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Background India faces a critical shortage of government doctors in rural and underserved areas. Several measures have been introduced to address the shortage, but significant problems still remain. The main aim of the current research was to understand the existing recruitment-related policies and systems in place for government doctors in Gujarat and to identify issues that prevent effective recruitment of doctors that could have implications for doctors’ shortage in the state. The research also aims to fill the knowledge gap in the existing literature on why recruitment in civil services is an important HR function to address the shortage of doctors. Methods The study aimed at identifying the existing recruitment policies and practices for government Medical Officers (MOs) from Gujarat state in India. The analysis is based on document review to understand the existing policies, 19 in-depth interviews with MOs to understand the systems in place for recruitment of MOs, construction of job histories from interviews to understand various nuances in the recruitment system and five interviews with Key Informants to understand recruitment policies and their actual implementation. Thematic framework approach was used to analyse qualitative data using NVivo. Results While the state has general recruitment guidelines called the Recruitment Rules (RRs), these rules are very wide-ranging and fragmented. The MOs were neither briefed about them nor received copies of the rules at any time during the service suggesting that RRs were not transparent. The recruitment system was considered to be slow and very sporadic having possible implications for attraction and retention of MOs. The study results indicate several other system inefficiencies such as a long time taken by the health department to provide salary benefits and service regularization that has a negative effect over MOs’ motivation. The study also found unequal opportunities presented to different categories of MOs in relation to job security, salary benefits and in recognizing their previous work experience leaving MOs unclear about their future thereby influencing the attraction and retention of MOs to government jobs negatively. Conclusions If long-term solutions are to be sought, the health department needs to have an effective recruitment system in place with the aim to (1) address the slow and sporadic nature of the recruitment system (that is likely to attract more doctors and prevent loss of any doctors during recruitment) and (2) address the job insecurity issue that MOs have which also influences their other employment benefits such as salary, pension and recognition for the years of service they have given to the health department. Addressing these issues can improve motivation among doctors and prevent loss of doctors through voluntary turnover leading to better retention.
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R E S E A R C H Open Access
Issues and challenges in recruitment for
government doctors in Gujarat, India
Bhaskar Purohit
1*
and Tim Martineau
2
Abstract
Background: India faces a critical shortage of government doctors in rural and underserved areas. Several measures
have been introduced to address the shortage, but significant problems still remain. The main aim of the current
research was to understand the existing recruitment-related policies and systems in place for government doctors
in Gujarat and to identify issues that prevent effective recruitment of doctors that could have implications for
doctorsshortage in the state. The research also aims to fill the knowledge gap in the existing literature on why
recruitment in civil services is an important HR function to address the shortage of doctors.
Methods: The study aimed at identifying the existing recruitment policies and practices for government Medical
Officers (MOs) from Gujarat state in India. The analysis is based on document review to understand the existing
policies, 19 in-depth interviews with MOs to understand the systems in place for recruitment of MOs, construction
of job histories from interviews to understand various nuances in the recruitment system and five interviews with
Key Informants to understand recruitment policies and their actual implementation. Thematic framework approach
was used to analyse qualitative data using NVivo.
Results: While the state has general recruitment guidelines called the Recruitment Rules (RRs), these rules are very
wide-ranging and fragmented. The MOs were neither briefed about them nor received copies of the rules at any
time during the service suggesting that RRs were not transparent. The recruitment system was considered to be
slow and very sporadic having possible implications for attraction and retention of MOs. The study results indicate
several other system inefficiencies such as a long time taken by the health department to provide salary benefits
and service regularization that has a negative effect over MOsmotivation. The study also found unequal
opportunities presented to different categories of MOs in relation to job security, salary benefits and in recognizing
their previous work experience leaving MOs unclear about their future thereby influencing the attraction and
retention of MOs to government jobs negatively.
Conclusions: If long-term solutions are to be sought, the health department needs to have an effective
recruitment system in place with the aim to (1) address the slow and sporadic nature of the recruitment system
(that is likely to attract more doctors and prevent loss of any doctors during recruitment) and (2) address the job
insecurity issue that MOs have which also influences their other employment benefits such as salary, pension and
recognition for the years of service they have given to the health department. Addressing these issues can improve
motivation among doctors and prevent loss of doctors through voluntary turnover leading to better retention.
Keywords: Gujarat, India, Medical Officers, Civil Service, Recruitment, Public Service Commission, Attraction and
Retention, Human Resource Management
* Correspondence: bpurohit@iiphg.org
1
Indian Institute of Public Health Gandhinagar (IIPHG), Sardar Patel Institute
Campus, Drive in Road, Thaltej, Ahmedabad 380054, India
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Purohit and Martineau Human Resources for Health (2016) 14:43
DOI 10.1186/s12960-016-0140-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Health workforce has been identified as one of the most
important resources to achieve effective health services.
However, there is a severe shortage and inequitable dis-
tribution of health workforce in many countries with
greater scarcity in countries where it is required most.
India has been identified as one of the 57 countries with
a critical shortage of health workers. Addressing the
issue of shortage is important because the health systems
of countries with a shortage of health workers are unable
to offer even the basic health services to their population
[1]. Empirical evidence indicates that an adequate size of
health workforce is essential to achieve a minimum level
of the health indicators [1, 2]. Among the health work-
force working with the government health sector, doc-
tors or Medical Officers (MOs) working with the Public
Health sector are very crucial as they are the frontline
health managers and service providers to the rural popu-
lation. Despite many efforts in India to address the
shortage of doctors in rural public health centres, India
has largely failed to attract and retain MOs in rural
health centres, and the shortage of doctors has been a
matter of concern for many years [3, 4]. The Indian Pub-
lic Health sector only employs at the most 10 % of total
MOs [5]. Further, India also experiences a big variation
in where the MOs are placed and distributed. Such dif-
ferences exist between the states as well as within the
states with the ratio of rural doctor to rural population
far less than the ratio of total doctors to total population
[5]. The overall figures for India suggest that there is a
vacancy rate of nearly 21 and 42 % for MOs at Primary
Health Centres (PHCs) and for specialists at Community
Health Centres (CHCs), respectively, and a shortfall of
62 % for specialists at CHCs [6].
The public sector in Gujarat, where the current study
was conducted, also suffers from a severe shortage of
MOs and specialists, especially in rural areas. While the
production of doctors in Gujarat has been sufficient to
meet the shortages, very few medical graduates from the
state actually join the government service which makes
addressing the shortage of doctors a complicated issue.
The state of Gujarat has taken various steps (explained
below) to increase the availability of MOs and special-
ists, especially in underserved areas, similar to those
used in many countries and across Indian states [7, 8].
Despite the use these strategies, the Public Healthcare
System in Gujarat suffers from a severe shortage of doc-
tors. Many medical graduates are trained in Gujarat.
