method. However, due care was taken to include a wide representation of respondents from different facilities.
A survey questionnaire was prepared, primarily based on the survey tool used by Venkat Raman (2002). The questionnaire was then pretested among 12 GDMOs (3 from each setting) to check for its comprehension, ease of use, relevance, time taken and other properties. Based on the feedback from the GDMOs, the questionnaire was edited and moderated. Since the study is exploratory in nature, the moderated questionnaire was used for collecting data. The health facilities of Delhi government and MCD were chosen purposively to represent the service delivery context, that is, in urban slum communities. Since railways and ESI did not have such outreach facilities, the survey was conducted in facilities that had the maximum number of GDMOs. The respondents were chosen based on the experience, that is, minimum of two years of experience as GDMOs.
Prior permission was obtained from authorities before the survey could be initiated. The participation of the respondents in the survey was voluntary. The questionnaire sought responses on five broad areas of HR systems and practices, namely, staffing, induction and probation, performance evaluation, training and development, and compensation, rewards and recognition. The key questions were related to satisfaction with the staffing pattern based on workload, their suggestions about attracting talented people for public health, their views on the utility of the probation period, satisfaction with the performance evaluation and suggestions for making it more effective, existing training programmes and improvement desired, and lastly the satisfaction with and recommendation for improving the compensation, rewards and recognition. As the GDMOs did not have any formal training in HRM, the researchers had to clarify some of the HRM terms used in the questionnaire (e.g., performance evaluation had to be rephrased as the annual confidential report system). During their interactions with the researchers, the respondents made informal and impromptu comments. Though not part of formal data collection, some of these comments have been presented in the article in order to provide a richer experience and understanding of the data.
Results
A total of 200 questionnaires were distributed, out of which responses were received from 180 medical officers, yielding an excellent response rate of 90 per cent. A brief summary of the respondent profile is given in Table 1.
Profile of Respondents from Different Health Facilities
Of the 180 GDMOs who responded to the survey, 60 were from Delhi government, 40 from MCD, 48 from ESI and 32 from the railways. The mean age of the respondents was 42 years (± 8.74), and it was similar across different facilities. This indicates that most of them have had a minimum of 10–15 years of experience, a right time for them to have experienced the HR issues and reflect on them candidly. Out of 180 respondents, 110 (61%) were male and 70 (39%) were females. Respondents from railways had the highest median years of experience, followed by medical officers from ESI, MCD and Delhi government. The mean number of promotions for the respondents was 1.4 for 10 years of experience from all types of health facilities. The higher mean number of promotions in railways and ESI implies quicker promotions for GDMOs employed in such organizations, as compared to their counterparts in MCD and Delhi government. This indicates slower career progression in government organizations than that in autonomous undertakings. A majority of the respondents (71%) possessed basic medical graduation (i.e., MBBS) and were not specialists with post graduate medical degrees (i.e., MD or MS). Therefore, the respondent group (GDMOs) and the care setting (dispensaries) clearly captured the perception of primary care providers.
In the following sections, the perception of GDMOs on various HR policies, systems and practices are analyzed further.
Staffing
The perception of doctors about issues related to staffing revealed that nearly half of them (44.5%) were dissatisfied with the volume of workload and the sanctioned staff strength at their health facilities. The most common reason for the staffing gap identified by more than half of the respondents was failure to recruit staff in time. Non-attractiveness of public sector (government) job and low salary were stated as reasons by 28 per cent and 18 per cent, respectively. However, nearly half of the respondents expressed satisfaction with the screening methods followed for recruitment and with the transparency of hiring process.
More women (72.2%) respondents expressed greater dissatisfaction with the staff deployment and resultant workload due to the shortage of manpower as compared to men (52.7%). This perceived high workload and consequent dissatisfaction among women doctors could be due to the fact that a majority of patients who seek services from primary care facilities (dispensaries) are women, who prefer being examined by female doctors, thus increasing their workload.
