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Human Resource Issues: Implications for Health Sector Reforms

February 2004
Journal of Health Management 7(1)

DOI:10.1177/097206340400700101

Source
RePEc

Authors:

Ramesh Bhat

Narsee Monjee Institute of Management Studies

Sunil Kumar Maheshwari

Indian Institute of Management

Given the growing complexities and challenges the health sector faces, reforms in this sector are inevitable. Often health sector reforms aimed to address many of these deficiencies and ensuring effectiveness and efficiency of resource use, they focus on making the health systems responsive through strengthening financial systems, ensuring local participation and public private partnerships, and autonomy of health facilities. The reform process, among other things, intrinsically makes some fundamental assumptions some of which are as follows: high organisational commitment of health care providers, high professional commitment of health care providers, and adequate skills of health care providers. This paper examines the commitment of district level health officials in the newly carved out state of Chhattisgarh in India. Since development oriented HR practices (HRD) are powerful tools to commit people working in health sector to enhance the quality of care, we believe that health sector reforms will have to concentrate on human resource issues and practices more than ever before in near future. The papers attempts to examine the following questions: (i) what is status of professional commitment, organisational commitment and technical competencies of health officials? (ii) what are the characteristics of human resource management practices in the health sector in the state? and (iii) how these management practices are linked with professional and organisational commitment? Finally the paper discusses the implications of these to health sector reform process.

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Human resource issues: Implications for health sector reforms

Ramesh Bhat

Sunil Kumar Maheshwari

Indian Institute of Management

Ahmedabad

January 2004

Human resource issues: Implications for health sector reforms

Abstract

Given the growing complexities and challenges the health sector faces, reforms in this sector are

inevitable. It is only through these reforms deficiencies in the health sector can be addressed and also

the process helps in developing strategies which ensure effectiveness and efficiency of resource use.

They focus on making the health systems responsive through strengthening financial systems,

ensuring local participation and public-private partnerships, and autonomy of health facilities. The

reform process makes some fundamental assumptions about the intrinsic organisational and

professional commitment and availability of skilled and competent health care professional. This

paper examines the commitment of district level health officials in the newly carved out state of

Chhattisgarh in India. Since development oriented human resource practices are powerful tools that

commit health professionals to enhance the quality of care, we believe that health sector reforms

should concentrate on human resource issues and practices more than ever before in the future. The

papers attempts to examine the following issues: (a) the status of professional and organisational

commitment and the technical competencies of health officials managing the sector; (b) the

characteristics of human resource management practices in the health sector in Chhattisgarh; and (c)

the linkage of these management practices with professional and organisational commitment. Finally

the paper discusses the implications of these issues in the health sector reform process.

Human resource issues: Implications for health sector reforms 1

1. Introduction

The importance of human resources can not be overemphasised for implementation of any health

sector reform agenda. Adequate number of people to man and manage the programmes alone may not

necessarily lead to successful implementation of programmes and reforms. The health systems need

to ensure their competencies and commitment to make health reform process a success. Way back in

1946 the Bhore Committee had suggested focusing on primary health care approach and ensuring that

health facilities have autonomy and local governance of health institutions be given due importance.

Inter alia, the committee had also suggested developing strategies to control infectious diseases, and

enactment of public health legislation. The Government of India had accepted the committee report.

The Alma Ata declaration in 1978 also echoed many of these suggestions and emphasised the primary

health care approach to achieve health for all goal by the year 2000. India created an impressive

network of primary health care facilities and implemented this strategy.

Despite the success in creating a noteworthy network of health facilities, the overall achievement of

health goals remained unimpressive. While communicable diseases continue to be problematic, the

spread of chronic non-communicable diseases such as heart disease, diabetes, cancer, HIV/AIDS

became emerging threats. Most of the health systems faced a dual challenge: that of addressing non-

communicable diseases (e.g., incidence of diabetes and heart disease in India is double that of China)

and persevering with attempts to control communicable diseases. Indian Primary Health Centres

(PHC) remained less equipped to diagnose and treat chronic degenerative diseases. Health service

facilities, particularly in rural areas, are still challenged by lack of adequate personnel required to

ensure access to health care services.