Currently, there are 19 medical colleges in Gujarat, both
private and government. According to the latest data
available from 20072008, the six government medical
colleges in the state produced as many as 975 doctors
with bachelors degree and a total of nearly 551 doctors
with Post Graduate Degree in the year 20072008. This
number increased to 1233 for medical graduates with
bachelors degree and 595 for the medical post graduates
in the year 20122013 [9, 10]. Nevertheless, according
to the most recent available data, only 7 and 10 % of the
medical graduates from government medical colleges
appointed under the bonded category (a form of com-
pulsory rural service) [7] actually joined the government
service in the year 20042005 and 2005206. This was
explained by problems in the recruitment-related system
such as legal hassles involved in bonds implementation
and eagerness of medical graduates to pursue Post
Graduate studies [11]. Similarly, 50 % of MOs appointed
under a different recruitment categories (on an ad hoc
category explained later) actually joined the government
in 20042005 and 2005-2006 [12]. The vacancy level is
24 % for MOs at Primary Health Centres (PHCs) while
the vacancy level is particularly high (77 and 93 %, re-
spectively) for all specialists working with CHCs [6] (see
Table 1 for details).
The Department of Health and Family Welfare or the
Department of Health in Gujarat is headed by the Minister
of Health and Family Welfare while the Principal Secretary
of the Health and Family Welfare is the administrative head
of the department and responsible for implementing the
policies. There are various directorates under the Principal
Secretary which are directly involved in implementation of
various programmes and activities. The Department of
Health and Family Welfare in the state has three director-
ates (Health, Medical Services and Medical Education) that
are mainly responsible for technical as well as administra-
tive support to the health-related activities in the state.
Organizational structure and health system in Gujarat
The state of Gujarat is divided into six regions with all
the 32 districts in the state falling under the six regions.
Six Regional Deputy Directors (RDDs), one for each re-
gion, are in-charge for the health-related activities for
the districts that fall under their region.
As per the states Civil Services Recruitment Rules
1967, the MOs working with the Health Department in
Gujarat have been categorized into two classes, i.e. I and
II. Both class I and II are gazetted posts [13]. Gazetted
officers are government employees or public servants
working at a professional/managerial/supervisorial level
and have the authority to issue an official stamp.
At the district level, Chief District Health Officer
(CDHO) is the overall in-charge of the Community Health
Centers (CHCs) and the Primary Health Centers (PHCs)
within the district. Several blocks or the administrative
units constitute a district. Blocks are administered by the
Block Health Officers (BHOs) who are MOs. Similarly, all
the District Hospitals (DHs) within the district are headed
by the Chief District Medical Officer (CDMO) of the
District Hospital.
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The public health delivery system in Gujarat has sev-
eral tiers. At the top and district level is the DH which is
a government hospital that caters to the health needs of
the entire district providing mainly tertiary care. Next, at
the block level, CHCs exist which are 30-bedded hospi-
tals that constitute the secondary level of health care
and provide referral as well as specialist health care to
the rural population at the block level. CHCs cater to
80,000120,000 population. According to health service
norms, each CHC needs to be staffed with specialists as
well as regular doctors or MO. One level lower to CHCs
exist the PHCs that cover a population of 20,000 in hilly,
tribal or difficult areas and 30,000 populations in plain
areas with four to six indoor/observation beds. PHCs act
as a referral unit for six sub-centres and refer out cases
to CHC (30-bedded hospital) and higher order public
hospitals located at sub-district and district levels. Each
PHC needs to be staffed with at least one MO.
All graduate doctors are recruited as Medical Officers
(MOs) in a class II position to work in Primary Health
Centres (PHCs) and/or Community Health Centres
(CHCs) whereas those holding a Post Graduate degree
in clinical areas are recruited as specialists as class I. In
addition to specialists, senior level positions at state,
regional and district such as RDD, CDHO and CDMO
are class I positions while the MOs working with PHCs
and CHCs without Post Graduate specialization are class
II positions.
Recruitment and service-related terms
The states Gujarat Public Service Commission (GPSC)
is responsible for recruitment of all gazetted posts in-
cluding MOs. The main function of the GPSC is to con-
duct examinations for appointment to the services of the
state and advises on the matters relating to methods of
recruitment to various Civil Services of the state [13].
Medical staff in classes I and II in the state of Gujarat
can be employed on four different types of contract: (1)
bondedcontracts (for graduates from government train-
ing institutions); (2) ad hoccontracts on indeterminate
length; (3) fixed-term contracts; and (4) permanent con-
tracts on passing the GPSC exam.
Under the compulsory rural service in Gujarat, all the
medical graduates from the Government colleges enter
the government service under the bondedcontract and
have to sign a bond at the time of admission to medical
college that requires them to compulsorily serve in rural
areas for 2 years. For the bonded category, the govern-
ment heavily subsidizes the tuition fee. Such candidates
are required to join the rural service after they finish
their medical internship. The bonded candidates do not
have to go through any exam or interview as part of the
selection process. The employment status of bonded
contact doctors with the government remains temporary
(meaning that they are not permanent employees of the
government or gazetted officers) until they pass the
Gujarat Public Service Commission (GPSC) exam. Once
such MOs pass the GPSC exam, they are appointed as
permanent employees of the government and are on
regular serviceand get service regularization(ex-
plained below). This gives them a permanent and pen-
sionable employment status. In case these MOs do not
wish to serve the government after graduation, then they
are required to pay the bond amount of Rs. 5,000,000
(USD 8,300). MOs are considered as civil servants after
they clear the GPSC.
To address the shortage of MOs in the state, the
Department of Health and Family Welfare in the past re-
cruited MOs from Gujarat such as candidates from pri-
vate medical colleges or outside the state. Recruitment
of such MOs is called ad hocappointment and is tempor-
ary. Ad hoc MOs were required to pass the GPSC exam
in order to be appointed as permanent employees. How-
ever, the contract of any temporary employee [or ad hoc
MO] is terminated if they fail to pass the GPSC exam be-
fore the age of 45. Selection of ad hoc candidates is done
through walk-in interviews that are conducted weekly
either at the Commissionerate or at the RDD office. Cur-
rently, the government has stopped recruiting MOs in the
ad hoc category. The MOs under the ad hoc category may
not get employment benefits which are otherwise available
to MOs who are on regular service.
A third type of employment contract is for 11 months
and is referred to as contractual appointment.The
contractual category includes all graduates from private
Table 1 Vacancy and shortfall of MOs at CHCs and PHCs in Gujarat
Required (R) Sanctioned (S) In position (P) Vacant (S-P) Shortfall (R-P)
MOs at PHC 1096 1096 837 259 259
Surgeons at CHC 290 278 63 215 227
OB and GY at CHC 290 34 11 23 279
Physicians at CHC 290 0 0 0 290
Ped at CHC 290 34 5 29 285
Total specialists CHC 1160 346 79 267 1081
Source: Rural Health Statistics 2010
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medical colleges and MOs either from states outside Gu-
jarat or MOs over the age of 45 who have not passed the
GPSC exam. The MOs under contractual category do not
get employment benefits which are otherwise available to
MOs who are on regular servicesuch as higher salary,
pension and promotion as per government rules. The
years of service that contractual category MOs serve are
not counted as government service which affect future
salary level benefits Tikoo grade(explained below) and
pension benefits.
The central government in 1994 constituted a committee
called Tikoo Committee to look into various salary- and
promotion-related issues and to make the salaries of MOs
at par with the central level. Since all the MOs who fulfill
the requirement for promotion cannot be promoted due to
limited availability of positions, a time-bound promotion
based on length of service to MOs is provided which is
equivalent to different senior level selection grades with
accompanying increase in salary after 6, 13 and 19 years. In
ordertobeeligibleforahigherTikoograde,oneneedsto
be on regular service.MOswhodonotpasstheGPSC
exam and attain service regularizationdo not get higher
Tikoo grade irrespective of number of years served prior to
passing the GPSC exam.