In recent years, health policy analysts have been advocating for the use of morbidity-based (i.e., epidemiological data) staffing norms for the planning of HR (e.g., Lopes, Almeida, & Almada-Lobo, 2015). This means that if a geographical location or a community faces a greater risk of maternal deaths, the health facility serving that community (or area) should have an obstetrician and support staff who can provide maternal health services. But most governments across the world, including India, rely only on creating health facilities according to the population norms and HR planning according to the health facility staffing norms. The exact methodology for arriving at estimates using such techniques is still evolving. Though nearly 31.7 per cent (one-third) of the respondents felt that staff estimates should be based on bed capacity (which is true in hospital settings), 22 per cent felt that morbidity-based estimates would be more appropriate.
Induction and Probation
Induction and formal orientation of new employees is an important stage of an employee’s career. Incoming employees not only need to be acquainted with the job responsibilities but also with the organizational culture, people and work context. This allows both the employee and the organization to test their mutual “fit”. It is obvious that probationary training enhances work place adaptability, thereby improving performance and efficiency. Unlike the probationers in more prestigious civil services (e.g., Indian Administrative Service or Indian Police Service), the probationary period is a mere formality for medical officers in the Indian public health system, with no attention paid towards their grooming or orientation to the community they serve or work place culture. They are expected to “learn the ropes” all by themselves. Further, the absence of probationary training leads to an inadequacy of adaptability among the doctors, especially those serving in rural areas or in urban slums. As a result, doctors who are posted in public health facilities are often socially and culturally alienated from the community they are expected to serve (Venkat Raman, 2002).
The respondents were asked: Whether this probation period could be turned into an effective mechanism for induction and thereby improve performance? The results show that an overwhelming majority (95.6%) favours probationary training. More than half of the respondents were of the opinion that probationers who perform poorly during this period should not be confirmed. A significant proportion (63%) of respondents did not consider that the current format of the probationary period objectively assesses their ability to serve in a public health facility.
One of the respondents commented:
[W]hen we are hired, we are simply asked to report to a health facility and meet a particular officer; we do not know the people we are going to work with or work for; we do not know what clinical skills and social skills are needed to work in a dispensary in a slum community; although we did our extension work, but much of it was for few days in a month.
Performance Evaluation
In government health departments, the appraisal system (commonly called as the annual confidential report) has generic evaluation parameters and is highly subjective in practice. The appraisal system varies in its format, objective and content across the four organizations mentioned. The appraisal system in MCD is most rudimentary. Allegedly designed in the 1970s, the format contains four pages of information containing appraisal criteria such as “quality of work,” “quantity of work” and “job knowledge.” Although the appraisal form of Delhi government is more elaborate, both MCD and Delhi government system are invoked primarily for the purpose of promotion decisions, that too only to verify for any adverse remarks. The appraisal forms of ESI and railways are more contemporary in its format wherein all the appraisees are required to fill in the self-appraisal form prior to supervisor’s assessment and are therefore well versed with the current performance appraisal parameters. As is the case with most other organizational settings, the appraisal system in this case too is subjective and is susceptible to biases.
Despite the archaic system of the performance evaluation process, a majority of the respondents expressed satisfaction with the frequency of the appraisal (79%), evaluation parameters (63%) and transparency of the system (70%). More than one-third (40%) of the respondents were of the view that the performance appraisal process lacked follow-up measures, in terms of providing additional skills or competencies to overcome any performance deficiencies, thus indicating that the basic purpose of the appraisal was not being fulfilled. A majority of respondents (57%) felt that the current appraisal system has not made doctors complacent in performance and that most doctors are performing to their best abilities. The remaining respondents (43%) felt that the current performance appraisal process lacks incentives for good performers. A contentious issue in performance appraisal is the perception of bias, which often leads to dissatisfaction and even legal wrangling. Although half of the respondents (49.4%) felt that the performance appraisal process is riddled with bias, almost an equal proportion of respondents (47%) did not agree.
In government organizations, while the self-appraisal forms are submitted to and reviewed by a reviewing officer, the appraisal is carried out solely by the superior officer. In contrast, most private organizations follow a system of joint consultation between the appraiser and appraisee, in addition to self-appraisal. The respondents were asked whether there was a need to change the current system of reporting. They were also asked to suggest a better evaluation system. A majority of the respondents did not feel a need for change. Only 11 per cent of respondents suggested that a more comprehensive appraisal system be put in place, where the evaluation is carried out by superiors, subordinates as well as the patients.