This shows that the nature of the problem has remained the same because the two underlying

weaknesses of the health system, i.e., non-availability of trained health personnel in rural areas and

inadequate quality of care. These continue to pose major challenges. Often the behaviour of the

personnel is cited (Lee, 2001) as one of the major reasons and cause of poor perception of the health

care services. In rural areas such perception particularly drives the population to seek treatment from

traditional healers, less-qualified healthcare providers or delay the treatment.

Health sector reforms aimed to address many of these deficiencies generally focus on making health

systems responsive through local participation and autonomy. The reform process, among other

things, intrinsically makes some fundamental assumptions such as:

∙High organisational commitment of health care professionals providing services

∙High professional commitment of health care professionals providing services

∙Adequate skills of health care professionals providing services

These are important assumptions as health care being a highly people-dependent process, direct

monitoring of quality of care and supervision of key organisational processes is extremely difficult.

Hence, intrinsic commitment and competencies of care providers are critical. This paper examines the

human resource challenges in health sector particularly focusing on commitment and competencies of

medical doctors working in public health facilities and their implications for health sector reform.

The present study was carried out to examine this issue in Chhattisgarh, one of the newly constituted

states of India. This state was chosen for two reasons. Firstly the health policies of the state are

evolving. Hence a study of this kind provides adequate direction for this newly formed state.

1We would like to thank district and state officials of Chhattisgarh and Madhya Pradesh for sharing their views and

participating in this study. The views expressed in this paper are those of the authors.

Secondly, more that 70 percent of its population lives in tribal areas in the State. Hence, the findings

of this state could be applicable to many other poor states. A brief of the state and health services are

provided in Annexure 1.

2. Literature Review

Commitment is a multi-dimensional contextual construct. Organisational commitment refers to an

employee’s loyalty to the organisation, willingness to exert on behalf of the organisation, degree of

goal and value congruency with the organisation and desire to maintain membership (Porter,

Crampon, and Smith 1976; Porter, Steers, Mowday and Boulian 1974). Professional commitment

refers to a person’s loyalty to the profession and willingness to exert himself to uphold its values and

goals. A professional such as a doctor may just as well provide healthcare out of his concern for the

profession alone.

Effective implementation of health services requires adequate cooperation from health professionals.

Such behaviour instigates concern for patients, their relatives, peers and other health service

providers. It facilitates team working and strengthens team functioning in organisations. Cooperative

behaviour is an outcome of professional and organisational commitment (Lee, 2001). Hence, the

quality of care in health sector is dependent on both professional and organisational commitment.

Allen and Meyer (1990) proposed a three-component model of organisational commitment. The

‘affective component’ of organisational commitment refers to employees’ emotional attachment to,

identification with, and involvement in the organisation. The ‘continuance component’ refers to

commitment based on the costs that employees associate with leaving the organisation. Finally, the

‘normative component’ refers to employees’ feeling of obligation to remain with the organisation.

Affective, continuance and normative commitment are viewed as distinguishable components, rather

than types of commitment; that is, employees can experience each of these psychological states in

varying degrees. Meyer and Allen (1991) argued that common to these approaches is the view that

commitment is a psychological state that (a) characterises the employee’s relationship with the

organisation, and (b) has implications for decisions to continue or discontinue membership in the

organisation.

Organisational commitment and related variables

Organisational commitment has been shown to be consistently related to following factors:

∙Employee behaviours, such as job search activities, employee turnover, absenteeism and, to a

lesser extent, performance effectiveness (Angle & Perry, 1981; Bluedorn, 1982; Arzu Wasti,

2003; Morris & Sherman ,1981; Porter et al. 1976; Porter et al. 1974; Steers, 1977).