The GPSC prepares a list called seniority listof all
MOs in the state, and this list is handed over to the
health department. This main use of the list is for
promotion-related decisions. The MOs higher in the list
are given preference for promotion. MOs who pass the
GPSC exam before other MOs are ranked/placed higher
on the list irrespective of total years served in the
government before GPSC. However, if more than one
MO appears for the GPSC at the same time, then the
MO who scores better in the GPSC exam is placed
higher in the seniority list.
Civil services recruitment process
Historically, the recruitment of civil servants in many
countries has commonly been through patronage [14]
and is associated with higher levels of corruption and in-
competent people being recruited [15, 16]. Hence, civil
service reforms have focused on public administration to
be free from corruption [17]. One of the most important
aspects of civil service reform is merit-based recruitment
which not only is conducive to economic growth and
prevention of corruption [18] but also promotes more
competent people getting into the system with less scope
for corruption [19]. However, despite the advantages of
having a recruitment systems in place to ensure recruit-
ment of competent staff and prevention of corruption,
some researchers report that progression based on merit
through staffing agencies for civil services can be slow,
rigid and complex [20].
The importance of the recruitment
Recruitment is the first step in an employment cycle. The
need to have right Human Resource (HR) policies and
management at the core of Human Resource Management
(HRM) systems for sustainable solutions to health system
performance has been greatly emphasized [21, 22]. But
what does HRM include? HR policies and management in-
clude several functions such as recruitment, placement and
managing performance through appraisal systems [2325].
Further, managing the workforce is a constant cycle of
recruitment, selection, training and retention strategies.
However, there is very limited research and information on
the Human Resource Management (HRM)-related dimen-
sion and systems [26].
Recruitment is an important function of HRM that
cannot be overlooked as it is the first step in matching
the organization needs with individual needs [23]. Fur-
ther, HRM practices including recruitment have been
found to be a significant predictor of intention to leave
in a business sector [27]. Recruitment practices have also
been found to have positive effects on organizational
commitment [28]. Understanding recruitment becomes
particularly important as the limited research in the area
of recruitment in civil services involving MOs suggests
that the recruitment process involving Public Service
Commission (PSC) can be very lengthy not only in India
but also in other countries such as Malawi, Bangladesh
and Nepal [29, 30].
Conceptual framework for the study
Protracted recruitment processes can be a major demo-
tivating factor among MOs affecting their attraction to-
wards the government service and can negatively affect
their final decision whether to join government services
or not [9, 31]. Hence, the success in securing needed
human resources for the civil service depends directly
on public personnel recruitment practices as well as the
ability of civil service to attract enough number of com-
petent HR from the eligible pool [31].
An effective recruitment system therefore has two
main purposes: (1) to attract people to the jobs through
promises of what they get immediately and subsequently
as benefits in the jobs [23] (the benefits people are likely
to get also influence their decisions concerning whether
to join or/and continue or quit their jobs having a direct
influence over both attraction and retention) and (2) to
select people with appropriate competencies and skills
[23]. In a competitive labour market such as in Gujarat,
doctors may prefer long-term benefits such as pension
and job security provided in government jobs over im-
mediate higher salary earning in the private sector. The
conceptual framework for the study is based on the
premise that the initial attraction of MOs to apply for,
join and continue services with the government not only
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depends upon the long-term benefits that a government
job offers but it also depends upon HRM-related recruit-
ment policies and systems and how these policies and
systems affect the long-term gains such as pension and
job security.
The conceptual framework of the study is adapted from
Boxall and Macky that refers to the importance of not
only having the Human Resource Management (HRM)
policies in place but also the way HRM policies are prac-
ticed, perceived and implemented [32]. The Boxall and
Macky framework suggests link of Human Resource Man-
agement (HRM) performance causal chain with intended
Human Resource (HR) practices, actual HR practices, HR
practices as perceived by employees and employee reac-
tions or behaviour [32]. Our study framework draws a link
between intended recruitment policies and practices,
MOsperceptions about these policies and practices,
MOsreactions driven by motivation and its potential link
to final attraction to the job as well as retention.
The recruitment policies and systems could play an
important role in influencing the key Human Resource
for Health (HRH) outcomes such as turnover and per-
formance. The health department in the effort of better
HRH management may have certain policies and prac-
tices. These policies and practices may shape the positive
or negative perceptions MOs have about recruitment.
The negative or positive perceptions may further affect
the MOsmotivation (positively or negatively) having an
influence over their behaviour leading to either decisions
to join or continue the services affecting both attraction
towards job as well as affecting the turnover (see Fig. 1).
Therefore, we argue that addressing the shortage of gov-
ernment MOs requires a greater understanding of the
recruitment-related policies and systems. The main aim of
the study described in this paper was to understand the
existing recruitment-related policies and systems for MOs
working with the government in the Department of Health,
Gujarat, and to identify issues that hinder effective recruit-
ment of doctors with negative consequences for MO staff-
ing in the state. The study only included government
doctors as the aim was to understand the effectiveness of
government recruitment systems. The research aims to fill
the knowledge gap in the existing literature on why recruit-
ment in civil services is an important Human Resource
Management (HRM) function with a potential to address
the shortage of MOs in the state.
Methods
Study design
This was a qualitative study that included document re-
view and interviews with Key Informants (KIs) to iden-
tify the policies and official procedures for recruitment.
This was complemented by interviews with KIs and
Medical Officers (MOs), and job histories, constructed
from the data available through interviews, identify the
actual recruitment practices. The study used qualitative
methods as it was best suited to the scope of current
study that aimed at assessing the recruitment-related
policies, systems and perceptions of MOs that would not
have been possible through quantitative study. Qualita-
tive design also justifies the need for the study aimed at
organizing the data into themes.
Study setting
This study was conducted in Gujarat, India, in 2013. MOs
working for the government health department placed at
rural health centres from three different districts from the
state were included in the study. The districts were purpos-
ively selected. Based on initial discussions with several MO
and state level officers (outside the study), a list of a few de-
sirable, not so desirable and not at all desirable districts for
MO posting was made. As several districts were identified
in each of the above category, three districts meeting the
above criteria were selected from three different regions
from the state for a larger geographical representation.
Data collection methods and sampling
Document review
Document review was carried out to understand the
recruitment-related rules and policies. The review included
the Civil Services Rules and the RRs for various cadres of
MOs in the state as detailed under various government
Fig. 1 Conceptual framework for recruitment and how it is linked to attraction and turnover
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orders. Documents relating to service conditions such as
job descriptions were excluded.
Interviews with KIs
This group included informants who occupied key
state and district level positions purposively selected
for their knowledge of the study topic and to gauge
their opinions on the existing policies and systems re-
lating to recruitment. The study included five KIs to
ensure that the views and perspectives of a range of
stakeholders on study topic could be represented. A
number of interviews with KIs were conducted until
saturationwas reachedthat is new data no longer
shed new light[33].
Three out of five interviews with KIs were conducted in
Hindi (the main language spoken in India) and two inter-
views in English as the two KIs preferred to give interview
in English using topic guides. The main focus of inter-
views with KIs was to understand the recruitment-related
policies and rules, systems involved in recruitment, per-
ceptions of KIs on effectiveness of existing recruitment-
related policies and strategies to address the shortage of
MOsandrecommendationsforfurtherimprovement.