It is interesting to note that, although there is certain dissatisfaction with the current system of performance appraisal, the doctors do not seem to be in favour of implementing any changes that may lead to a wider scrutiny of performance (by patients, subordinates, etc). As reflected in the following comments, this is mostly due to a sense of resignation and frustration over current working conditions:
[G]iven the working conditions in which we are working, how can you ask for more performance; … what do we gain from better performance? Same increment, same promotion? … here there is no one who bothers how hard you work; In fact if I work hard I am likely to be given more work.
Training/Continuing Medical Education (CME)
In the health sector, training is widely and frequently used to upgrade the technical skills of health staff (i.e., clinical skills). Training in public health (i.e., non-clinical issues such as sanitation, nutrition, community mobilization and disease prevention programme) is provided only if a new national or provincial-level health campaign or programme is launched or whenever a health crisis (such as an outbreak of an epidemic) occurs. Training on clinical skills for doctors is usually called the CME programme. Most physicians do not get training in management/leadership development till they reach a level of seniority and/or occupy an administrative position. Such programmes are on general management rather than focused on any specific management domain such as HRM.
A majority of the respondents (81%) viewed training and CME to be highly important. A large number of respondents (43%) felt that all the deserving people were not sent for training. As stated by some respondents:
(“… people who are sent to the training are those who are easily dispensable people”; “…. you ought to have good relations with your boss to be nominated for a ‘good’ training program” as stated by couple of respondents).
Despite these reservations, most respondents (82%) felt that their knowledge levels had improved after attending the training programmes. It must be noted that many short duration, off-site training programmes are awareness creation programmes focused on imparting knowledge (e.g., new diagnostic protocols for tuberculosis), whereas most CME programmes are focused on imparting clinical skills. A majority (66.7%) of the respondents indicated an improvement in their skills, whereas many (62%) also believed that their performance had improved after attending the CME programmes. Many respondents (63%) stated that the training programmes, especially behavioural skills programmes, helped them to improve their attitude towards their work and improved their perspective towards others (colleagues and patients). Benefits of the programme in terms of the acquisition of skills and attitude towards work and others were significantly higher among doctors from Delhi government as compared to others.
Compensation: Non-practicing Allowance (NPA)
In some states in India, government doctors are prohibited from private practice and are given a NPA as part of compensation, whereas in some other states the government doctors are allowed private practice instead of NPA. All the respondents in this study receive NPA and are not allowed private practice.
A majority of the doctors (over 60%) felt strongly that the NPA should be uniformly applicable for all government doctors across the states and private practice should be discouraged as is the case in some states. However, nearly half of the respondents (46%) felt that NPA is not an adequate compensation and therefore additional revenue earning options should be permitted by opening private wards in government hospitals.
Some comments in this regard are given below:
“… when we joined the government service, we knew well that the salary and perks are going to be less than our friends who joined the private sector. But NPA is no compensation to what one can earn additionally.” “… there is no second opinion that government doctors should not be allowed private practice. But when NPA is pittance, doctors would be tempted to indulge in moonlighting.” “… incentivize our work. Let the doctors who want to do private practice, do it inside the government hospital. Open private wards and private clinics. Let’s share the patient fee; hospital will also earn money.”
It is apparent that all doctors, irrespective of gender, are not satisfied with the NPA alone, with differing views based on seniority. A significant proportion of respondents (40%) felt that private practice among government doctors should be legalized. Many doctors (43%) felt that doctors should receive monetary incentives in relation to their performance. These findings indicate a desire for higher earning in addition to the security of a government job.
This is not a surprising finding. Debate on the compensation package for professionals, like doctors, in government services has been raging since the 1980s in India. Due to the rapid growth, the compensation package in the private health sector has multiplied several times, compared to a highly regulated and structured government system. The government health system is no more an attractive place for a large section of medical graduates. Doctors are hired on short-term contracts, at lower wages, with no guarantee of regularization. This is compounded by the fact that medical education (especially in private sector) has become highly expensive. Previous studies (Central Bureau of Health Intelligence, 2007; Venkat Raman, 2002) have indicated that doctors would not mind existing salary structures, but would prefer better perks, benefits and incentives.