∙Attitudinal, affective, and cognitive constructs such as job satisfaction, job involvement, and job

tension ( Hall & Schneider 1972; Hrebiniak & Alutto 1972; Porter et al. 1974; Stevens, Beyer, &

Trice 1978; Stone & Porter 1976); and

∙Characteristics of the employee’s job and role, including autonomy and responsibility ( Koch &

Steers, 1978), job variety and task identity (Steers, 1977), and role conflict and ambiguity (Morris

& Koch, 1979; Morris & Sherman, 1981).

Employees with high levels of organisational commitment provide a secure and stable work force

(Steers, 1977). Due to their high identification with the organisation, highly committed employees

willingly accept the organisation’s demand for better outputs (Etzionl, 1975), thus assuring high

levels of performance and task completion (Mowday, Porter& Dubin, 1974; Van Maanen, 1975).

There are also evidences that employees’ organisational commitment relates to other desirable

outcomes such as the perception of a warm, supportive organisational climate (Fred Luthans et al.

1992). Hence, commitment leads to intrinsic desire among employees to contribute better outputs to

improved services in service sectors; it also reduces the need for external monitoring mechanisms.

Committed employees need less supervision to control their behaviour. In the health sector,

employees are expected to strengthen the organisation’s image among the customers through

cooperative behaviour. Literature studying organisational commitment portrays employees with high

organisational commitment not only as greatly productive (Mowday, Porter & Dubin, 1974) and

satisfied but also extremely responsible with high civic virtue (Nico, Agnes & Martin, 1999). All

these are important prerequisites to ensure adequate quality of health care services. Hence, the

importance of commitment of employees cannot be overemphasised in health sector.

Role of human resource practices in organisation commitment

Human Resource Management (HRM) practices like socialisation, hiring practices, career-oriented

performance management, open job posting and job transfer practices play critical roles in building

employee commitment. Through socialisation processes, managers can foster better employee

understanding of organisational values, norms and objectives (Pascale, 1985; Van Maanen & Schein,

1979), leading to organisational commitment of employees. It has been observed that the extent of

socialisation is also related to commitment (Jones, 1986).

Factors such as confirmation of pre-entry expectations (Arnold & Feldman, 1982; Premack &

Wanous, 1985) and role clarity (Morris & Koch 1979) are important at the time of hiring employees

to enhance organisational commitment.

Reward systems and forms of pay structures have their own implications on commitment. Long-term

benefits and retained benefits like provident fund and pension scheme (also including employee stock

options) and tenure-linked bonus are useful in eliciting continuance commitment (Klein, 1987; Klein

& Hall, 1988; Tucker, Nock & Toscano, 1989; Wetzel & Gallagher, 1990). Similarly benefits like

medical facilities, educational loans for children etc., elicit affective and normative commitment of

employees.

Performance appraisal that enhances job clarity (Jackson, Schlacter, and Wolfe 1995) and involves

people in the process (Behrman, Bigoness, & Perreault, 1981; Brown & Peterson, 1994; Mowen et al.

1985; Thomas & Bretz, 1994) increases organisational commitment. Additionally, the purpose of the

appraisal process also influences organisational commitment. Appraisal, aimed at developing people,

is more likely to induce organisational commitment.

According to the social exchange theory, perceptions about investment in employees’ development

are positively associated with affective commitment of the employees. Similarly researches (Lee &

Brouvold, 2003) have also shown that affective commitment mediates between the investment in

employees’ development and his/her intent to leave. When the employees’ perceive that the training

program is highly useful in improving his or her skills it may increase the employee’s normative

commitment, since he or she may feel it is his/her duty to return back to the organisation. On the other

hand training improves the employability of the employees and thus when proper career advancement

or opportunities to use the acquired skills are not provided; there are great chances that the employee

may quit.

Promotion and internal recruitment policies help employees to grow from within. This elicits a sense

of belongingness among the employees, leading to both emotional and moral sense of belonging.

This paper examines the commitment of district level health officials in the newly created state of

Chhattisgarh in India. Since development oriented HR practices (HRD) are powerful tools to commit

doctors to enhance the quality of care, we believe that health sector reforms will have to concentrate

on HRD practices more than any other in the near future.