Saturation was reached after five KIs were interviewed;
hence, no more interviews with KIs were conducted
after the five.
Interview with MOs
This group consisted of class I and II MOs who were
the main subjects of the study and included MOs from
PHCs and CHCs as well as the BHOs. The study used
purposive sampling to ensure representation of MOs
from three different districts (representing three differ-
ent geographical regions) from the state. A number of
interviews with MOs were conducted till the time satur-
ation in information was experienced. In total, 19 inter-
views were done with the MOs that included three
female MOs.
In-depth interviews with all the 19 MOs were con-
ducted in Hindi (national language of India which is
widely spoken and understood across India). The main
objective to interview was to explore MOsknowledge,
perceptions and understanding and their experiences of
recruitment-related systems.
All interview recordings with KIs and MOs were tran-
scribed verbatim and then translated into English text by
the primary researcher (BP). Written consent was sought
from study participants, and the interviews were audio
recorded. Important notes relating to job history were
also taken during the interviews.
Job histories
During the interviews with MOs, brief job histories were
constructed from the data available through in-depth
interviews with MOs to get deeper insights into recruit-
ment systems.
Data analysis
Document review analysis
Simple content analysis of the documents was done to
understand the recruitment policies and rules. This
included the main policy document called Civil Service
Rules and various Recruitment Rules as detailed under
various government orders.
Analysis of interviews
Interviews were analysed using a thematic framework ap-
proach which is a matrix-based method to arrange and
synthesize data [34]. The framework analysis approach was
best suited to the scope of current research as the aim of
the research was to present themes identified in the data.
The framework approach was used to identify key words,
themes and sub-themes that emerged from the 24 tran-
scripts, and the results of the study are reported against
the key themes and sub-themes. The transcripts of the 24
participants (KIs and MOs) were coded and grouped
according to the themes and sub-themes identified based
onaprioriandtheemergentcodesfromthedata.A
detailed analysis was performed using NVivo on the tran-
scribed texts [35].
Analysis of job histories
Simple descriptive statistics derived from the interviews
were used to calculate the average time it took for job
regularization for the MOs.
Research ethics
The ethical approval for the study was sought from
institutional ethical review committee at the Indian
Institute of Public Health Gandhinagar (IIPHG). Rele-
vant permission for the study was also obtained from
the Department of Health, Government of Gujarat and
the Commissionerate of Health. Written consent was ob-
tained from all the MOs and KIs. The participation in the
study was completely voluntary, and respondents were as-
sured of anonymity at all times of the study.
Results
We first present the demographic profile of the study re-
spondents. Next we explain the MOsknowledge about
the Recruitment Rules (RRs). In the final part of the Re-
sultssection, we explain the implementation of the RRs
by explaining in details the systems of recruitment,
issues identified by the study respondents in the recruit-
ment systems and suggestions from the respondents to
address the issues identified under recruitment.
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Demographic details
The demographic profile of the study respondents is
presented in Table 2. Although the study used purposive
sampling to try and maintain gender balance by includ-
ing a good number of Lady Medical Officers (LMOs)
(specific term used in India for female MOs), the overall
availability of LMOs was low and the present study
could only include three LMOs out of 19 total respon-
dents. However, there was a balance of ad hoc and
bonded MOs with an almost equal representation of
both the categories in the study.
Recruitment rules and policies
The study findings suggest that the state does not have
any specific Recruitment Policy for MOs. What exist in
the name of Recruitment Policy are the some Recruitment
Rules (RRs) which are overall governed by Civil Ser-
vices rules. The RRs for staff in the Health Department
of Gujarat are regulated by the Gujarat Civil Services
Classification and Recruitment (General) Rules 1967.
These rules have undergone modifications from time to
time based on amendments [11, 13].
The study found that the RRs for different categories
of MOs are fragmented which means that they do not
exist in one single document, and such rules have under-
gone changes from time to time. The RRs for different
cadres of doctors are laid down in a form of notifications
that are usually three to four pages long.
Based on document review and interviews with KIs, it
could be concluded that the RRs are very broad and
consist details like qualification required and experience
required and promotion-related details such as ratio
between promotion and direct selection for different
positions of MOs.
I would say that there is no recruitment policy, but
there are policy documents which are fragmented.
These fragmented documents relating to recruitment
and transfers are considered as policies. These
documents may not give complete idea about the
policies but they give some idea. But there is no
complete, comprehensive policy statement. There are
recruitment-related rules called RRs that talk about
the qualification, experience, ratio between promotion
and direct selection, process of how ad hoc need to be
appointed, how MOs need to be confirmed on long
term basis after clearing GPSC etc (KI 1).
Knowledge relating to recruitment rules/policy
Most of the MOs knew only about two aspects of the
recruitment rules: (1) various categories under which
MOs are recruited, i.e. bonded, ad hoc and contractual
appointments and (2) the actual system and steps
involved in recruitment and selection followed for differ-
ent categories under which MOs are appointed. The
responses of the participants indicated that their overall
knowledge about RRs was generally low.
I know this much that every Monday there are
interviews and that one can walk-in and give interviews,
and then they will give you placement (MO 11)
Only one MO reported understanding about the RRs
beyond the two aspects presented above where the MO
described some of the promotion rules that are included
in the RRs.
The recruitment rule is such that once an MBBS gets
an experience of working with a PHC or CHC, he
then enrolls for Diploma in Public Health. So after
that his experience plus Diploma in Public Health,
qualifies him for Class 1 with an experience of Health
for 5 yrs is a must (MO 17)
All the MOs in the study reported that they were not
given a copy of RRs anytime during their service nor were
ever briefed about the RRs. The importance of knowing
RRs was reflected by one of the MOs who suggested that
lack of awareness about the rules can delay the service-
related benefits MOs are eligible for.
No one told me anything about the RRs (MO 9)
I did not get any rules from anyone and I did not
even know about Tikoo grade. So when I got to know
about it, I enquired at the state headquarters that its
Table 2 Distribution of MOs based on demographic and work
profile
Gazetted officer District 1 District 2 District 3 Total
Class I 1 1 1 3
Class II 4 5 7 16
Gender
Male 5 5 6 16
Female 0 1 2 3
Entered service through
Bonded 3 4 4 11
Ad hoc 2 2 4 8
Place of work
PHC 1337
CHC 0224
SDH/DH 3 1 0 4
BHO 1034
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been 6 yrs and I am due for the benefit. So from there
I got to know that my Confidential Reports (CRs) are
missing (CRs are important for the decision to be
made in this regard) (MO 11)
Since most of the MOs did not know about the RRs,
one of the KIs was of the opinion that the RRs are not
transparent and such rules are not publicly available on
the government website.
The RRs are not transparent. See after 20 years of
service, I have got some set of rules or a copy of rules.
There are doctors who have not thought of joining
government service because they always wanted to do
private practice or Post Graduate. But tomorrow
when they enter Government service, they know
nothing about the RRs. These rules are not available
on the website. So there is no transparency (KI1)
Implementation of RRs and policies
According to the study respondents, the MOs in the
bonded, ad hoc and contractual categories may be
recruited at two stages, one before GPSC which is an
initial recruitment and the other at the time of GPSC
(which could be through direct recruitment or promotion).