Perks and Benefits
Respondents were asked about their satisfaction with respect to the various perks and benefits available to them. Questions on perks and benefits include allowances and provisions, such as house rent, leave, children education and financial assistance schemes (housing loan, provident fund). A majority (67%) of the respondents expressed satisfaction with various provisions governing leave. More men (69%) appeared satisfied with leave provisions as compared to women respondents (63%). Satisfaction with children’s educational assistance was low among all respondents (40%). Even doctors in railways who were otherwise found to be most satisfied on all parameters were dissatisfied with regard to the children’s education assistance. Although railways have dedicated schools for the wards of employees, officers posted in cities tend to send their children to private schools, and the unsubsidized fee could be a matter of concern. Another factor could be due to the transferability of railway officials affecting their children’s education. Only 61 per cent of women doctors indicated satisfaction with maternity benefits from their employers.
Although a large number of government doctors are provided with government accommodation, satisfaction with residential accommodation was found to be considerably low (32%). This may be due to the fact that the residential accommodation provided by the government is in short supply in Delhi and/or the rental costs of private accommodation are very high in a city like Delhi. Some of them do not avail the government accommodation due to their own housing and they tend to compare the rental value of their accommodation vis-à-vis the house rent allowance they receive. This is evident from the fact that only half of the respondents (55.6%) are satisfied with house rent allowance.
Provident fund is a uniform, statutory provision for all government employees, but only 54% of them were satisfied with the provident fund scheme. Only 47 per cent of doctors expressed satisfaction with conveyance allowance, whereas satisfaction with pension benefits were even lower (46%). In recent years the governments have moved away from employer-(in this case, the government) supported pension scheme to voluntary (privately managed) pension fund scheme evoking dissatisfaction across employees who recently joined government services. This disaffection could be higher among the younger employees.
As indicated earlier, professionals in government services apparently are willing to accept a grade-based salary system, but wish to receive more/better perks and benefits. Unlike corporate employees, whose perks and benefits are monetized (expressed as cost to the company), in government services several perks and benefits are indirect and not monetized and therefore the employees are unable to comprehend the real value of the perks and benefits (for example, government accommodation in a prime location of the city could fetch a rental value much more than the gross salary). High satisfaction level on account of leave provision is not surprising considering the liberal provision of leave for government staff, compared to corporate employees.
Recommendations for Reforming Public Sector HR System in Primary Health Care
Major changes in the existing HRM practices, especially for government departments such as MCD and Delhi government, are considered to be urgent and imperative. However, effecting changes in government systems are time consuming and slow process. Resistance to change is more forceful among government departments compared to autonomous government bodies. It is equally important to seek the views of the government employees, in this case GDMOs, to identify the scope and areas for reform.
The respondents were asked about the type of changes they would like to recommend for improving the HR management systems, policies and practices, in order to improve the functioning of government primary health care system. Table 2 presents some of the recommendation for improving HR systems in public sector health care system.
Respondents’ Recommendations for Improvement
Discussion and Conclusion
The research referred to in this article aimed to understand the perceptions of middle-level medical officers, providing primary health care services, in urban settings about the manner in which HR are managed in their respective organizational context. The study also sought to measure the degree of satisfaction of these officers, about the existing HR practices, and sought specific feedback on how to improve the management of HR. In a developing country context like India, primary care settings are resource deficient, overcrowded and located in highly demanding physical locations. Motivated staff, with skills and competencies commensurate to the demands of the work situation, is key to the success of any community-based organization underscoring the importance of effective HRM system.