Accordingly, the problem statements are:

∙What is status of professional commitment, organisational commitment and technical

competencies of health officials in the State?

∙What are the characteristics of human resource management practices in the health sector in the

state?

∙How are these management practices linked with professional and organisational commitment?

The answers to these questions are critical in designing and implementing health sector reforms.

3. Methodology

The paper uses a mix of qualitative and quantitative methodologies to study human resource practices

in the health sector. As this state is new, there was no documented evidence of health issues. An

exploratory study was conducted through focused group discussions in which 6 district health

officials and 4 officers in the state directorate participated. This was followed up by individual

interviews with four doctors at a Community Health Centre (CHC).

Based on focus group discussions and interviews, a questionnaire was prepared. The objective of the

questionnaire was to assess relevant issues at management training programmes at the Indian Institute

of Management, Ahmedabad attended in three batches by all 75 district level and state level health

officials. Out of them 70 responded to the questionnaire. Hence the study represents the collective

view of all the senior officials at the district level. The survey shows that health officials at the district

and state level carry rich experience. Their average experience in the department and age are 19.4 and

48 years respectively. The average experience of the group in medical care is 22.55 years.

The questionnaire included 62 variables with multiple items. The items were measured on 5-point

Likert type scale. While the scale for the questionnaire was developed to measure professional and

organisational commitment, technical competencies were measured through professional

qualifications of doctors in the state. Commitment scales were developed based on three dimensions:

affective, normative and continuance (Meyers and Allen 1991). These three dimensions have been

widely accepted to constitute commitment. Figure 1 shows the model for the study.

Figure 1: Model for the Study

Sector’s Structure

Autonomy

Continuity and holes

Provisions for Private Practice

Characteristics of Reforms

Objectives

Structural Implications

HR Implications

Commitment and Competencies

Professional Commitment

Organisational Commitment

Functional Skills

Behavioural Skills

HR Policies

Involvement in HR Practices

Transparency and Fairness of HR Practices

Performance Management Practices

Career Management Practices

Training and Development Practices

Reward Management Practices

Likely Success of Reform

Process

Meeting Objectives

Institutionalising reforms

The study was limited to district and state officials. It provided the flexibility of studying the strategic

level at the top and the more crucial operational level at the district. Its limitation was of not having

studied the field units in villages and blocks.

The characteristics of the sample and the mean of different dimensions are provided in Annexure 2.

Using factor analysis, these variables were reduced to eight orthogonal factors (see Annexure 3).

These actors relate to professional growth and developmental climate, autonomy at work units,

capability-based staffing practices, willingness for higher responsibility, role in staffing of

subordinates, willingness to stay in clinical settings, willingness for competence-based assured pay

and satisfaction with recognition and reward practices in the state. The factored scores were used as

independent variables for regression analysis to estimate the relationship with commitment

dimensions. We used forward regression equation with the F probability of 0.05 for entry in the

equation.

The findings of the study were presented to one of the batches that came for training. Intense

discussion to examine the causes behind linkages followed the presentation.

The initial focus group discussions and interviews revealed the following SWOT:

Strengths

∙Professionally committed doctors

∙Team spirit among the officials

∙Liking for job-security among doctors

∙Appreciation for community-based health

system

Weaknesses

∙Lack of autonomy and

experimentation in the field

∙Lack of transparency and fairness

∙Lack of performance orientation

∙Lack of skilled manpower and

infrastructure

∙Interferences of political leaders

Opportunities

∙High concern among doctors to improve

health services

∙To develop fresh policies and strategies

∙Financial help owing to being a new state

Threats

∙Political instability

4. Findings: Commitment

The district health officials like their profession. Most of them took pride in their contribution to

society. Some doctors stated:

We want to provide best health services to the society. This is the responsibility of our

profession which we like so much.

Having concern for the profession, they are extremely keen to improve the administrative systems in

the department to facilitate better services.