Since the recruitment system before GPSC for the three
categories is different, it is briefly explained below. How-
ever, the recruitment system is the same for all categories
of MOs during the GPSC.
Bonded category
The KIs and MOs indicated that there is no formal recruit-
ment and selection system followed for bonded candidates
when recruiting them directly from the government med-
ical colleges. Every bonded candidate irrespective of marks
scored in the Government Medical College is recruited and
placed in the Government Health Centers in rural areas as
a bonded candidate.
MOs under the bonded category usually receive an
order from the health department during the final year of
their MBBS studies (at the time of internship) that con-
tains the details of their first posting with the government.
According to the MOs, the time it took for them to re-
ceive such order varied significantly. While in most cases
MOs responded that they received their orders during the
final month of internship, however, in few cases, MOs
responded that they received such orders several months
later after completing their MBBS. According to one of
the MOs, the delay in receiving orders can influence the
decision of MOs whether to join the government or not.
However, no data was available to explain the reasons why
bonded doctors received their orders in varied periods.
There was no interview and they took me directly as
bonded candidate. After the internship [MBBS
internship] a list is prepared and bonded posting is
made based on that list (MO 5)
As soon as bonded MO finish the internship, they
should receive the order. Ideally one should receive
such orders at least 2 days before finishing the
internship. However such orders are received after
36 months of finishing the internship. If the health
department can send the orders just before the
completion of internship, at least 5 % [of the bonded
MOs] would join. The health department sends such
orders after 6 months and in this process they are
not even aware how many of the Medical graduates
have enrolled for Post Graduate (MO 17)
Another issue raised by MOs was ineffectiveness of
bonds in order to make the MOs serve in rural areas
and the small amount required to be paid to relieve one-
self from the bond.
Although the bonded candidate are given their choice
of location for posting but still the bonded candidates
dont join. And the reason for not joining in Gujarat
is that they can pay the bond amount of 75 thousand
rupees [USD 1250] so if they have money, they pay
the amount. Only 20 % of the bonded doctors join the
government while others pay the amount and dont
join. So this is one of the reasons for the shortage of
doctors (MO 11)
Another issue indicated by MOs was lack of any sys-
tem in place to notify the MOs about available vacancies
they can opt to while getting required and placed after
finishing their MBBS.
I made my own effort to find out about available
vacancies and thats how I got XYZ [my current place
of work] (MO 2)
Due to low number of MOs joining the government
service under the bonded category, it was suggested that
certification of registration as a doctor by a medical council
must only be provided to MOs (under the bonded
category) after they complete 3 years of compulsory rural
service. Yet another recommendation was to reduce the
bond period from 3 to 1 year.
Ad hoc category
According to study respondents, the MOs under an ad
hoc category appeared for walk-in interviews that were
held at all the six RDD regions. As far as the system of
selection was concerned, the MOs responded that the
interview panel included RDD along with some officials
from the state health department.
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I joined in 2004 November and the interview took
place at [place x]. It was a walk-in interview taken by
RDD. The interviews are held every Monday (MO 1)
Two issues were brought up by the MOs relating to
the recruitment system of the ad hoc category that may
have influence attraction and actual number of MOs
who join the government. First is that sometimes the
system is slow and second is that there is an absence of
a system in place to notify the ad hoc MOs about the
available vacancies in the region.
The recruitment process for Class 2 particularly for ad
hoc category before GPSC is lengthy as well as
complicated. Although on papers it is walk-in interview
but its nothing like that you walk-in and you get a choice
of your place the next day. The file keeps moving from
one place to another. For class 2 officer the health
department does not revert back for 2 months, so in the
meanwhile the MOs figure something else out (MO 17)
The health department havent developed a system
yet, that a person walks in and is asked for his choice
of location. Only if there is a vacancy then the person
is given his choice. Hence either they leave after
joining or dont join at all (MO 17)
I managed on my own to find about the vacant
positions (MO 7)
Contractual category
As the study did not include any MO from the contractual
category, the study did not document the detailed system
involved in recruitment and selection of contractual MOs.
However, several recruitment- and service-related issues
relating to contractual MOs were brought up by the KIs
and MOs.
According to one KI, the current policy of the govern-
ment to recruit MOs under a contractual category causes
a lot of inconvenience to such doctors as the contract
needs to be renewed periodically. Further, such a strategy
does not assure them that they will remain posted at their
previous work place/posting. According to the KI, this is
one of the reasons for dissatisfaction among the contrac-
tual MOs and may lead to a high turnover. One of the
other drawbacks of working as a contractual MO was that
the work experience with the government (prior to GPSC)
is not counted towards service continuation which affects
the benefits such as job security, promotion and other
salary-related benefits.
There are problems in contractual appointments.
Problem in the sense that first the posting used to be
for 11 months, then in between there were orders that
the posting will be for 6 months. The main problem is
that the renewal process happened every 6 months or
after 11 months. If someone is with a PHC or CHC,
then after 6 months he will be transferred. Then the
person will be sent to state headquarters, and then he
will be removed from there and then will be sent
elsewhere and then back to headquarters. The file [for
recruitment and posting] keeps moving from one
place to another. This person will get his salary for
6 months, and then he will be without salary for
2 months [till new appointment is given] and so on.
So the doctor goes through a lot of inconvenience. So
such a doctor will go through transfers one or two
times and the third time he will resign (KI 2).
The work experience of the contractual is not
counted in service continuation (MO 19)
Recognizing the recruitment issues involved in the
contractual category such as insecurity of job and lack of
employment benefits that are otherwise available to
MOs in the regular service, MOs and KIs suggested that
rather than renewing contracts every 11 months, a sys-
tem should be developed that allows contractual MOs to
be recruited on a probation period, and on successful
completion of the probation period, these MOs must be
given a permanent employment status without the in-
volvement of GPSC.
Recruitment through GPSC
The recruitment under GPSC is open to ad hoc, bonded
and contractual candidates provided they are within the
age limit. Once the candidates under the bonded cat-
egory complete the bond, they are eligible to appear for
the GPSC exam. Similarly, MOs appointed under ad hoc
and contractual categories are free to appear for the
GPSC interviews whenever such exams/interviews are
offered.
Several issues were indicated by the KIs and MOs with
the recruitment system under GPSC. These issues were
as follows: (1) Periodicity of the GPSC exam that delays
the MOsservice regularization and may reduce the
scope for MOs to be eligible for GPSC as they cross the
age limit required for GPSC and (2) a slow recruitment
system under GPSC that may influence the decision of
MOs whether to work with the government or not. The
quotes given below suggest that the sporadic nature and
slow recruitment system under GPSC may influence
MOsdecision negatively to join the government, or
some MOs may lose interest in the job during this long
system and may decide to either not join the govern-
ment or join the private sector or start private practice
instead.
GPSC is not regular, it is announced once in 8-10 yrs.
The system is lengthy as well as complicated for Class
2 MOs particularly (MO 17).
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The process of recruitment right from when
government sends requirement to the GPSC to the
time candidates are selected can take at least
9 months to 12 months.. And definitely in the
meanwhile MOs get some another jobs and those
candidates who are willing to join the government will
not wait till their appointment order comes (KI 4)
Unless and until the person has a regular appointment
he or she wont be interested in continuing the job.