The article contributes to our understanding of the perception of primary health care providers regarding various components of the existing HRM practices and identifies solutions to improve the system. The respondents perceived a regular shortage of staff and considered delay in recruitment as the reason for this. This implies the need to find other ways for effectively filling the staff vacancies (especially doctors) in time, instead of excessive dependence on the public service commission, as is presently the case. The age distribution of the health workforce can be an indicator of how frequently younger health personnel are hired (renewal of personnel). In our study the average age of primary care physicians was more than 40 years, which may be indicative of a low rate of renewal given the long drawn recruitment process. The gender dimension is crucial to a comprehensive assessment of HR in health systems. In some contexts, access to female providers is an important determinant of woman’s health service utilization patterns (Gupta & Dal Poz, 2009). In the present study, it was found that women doctors felt their workload was higher as compared to male doctors. It is important to recognize these social and cultural factors, while determining the composition of the workforce being deployed in the primary care facilities.
The challenges in managing HR in health care organizations, as found in the current investigation, are also faced in other countries of the South Asian region. The strategies suggested by the respondents in our study to overcome these challenges (for instance, providing career development opportunities for those serving in remote and rural areas) are similar to the ones outlined in the World Health Organization’s report (WHO, 2014).
Compensation plays a significant role in determining the attractiveness of a workplace. Physicians in the private sector tend to earn considerably more than their counterparts in public facilities. In the Indian context this situation is not uniform. In Madhya Pradesh, doctors in government health facilities were perceived to receive better remuneration than their counterparts in the private sector, whereas in Gujarat it was the reverse (Central Bureau of Health Intelligence, 2007). Through this study, it can be seen that in Delhi the doctors perceive that remuneration in government health services is not attractive. Inequities in access to health service utilization result from absence of policies to encourage providers to work in remote areas. A report by the World Health Organization (WHO, 2014) recommends development of strong HR policies, provision of better living conditions, continuation of professional career development and better remuneration for doctors in the South East Asian region who work in disadvantaged areas. The report also mentions that in Myanmar, doctors in such areas are given twice the regular salary leading to better retention. In the studies from Gujarat, Madhya Pradesh and this one from Delhi, it is evident that physicians want monetary benefits and incentives to work in primary care settings in rural areas and urban slums. Motivation in health staff is influenced not only by specific incentive system, but by a range of reforms that would affect organizational culture, reporting structures, channels of accountability, etc. (Bennett & Franco, 1999). In the present study too the medical officers have recommended a range of reforms, including decentralizing hiring, setting up a separate pay commission for health staff and de-freezing the upper limit of salary. Medical officers in this study indicated dissatisfaction with the performance appraisal system and a perceived lack of transparency in the training programmes. They expressed satisfaction with the frequency of supervision, but not with the quality and transparency of performance feedback. A similar finding was reported by Marjolein, Pham, Le, and Martineau (2003). Induction training or probationary training is another major area of concern for government doctors.
It is well established that effective management of care providers in high intensity human service delivery settings, such as clinical care, old age care, etc, influences the clinical outcomes. Effective management of HR not only depends on designing appropriate policies and systems but also how they are implemented. There are both direct and indirect ways to measure the effectiveness of HRM system. Perceived effectiveness of the HRM system by employees is one such measure. Research studies confirm that the policies and practices in managing HR in the public health system continue to be archaic and are perceived as such by the doctors providing primary health care. In a country like India, where a large proportion of primary care services are sought in the private sector, even by the poor households, due to the inadequacies of the public sector, there is an urgent need to reform the manner in which government attracts, motivates, develops and retains doctors in its health facilities.
The ability to attract, deploy and retain skilled and motivated health staff in primary care facilities is directly related to the quality of HRM policies and practices. This is more so for professional health staff such as doctors. Unless the existing, archaic civil service rules (or HR policies) are thoroughly reviewed keeping in mind the perceptions and suggestions of the primary health care providers, and keeping in view the competitive market for talent, and HR practices in other health care settings, it is unlikely that the government will be able to provide health care services to a large section of the population. Strengthening the service delivery capacity of the public health system through reforming the way it manages its workforce is critical for ensuring UHC, which is one of the SDG of the United Nations. One key step in this direction could be creating dedicated HR department within the Directorate of Health Services in every state, staffed with HR professionals, who could identify and effectively handle the complexities of managing a wide range of employees varying from super-specialists in a tertiary care hospital to village-level health workers. In many countries, governments have embraced such initiatives termed as New Public Management (NPM). Such initiatives require the willingness and support of governments at all levels (federal, state and local).