The officials carried team feeling among themselves. The job-security and seniority-based pay system

in government jobs add to cooperative than to competitive behaviour among the doctors and promotes

team feeling. However, this cooperative behaviour was partially diluted by competitive private

practices by government doctors. Some officials stated, “Those who have attractive private practices

often try unfair means not to get transferred from such locations. It creates problems for others.”

Most of the health officials felt that management systems are highly centralised which constrain them

from experimenting with ideas to improve the services. They also express their concerns for the lack

of transparency and fairness in staffing matters. Some doctors stated:

Transfers are completely banned in their state. However, people can be transferred with the

approval of the Chief Minister. Employees frequently seek such approval with the help of

local political leaders. This contributes to political interferences in the administrative

processes. These interferences have caused significant dissatisfaction among many doctors.

Most of the respondents have expressed desire to assume higher levels of responsibilities, and expect

more transparency and involvement in manpower planning and deployment of people, particularly in

their districts. Among other things they suggest having sound HRD policies and practices, continued

medical education and training, and respect and recognition for their work. In this context, the

questionnaire survey indicated varied levels of commitment among the doctors (see Table 1).

Table 1

Commitment of Doctors at District and State Level to the department

and the profession and the differences between them (Scale: 5.00)

Mean

(Scale: 5.0) N

Std.

Deviation

Mean

Differences t Significance

Affective Commitment to

the department 3.61 69 .58

- 0.32 4.34 0.000

Affective Commitment to

profession 3.93 69 .41

Normative Commitment to

the department 3.57 69 .49

- 0.39 5.21 0.000

Normative Commitment to

profession 3.96 69 .45

Continuance Commitment

to the department 3.17 69 .63

- 0.35 5.14 0.000

Continuance Commitment

to profession 3.52 69 .54

Table 1 shows that the commitment of doctors at district and state level is significantly higher towards

their profession than towards their departments (organisation). The high commitment to the

profession drives doctors to execute their professional responsibilities effectively even if their

commitment to their departments is low.

The affective organisational commitment is found to range from 1.43 to 4.71 (mean: 3.61). This and

normative commitment of 3.57 indicate that district health officials do not share strong emotional

bonds with the department. Hence, the success of any reform process in health sector would remain

doubtful unless the issues relating to affective and normative commitment are taken care. To

understand the actions that could lead to improved organisational commitment, regression analysis

was done. The regression equation of affective commitment with factors provides the following

results:

Table 2

Dependent Variable: Affective Organisational Commitment (Adjusted R square = 0.58)

Unstandardised

coefficients

Standardised

coefficients t Sig.

Constant 2.80 7.76 0.00

Factor 1: Professional growth and developmental climate 0.31 0.51 6.19 0.00

Factor 8: Satisfaction with recognition and reward 0.25 0.43 5.24 0.00

Factor 6: Willingness to stay in Clinical Settings -0.19 -0.34 -4.07 0.00

Age 0.02 0.19 2.24 0.03

The result presented in Table 2 indicates that reform initiatives which ensure developmental climate

of the department are more likely to succeed. A detailed examination of factors shows that the climate

can be improved through following initiatives which will also help doctors in their growth and

development:

∙providing opportunities for Continued Medical Education (CME) and professional growth by

increasing training intensity

∙supporting local training initiatives

∙providing opportunities for promotions and career growth, and showing concern for development

for higher roles and responsibilities

∙improving the perception of fairness in training opportunities, selections, appraisal, and

promotions

∙empowering the lower level managers

∙linking rewards and recognition with performance

∙facilitating doctors stay longer in clinical settings

∙providing autonomy at the workplace

These are likely to strengthen the affective commitment of doctors for the department. These variables

indicate that the doctors in the state prefer professional growth to financial gains. This relationship is

to be understood in the context of the state where doctors are allowed private practice. A score of

3.61/5.00 of affective organisational commitment clearly suggests that the organisation must make

efforts to improve the above variables. Such committed doctors are likely to contribute to the success

of reform process. Conversely, reform processes that enhance these factors are likely to be better

accepted by doctors and thus are likely to succeed better. Further, affective organisational

commitment is also an important antecedent of pro-social organisational behaviour. People with high

affective organisational commitment are likely to increase their efforts on the job through mechanism

of social reciprocity.