Despite repeated request from government side to
GPSC, conducting GPSC is a difficult task. The GPSC
exam is not happening regularly. So the person who is
serving for 11 months may not like to serve in the
remote part unless their job is secured. (KI 3)
The job histories extracted from the interviews with
MOs suggest a gap from 1 year to as long as 11 years
between the time candidates joined (both ad hoc and
bonded categories) the government service to the time
the candidates appeared for the GPSC exam. According
to most of the MOs, such a huge gap was primarily be-
cause the GPSC exam was not offered during this period
(see Table 3 for details).
The very few MOs who passed the GPSC exam within
their 1 to 2 years of joining the service considered
themselves lucky that the GPSC exam was offered within
a reasonable time after they joined the service.
I was very fortunate that I got my GPSC examination
very soon after my joining and I cleared that (MO 3).
One of the other issues that KIs and MOs indicated is
that the Medical Services/Health and Medical Education
departments were water-tight meaning that a shift of
MO from Medical Education to Public Health and vice
versa requires passing the GPSC exam again. For example,
if a MO (who is part of the Public Health Department)
wants to be a tutor at a medical college (part of the
department of Medical Education), then such a MO needs
to clear GPSC exam again for Medical Education and vice
versa. Yet another issue which was pointed out was that
the prior experience in the other department (Medical
Education or Health Department) is not counted towards
service continuation if the person moves to another
department.
I voluntarily got myself transferred because the
experience in Medical College is not counted in
Health. So the 3 yrs I spent in the Medical College is
Table 3 Distribution of respondents according to various demographic and work-related variables
Respondent Gender Age Class Category Total years
of experience
No. of years between joining the
service and passing the GPSC exam
a
1 M 36 2 Ad hoc 9 1
2 M 35 2 Bonded 10 1
3 M 53 1 Bonded 22 1
4 M 43 2 Bonded 10 5
5 M 42 2 Bonded 15 7
6 M 31 2 Bonded 7 6
7 F 39 2 Ad hoc 13 6
8 M 46 2 Ad hoc 16 1
9 M 51 1 Ad hoc 21 3
10 F 30 2 Bonded 4 1
11 M 44 2 Ad hoc 11 4
12 F 32 2 Bonded 4.5 3
13 M 42 2 Bonded 18 11
14 M 40 2 Ad hoc 8 3
15 M 32 2 Bonded 8 1
16 M 54 2 Ad hoc 30 NA
17 M 37 2 Bonded 10 4
18 M 55 1 Bonded 29 8
19 M 36 2 Ad hoc 10 5
Average 40.94 13.44 3.94
a
The gap between the time when MOs (either ad hoc or bonded) first joined the government service and the time they were confirmed in the government
service through GPSC. As explained through the table, this gap was fairly large in the case of most of the MOs
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gone a waste and does not count towards my
experience (MO 17).
The various department within health (Medical
Education and Public Health) are water tight
compartments. Suppose an MO has worked with a
PHC for 5 yrs and now he wants to join as a tutor then
he has to appear in GPSC again. In this process if he
crosses the age to 35, then he has to apply through the
department and get an NOC from the Medical College
and only then he can appear for GPSC (KI 1).
In light of the issues concerning GPSC, several sugges-
tions were given by the KIs and MOs. One of these was to
create a separate medical board that looks into the recruit-
ment of MOs. One common suggestion was the need to
conduct the GPSC exam regularly as it can prevent dissat-
isfaction that many contractual doctors have about getting
their contact renewed every 11 months.
Regular appointments through GPSC will help us a
lot. If we have GPSC on yearly basis, then it can
prevent the dissatisfaction and frustration of many
MOs who join the services in ad hoc and contractual
category for 11 months (KI 2)
The only problem with recruitment is GPSC but they
highly over-burdened as they are doing recruitment
for all gazetted posts which are in thousands of num-
bers. Naturally GPSC cannot cope with this kind of
challenge, so we have proposed a separate recruitment
board which may be called Medical recruitment Board
(MRB) (KI 3)
Issues with service continuation, regularization and Tikoo
grade
As mentioned in the Resultssection, the matters relating
to service continuation, regularization and Tikoo grade
can be very important to MOs. These issues closely relate
to what implications recruitment systems and rules may
have on employment benefits such as getting a higher
grade (Tikoo grade) depending on the number of years
the MO has been on regular service, whether work experi-
ence of a MO (prior to GPSC) is counted towards service
continuation which can impact the Tikoo grade.
While most of the MOs indicated that their period of
service before GPSC was counted towards service con-
tinuation, the process of applying and getting service
continuation can be cumbersome and very slow. How-
ever, there were MOs who reported that they did not get
service continuation despite being long due for service
continuation.
Although I have been confirmed by the GPSC in
2007-08, I havent received any letter for Seniority,
nor for Service continuation. The government needs
to give a letter for service continuation from my date
of joining but they havent as yet. The last seniority
list prepared is updated till 2007 and my name is not
in the seniority list (MO 11)
I have completed 18 years and eligible for two Tikoo
grades but I have not got even oneThere are so
many Doctors whose 2nd Tikoo is pending. The
health department has no idea how much are we at
loss. If you calculate, we get Rs. 10,000 [USD 170] less
every month (MO 13)
Discussion
This was an exploratory study aimed at understanding
the recruitment-related policies and system for MOs and
its implications for improved recruitment in the state
that could potentially address the shortage of MOs in
the state. Although the study aimed at throwing light on
recruitment-related systems, the study has several limita-
tions. Because of the wide-ranging nature of recruitment
rules and system in how the government defines recruit-
ment (that often includes cross cutting issues such as
promotion, service regularization, Tikoo Commission), it
was difficult to separate out these issues from recruit-
ment. Secondly, it was beyond the scope of current re-
search to assess actual implementation of all aspects of
recruitment-related rules such as promotion. Hence, the
system audit to understand the actual recruitment prac-
tices is confined only to the recruitment and selection
system that took place before and during the GPSC
exam for MOs. Since the RRs were not easily available
and were very fragmented, the document review for the
current study is based on a limited set of documents
that was available at the time of study. More in-depth
understanding of recruitment system and how such sys-
tem links with other HR systems such as salary, promo-
tion and other service benefits is a subject for further
exploration. As the study was conducted only in Gujarat
based on views and experience on 24 respondents, the
results cannot easily be generalized across the states and
nationally.
The task of locating and identifying the recruitment
rules and policies was challenging because of the ab-
sence of clearly laid down rules and policies in one
place. Although RRs exist, they were not available and
accessible under the public domain such as government
websites or any other government repository. In the ab-
sence of availability and access of RRs to the MOs either
on the government website or in other ways such as
booklets, the RRs were perceived to be non-transparent
as most of the study respondents did not know about
the rules. The study findings suggest that if the MOs do
not know the rules then they are also not likely to know
certain future benefits, which influence their behaviour
and affects attraction and retention. Also, the RRs were
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present in a very fragmented form and were wide-ranging
that included serviced-related matters such as promotions.
This reflects the complexity and the difficulty to manage
such rules which was also indicated by one of the KIs.
Since the RRs contain important details about several
service-related rules, it is important from an HRM per-
spective that such rules are made available to MOs, espe-
cially in the absence of any formal induction programme
in place for MOs in Gujarat. Transparency relating to HR
policies in Civil Services is now an important issue, and
many Indian states and several other countries that follow
Civil Services Rules for recruitment have such rules avail-
able on the their websites. Although RRs often cover is-
sues relating to promotion and transfer, an attempt should
be made to separate these out for a better understanding
and implementation of HR-related functions.
The study indicates several system inefficiencies such as
a long time taken by the health department to provide
Tikoo grade (salary benefit) and service regularization (job
security). Such system inefficiencies cause inconvenience
to the MOs and may affect their motivation negatively. In
a few cases, the MOs working on an ad hoc basis for long
duration were denied service-related benefits. This was
found to be an important reason for demotivation, which
is not only indicated in the current study but also corrob-
orated by another national study with MOs in two Indian
states [9]. The current study also suggests that the recruit-
ment system under GPSC was infrequent and can be very
slow similar to that of other states in India such as UP
[36] and other countries such as Bangladesh and Nepal
[37, 38]. For example, recruitment through PSC in Nepal
can take almost a year having implications for frequent
occurrence of extended vacancies for frontline health ser-
vice provider positions [38]. The slow recruitment system
by GPSC has been suggested as a main reason for the
shortage of MOs in Gujarat [9]. Similarly, recruitment
under the Civil Service Commission in Malawi is not only
lengthy (that can take at least 6 months from the time a
post is advertised before it is filled) but also expensive for
the government with the average cost, in replacing one
professional officer, of $74,504 between 1990 and 2000
[29]. However, the ineffective recruitment systems in civil
services not only involve high cost for employers or the
government, the study results also indicate that MOs have
to pay even higher cost because of such laggard recruit-
ment systems. This sporadic nature of GPSC creates a
long gap between the time MOs first join the government
service and the time they pass GPSC exam that has impli-
cations over service-related benefits such as seniority list
and service continuation (important for promotion and
recognition of work MO has put through years), service
regularization (job security) and Tikoo grade (higher
salary), which are all found to be important factors of
motivation among Indian government MOs [39].
The issues brought up in the study relating to service-
related benefits were a cause of concern and demotivation
for MOs as the inefficiencies in such a system creates cer-
tain parity issues with salary, seniority and other benefits
mainly due to infrequency of the GPSC. Such parity issues
have been also reported in a study with MOs in the state
of Madhya Pradesh, India [9]. Hence, one of the possible
solutions to the problem of infrequent GPSC could be lat-
eral recruitment from outside the civil service, but such
recruitments must be on a regular basis and must ensure
employment-related benefits such as job security and pen-
sion to the MO. Recruitments through lateral entry will
not only reduce the burden on GPSC but can also make
the system or recruitment more frequent as has been initi-
ated in China [40] as well as Haryana, India. The study re-
sults also indicate that slow recruitment systems and their
implications for other service-related benefits may create
a negative feeling among MOs about their job security,
the most important motivation factor found among India
MOs working with the government [39]. Lack of motiv-
ation and frustration with the current system further
affects the HR levers of attraction and retention making
the shortages even more severe.
The study also found difference between the recruit-
ment and selection process for MOs appointed on con-
tractual and ad hoc basis. While the MOs appointed on
ad hoc basis have to go through a walk-in interview,
there is no selection process followed for the bonded
candidates before GPSC. One possible explanation for
having no selection process for bonded category is the
very limited number of MOs who join the government
against the huge vacancies, and if the selection process
is in place, it may further limit the MOs who join in the
bonded category. However, this puts a question mark
against the whole idea of competence-based or merit-
based recruitment, identified as the most meritocratic
way of recruitment [41].
One of the most concerning aspects of recruitment
from an HRM point of view was the unequal opportun-
ities presented to different categories of MOs (such as ad
hoc, bonded and contractual) in relation to job security
(regular service), salary benefits (Tikoo grade) and recog-
nizing their previous work experience and efforts (service
continuation) despite being recruited for similar positions
and with similar educational background. Studies done
with civil servants in Bangladesh also report such discrep-
ancies [30]. The study results clearly indicate that the
contractual category is the worst affected in this matter
and it was clear from the study that such recruitment is a
deliberate strategy so that the government can get away
from paying benefits to contractual staff that are otherwise
available to regular MOs as the contract model is used
with the objective of reducing government expenditure
[42]. Clearly, the MOs recruited under such a category
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never feel secured about their job and have the fear of
being discontinued from the job anytime. Such issues can
create demotivation and frustration among those in the
contractual category, and currently, with no appointments
of doctors in the state in the ad hoc category, and with
very less joining in the bonded category, the government
really needs to look how the recruitment under the
bonded category can be made effective to address the
issue of attraction and retention of MOs appointed under
this category. A study done in India with government
health staff found that job satisfaction is higher among
regular staff compared to contractual staff, especially in
relation to privileges and facilities relating to the job and
career development [43]. The issues identified under the
study are contrary to some of the characteristics of good
HRM systems with emphasis on providing employment
security, selective hiring of new personnel and reduced
status distinctions and barriers [44]. As reflected in the
study findings, the slow recruitment and posting systems
were also a cause of concern among MOs in the ad hoc
category which suggests that same problems may persist
in the system of recruitment for the contractual category.
Literature from other countries such as Nepal supports
the current study findings that regulations such as limiting
the duration of temporary contracts and the lengthy dur-
ation of the contracting system (reportedly up to 5 months
in Nepal) are important contributing factors to high turn-
over among contractual staff [38].
Conclusions
There is a great need to address the shortage of MOs in
the government health institutions of Gujarat. While
production of more doctors and regulatory measures
such as compulsory rural service could be possible so-
lutions to the problem, they do not address some of the
fundamental recruitment problems identified by the
study that greatly influence the availability of MOs in
the state. Some of the issues identified under the study
are not confined to Gujarat. These problems are in
many respects similar to those in many Indian states
[36] and other developing countries such as Bangladesh
and Nepal [30, 37, 38].
The current study identifies several issues in the sys-
tem of recruitment and with other HR systems such as
employment benefits and job security which are found
to be closely related to recruitment policies and systems
that can have potential contribution to MOsshortage
and turnover in the state. Hence, if long-term solutions
are to be sought, the Department of Health needs to
have an effective recruitment system in place with the
aim to (1) address the slow and sporadic nature of the
recruitment system (that is likely to attract more doctors
and prevent loss of any doctors during the recruitment
system) and (2) address the job insecurity issue that
MOs have which also influences their other employment
benefits such as salary, pension and recognition for the
years of service they have served the health department.
Addressing these issues can improve motivation among
doctors leading to better performance, and prevent loss
of doctors through voluntary turnover leading to better
retention.
Given that there is no alternative to recruiting compe-
tent MOs and retaining the existing and the new recruits
with higher motivation, the problems identified through
this exploratory research must be addressed. This would
require the Health Department to take a more holistic
perspective of the process and consequences of recruit-
ment. From a strategic HRM perspective, attraction,
retention and effective management of HRH is really
important for better availability, distribution and man-
agement of doctors. In addition, to understand the full
impact of current recruitment practices, we suggest larger
scale research, possibly using survey data, in Gujarat and
other states. It may also be useful to carry out research for
other contractual cadres who practice Ayurveda and hom-
eopathy (alternative systems of medicine). Such contrac-
tual staff have been widely recruited throughout Gujarat
under the contractual category and in other states in India
to fill the gap in shortages of MOs, especially at PHCs.