The result shows that doctors’ longer tenure in clinical setting is positively related to affective

organisational commitment. However, senior doctors have career incentives to move to administrative

settings owing to the prevailing structure. Administrative positions are hierarchically superior to

clinical positions. It adversely influences the affective commitment of doctors. This indicates a need

for structural interventions in health sector to provide recognition in the hierarchy for clinical roles.

The regression results of normative organisational commitment indicate that they are not greatly

influenced by the HR practices in the state (Table 3). However, the same set of variables as discussed

above are likely to marginally improve normative commitment as well. The result also indicates that

HR practices in the state are not developing a sense of obligation among the doctors. Continuance

organisational commitment was not found to be significantly influenced by any of the HR practices.

Table 3

Dependent Variable: Normative organisational commitment (Adjusted R square = 0.14)

Unstandardised

coefficients

Standardised

coefficients t Sig.

Constant 3.57 61.19 0.00

Factor 6: Willingness to stay in Clinical Settings -0.16 -0.33 -2.84 0.01

Factor 8: Satisfaction with recognition and reward 0.12 0.24 2.09 0.04

Professional Commitment

The professional commitment of doctors is found to be higher than organisational commitment

indicating their higher identification with the profession. Health sector reforms can leverage on this

important strength of the state. The results indicate that professional commitment is not greatly

influenced by HR practices (Table 4). Professional commitment seems to be emerging primarily from

pre-service training and clinical practices of the doctors.

Table 4

Regression results of affective commitment, normative commitment and continuance commitment

Regressions

Unstandardised

Coefficients

Beta

Standardised

Coefficients

Beta t Sig.

Dependent Variable: Affective commitment

to profession (Adjusted R square = 0.24)

Constant 4.42 18.78 0.00

Factor 5: Role in staffing of subordinates 0.14 0.33 3.00 0.00

Factor 4: Willingness for higher responsibility 0.12 0.27 2.48 0.02

Gender -0.48 -0.24 -2.18 0.03

Factor 6: Willingness to stay in clinical settings -0.09 -0.22 -2.03 0.05

Dependent Variable: Normative commitment

to profession (Adjusted R square = 0.32)

Constant 3.97 84.83 0.00

Factor 4: Willingness for higher responsibility 0.22 0.48 4.61 0.00

Factor 7: Willingness for competence based

assured pay 0.14 0.31 2.97 0.00

Dependent Variable: Continuance commitment

to profession (Adjusted R square = 0.14)

Constant 3.51 55.61 0.00

Factor 3: Capability based staffing -0.18 -0.34 -2.88 0.01

Factor 6: Willingness to stay in clinical settings 0.13 0.24 2.07 0.04

While high professional commitment can be effectively leveraged to undertake reform processes, it

also puts some demands on the administrators of the health sector in the state. The factors that found

place in the forward regression equation indicate that the following activities are critical to foster

professional commitment and to make professionally committed doctors perform better:

∙Providing higher responsibilities to doctors. They are keen to get involved in the development

plans and staffing decisions for their workplaces. Affective professional commitment also leads to

desire for autonomy at the workplace. Hence, the states will have to review the current centralised

administrative practices.

∙Currently the doctors in the field are spending exceptionally long hours in the clinics owing to

lack of staff and high population burden on each health setting. It leaves little opportunity to

spend time on developmental and social concerns. Higher professional commitment is found to be

linked with higher concerns about hours of work. Long hours of work also adversely affect the

emergency service provisions.

∙Professionally committed doctors expect high fairness in HR practices, especially in staffing

decisions. Currently, the perception of fairness of staffing is extremely low (3.07/5.00). The

reform processes will have to address these issues to enthuse doctors to implement reform agenda.

∙Professionally committed doctors also expect that their competencies are valued in the

department. Reform processes that could address reward practices including the non-monetary

rewards and fringe benefits are more likely to succeed.

∙Structural interventions that could facilitate longer stay of doctors in clinical settings without loss

of hierarchical positions are likely to provide impetus to reform processes.

Professional skills

The professional skills of the senior doctors in the state are high. Nearly three-fourth of the doctors

are postgraduates with specialisations in different fields. This is also likely to have contributed to their

high professional commitment. The future growth of professional competencies is related to scope for

growth and development, opportunities for continuous medical education, fairness in training and

intrinsic desire among the doctors for assuming higher responsibilities and work-role. The results

decisively suggest that skill development strongly and positively contribute to engagement in pro-

social organisational behaviour. Policy makers should, therefore, provide reasonable training

opportunities for employees and help in their growth and development along with other

developmental HR practices to effectively implement reforms in health sector.

5. Findings: Sector Design and Work Environment Implications

Structural arrangements of the sector and developmental HR practices are the major intervention tools

that are needed to achieve required service capability in the health sector. Based on the findings of

this study, the following elements of structural design need immediate attention of policy makers:

Technical support from colleagues and superiors

The cooperation of colleagues and superiors enhances the affective organisational commitment of

professionals. There are mixed evidences of cooperation among colleagues and superiors. The study

indicates that the freedom to interact with superiors is low (the score is 3.02). It reflects the great

concern for status and hierarchy prevailing in the department which prevents even professionals like

doctors from sharing healthcare related issues openly and supporting each other.

In the state, government-supported health and private health service-providers co-exist. The doctors in

government health service are also allowed private practice. It instigates a sense of competition

among doctors to enhance their professional interests. This suggests that additional efforts would be

required to develop strong cooperative culture among the doctors. It is suggested that extensive

socialisation to indoctrinate professional values and required departmental culture should be taken up

by the department to encourage doctors to cooperate with each other. Such value based socialisation

mechanisms have proved to be strengthening strong coordination and control mechanisms in many

large organisations (Maheshwari, 1997). These socialisation mechanisms also significantly enhance

the commitment of people. It is suggested that district level forums could be created where all service

providers interact at least once a month to facilitate effective implementation of reforms.

Referral system

Referral system is critical for effective healthcare system. The key to strong referral system lies in

two factors: a) the hardware of the referral system, referring to the physical infrastructure and b) the

software of the referral system, referring to the ability of personnel to diagnose a need for referral,

their willingness to refer the patient to specialised services and their pro-social behaviour. In the

referral system, doctors often try to shield their interests by capturing key structural holes (Burt, 1997)

and shielding them from others if they try to duplicate the linkages. Hence, they tend to spend

significant efforts in information seeking, information screening and its careful dissemination. The

willingness to refer depends on the confidence and trust in the relationship between service providers

in the referral network rather than on formal linkages. Most of the public health facilities do not

qualify on this condition primarily owing to prevailing roles and responsibilities and management

structure of the health system as discussed below.

Roles, responsibilities and structural rigidities

Health professionals at the district level perform three distinct activities. These are regulating and

monitoring, provision of health care services and facilitating and coordinating the provision of

services. These three roles require different behavioural pattern. These are summarised in Table 5.

Table 5

Roles and Responsibilities in Health Sector

Activities Regulating the society Serving the society Facilitating the services

Goals and

objectives

Implementing the laws and

standards to protect the health

of people like laws related to

adulteration of food articles.

Caring for the patient Coordinating between

personnel responsible for

different health schemes

Expected

behaviour

∙Authority driven

∙Top-down

communication

∙Paternalistic

∙Bureaucratic behaviour

∙Influence driven

∙Bottom-up

communication

∙Benevolent leadership

∙Pro-social behaviour

∙Coordinating abilities

∙Both-way

communication

∙Customer sensitive

Supportive

structure

∙Centralised decision-

making

∙High power distance

between different levels

∙Long hierarchy

∙Empowerment at

lower levels

∙Low power distance

between different

levels

∙Short hierarchy

∙Democratic decision-

making

∙Equitable power

distribution

∙Medium hierarchy

Assumptions

behind the

structural design

∙Do not trust people

unless proven worthy

∙Do not leave things to

chance

∙Trust people unless

proven unworthy

∙Neither trust them not

mistrust them, be open

to evaluation every

time.