Abbreviations
BHO, Block Health Officer; CDHO, Chief District Health Officer; CDMO, Chief
District Medical Officer; CHCs, Community Health Centres, DH, District
Hospital, GPSC, Gujarat Public Service Commission; KIs, Key Informants; MOs,
Medical Officers; PHCs, Primary Health Centres; PSC, Public Service
Commission; RDD, Regional Deputy Director, RRs, Recruitment Rules
Acknowledgements
This work was supported by a Wellcome Trust Capacity Strengthening Strategic
Award to the Public Health Foundation of India and a consortium of UK
universities. BP was awarded the fellowship under the abovementioned grant
carried out with the support of the Liverpool School of Tropical Medicine (LSTM).
The authors would like to specially acknowledge Dr. Dileep Mavalankar for his
constant support and useful inputs. We acknowledge Dr. JG Gajjar for his useful
insights and for coordinating the field visits for the study. We would also like to
thank Dr. Joanna Raven (Lecturer at LSTM) for providing comments and in
helping authors develop the initial coding framework for the study. The authors
also acknowledge the state officials for allowing us to carry the study and special
thanks to all the study respondents for agreeing to take part in the study.
Authorscontributions
BP conceived and designed the study. BP and TM prepared the data collection
tools for the study. BP collected entire data for the study, performed the data
analysis and wrote the first draft of the manuscript while TM commented on
subsequent versions of the manuscript. BP prepared the final manuscript with
comments from TM. All authors have read and agree with the final submission.
Competing interests
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Informed written consent of the participants was taken before data
collection. The participation in this study was voluntary and confidentiality
was guaranteed. Necessary permission for the study was taken from
appropriate state level health authorities. The ethical approval for the study
was obtained from the institutional ethical review committee at the Indian
Institute of Public Health Gandhinagar (IIPHG).
Purohit and Martineau Human Resources for Health (2016) 14:43 Page 13 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Author details
1
Indian Institute of Public Health Gandhinagar (IIPHG), Sardar Patel Institute
Campus, Drive in Road, Thaltej, Ahmedabad 380054, India.
2
Liverpool School
of Tropical Medicine (LSTM), Pembroke Place, Liverpool L3 5QA, United
Kingdom.
Received: 1 September 2015 Accepted: 6 July 2016
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Despite many efforts from government to address the shortage of medical officers (MOs) in rural areas, rural health centres continue to suffer from severe shortage of MOs. Lack of motivation to join and continue service in rural areas is a major reason for such shortage. In the present study, we aimed to assess and rank the driving factors of motivation important for in-service MOs in their current job. The study participants included ninety two in-service government MOs from three states in India. The study participants were required to rank 14 factors of motivation important for them in their current job. The factors for the study were selected using Herzberg's two-factor theory of motivation and the data were collected using an instrument that has an established reliability and validity. Test of Kendall's coefficient of concordance (W) was carried out to assess the agreement in ranks assigned by participants to various motivation factors. Next, we studied the distributions of ranks of different motivating factors using standard descriptive statistics and box plots, which gave us interesting insights into the strength of agreement of the MOs in assigning ranks to various factors. And finally to assess whether MOs are more intrinsically motivated or extrinsically motivated, we used Kolmogorov-Smirnov test. The (W) test indicated statistically significant (P < 0.01) agreement of the participants in assigning ranks. The Kolmogorov-Smirnov test indicated that from policy perspectives, MOs place significantly more motivational importance to intrinsic factors than to extrinsic factors. The study results indicate that job security was the most important factor related to motivation, closely followed by interesting work and respect and recognition. Among the top five preferred factors, three were intrinsic factors indicating a great importance given by MOs to factors beyond money and job security. To address the issue of motivation, the health departments need to pay close attention to devising management strategies that address not only extrinsic but also intrinsic factors of motivation. The study results may be useful to understand the complicated issue of work motivation and can give some useful insights to design comprehensive management strategies that are based on motivational needs of MOs.
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An efficient, competitive, and resilient civil service depends largely on the quality of its human resources. The key to achieving this goal is to implement human resource management policies that attract, develop, and retain the best talent. Malaysia is a multiethnic country. The large size and role of the Malaysian civil service underline not only the importance of civil service performance but equal employment opportunities as well. The increasingly mono-ethnic civil service has highlighted issues of representation and responsiveness to all ethnic groups. To rectify the ethnic imbalance in the civil service, the Malaysian Public Service Commission has initiated innovations in its recruitment practices to attract more non-Malay job seekers. The purpose of this article is to examine how the personnel recruitment practices of the Malaysian public sector are affecting the representativeness and performance of its civil service.
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Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include "obligatory", "mandatory", "required" and "requisite." All these different programme names refer to a country's law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals' education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.
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'Global Human Resource Management is a timely and excellent resource, and its focus on developing and transitional countries fills something of a gap in the literature. It is a welcome addition to the list of resources available to HR managers working in the international scene.'- Geoffrey De Lacy, HR Monthly This book presents Human Resource Management (HRM) as a tool for improving the performance of organizations in developing and transitional countries. It does this through the presentation of an integrated model of human resource management, informed by the practical realities of applying such a model in developing and transitional countries.
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The role of bureaucratic authority structures in facilitating economic growth has been a sociological concern since Max Weber's classic contributions almost 100 years ago. Using a recent and original data set, we examine the characteristics of core state economic agencies and the growth records of a sample of 35 developing countries for the 1970-1990 period. Our "Weberianness Scale" offers a simple measure of the degree to which these agencies employ meritocratic recruitment and offer predictable, rewarding long-term careers. We find that these "Weberian" characteristics significantly enhance prospects for economic growth, even when we control for initial levels of GDP per capita and human capital. Our results imply that "Weberianness" should be included as a factor in general models of economic growth. They also suggest the need for more attention by policymakers to building better bureaucracies and more research by social scientists on variations in how state bureaucracies are organized.
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Sustainable competitive advantage has proved elusive for companies in the 1990s. While making enormous investments in technology, research, and state-of-the-art marketing, many of today's managers continue to ignore the single most important factor in achieving and maintaining competitive success: people. Yet all evidence indicates that the source of competitive advantage is shifting from technology, patents, or strategic position to how a company manages its employees. In this excerpt from his newly published book, Competitive Advantage through People, Jeffrey Pfeffer describes how successful companies have overcome the barriers to change and offers a solid framework—with specific actions—for implementing these changes in any industry.
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Recruitment to the civil service is, in order to prevent patronage, often centralized and based on performance in competitive examinations. This approach, albeit slow and occasionally cumbersome, is generally assumed to be the most meritocratic method of recruitment. However, while some applicants may have skills suited for a specific position, they may not perform best in a general examination. As long as the system is not abused, a more flexible recruitment process based on, for example, interviews and CV screening, may be more meritocratic. It is therefore necessary to weigh the risk of abuse against the potential gains from more flexibility. Formal civil service examinations are hypothesized in this article to be the most meritocratic way to recruit civil servants only in countries where the risk for patronage is high. Analysis of a dataset describing the structures and characteristics of bureaucracies worldwide lends support to the hypothesis.