The three different roles require three different patterns of behaviour. The health system lacks

enabling structures and communication process required to perform these roles effectively. The

existing structure with serious inherent rigidities is all that is available to manage these roles. These

structural rigidities are characterised by operating islands, fragmented sector, and broken hierarchy.

Various characteristics of these structural rigidities are described in the following diagrams.

Operating Islands

centre, state, district, sub-division, blocks,

sectors, villages

very little coordination and communication at

different levels

highly unpredictable resource flows (cash

and kind) high variability in performance and

inconsistent practices

inadequate systems to handle complexities

Consequently, as described above, because of these structural rigidities and discontinuities in the

health sector, mechanistic system of decision-making prevails over other options. Over the years

many of these rigidities have been reinforced and to a large extent have been institutionalised by

centralising decision-making powers at the state and centre level. This is reflected in low

empowerment in this sector (Annexure 2).

Consistent with the mechanistic decision-making, the system tries to overcome some of the concerns

relating to hierarchy, justice (both procedural and substantive) and HR issues by moving away from

performance-based system to favouring seniority based HR systems. Consequently the performance

focus in the state was found to be on meeting the documented targets relating to different national

programmes (like immunisation, malaria eradication, family planning etc.) rather than on enhancing

the quality of care to patients visiting the health facilities. Any reform process needs to address these

issues. For example, reforms in UK did address some of these issues and have created two different

cadres of professionals, one managing the health sector and other focusing on delivery of care.

Referral system requires a network of sustained relationships focused on working out problems as

they arise and linked by informal channels of communication and networking. At the micro level

health care providers need to connect, communicate, and collaborate through a web of interrelated

informal networks. Tight structural arrangements and various rigidities described above fail to

facilitate such communication required to provide adequate care.

The other central issue of structure relates to control and quality of supervision. Officials at different

levels collect information to achieve desired control and influence below them. Collecting relevant

information for this purpose is vital. However, officials collect required information through informal

networks rather than through formal hierarchy. Hence, effective provision of care would require

investment in the socialisation of officials and facilitating the development of their mutual informal

relationships.

Fragmented sector

structural divide: Health, Family Welfare, Indian

System of Medicines (ISM)

further divided into schemes, projects, components

very little coordination across different components

result of various policy instruments used

external agency policies and practices contribute to

this benefits of economies of scale lost,

inefficiencies

Broken Hierarchy

little influence to steer the programme and its

outcome

lack of clarity on linkages and resource flows

strategic policy and planning role inadequate

considerable gaps in capacities

inadequate decentralisation to address needs of

population

Staffing in health sector

The most striking feature of staffing is the high desire (score 4.13) among the health officials for

consultation in staffing decisions (Table 6). This desire increases with the increase in professional

commitment. They want to be consulted whenever an employee is posted in their district or district

hospital. Similarly, they want to be consulted when an employee is transferred out. However, the

occurrences of consultation are extremely low (2.7 in staff posting and 3.2 in manpower planning).

The denial of this consultative right is found to be adversely affecting the morale of the doctors in the

state. Further, the influence of the district level officials is extremely limited as they cannot t

significantly reward, punish or transfer subordinates in their districts.

Table 6

Staffing Practices: Key Characteristics (Scale: 5.0)

Staffing Practices Mean

(Scale: 5.0)

Standard

Deviation

Consultation on manpower planning 3.20 1.22

Desire for consultation in manpower planning 4.13 0.73

Consultation in staff postings 2.70 1.04

Job clarity 3.57 0.88

Fairness in staffing decisions 3.07 1.10

Testing skills in selections 2.48 1.00

Participation in manpower planning as well as staff posting develops a sense of understanding and

belongingness in the mind of the line managers. The department can secure commitment of their staff

by involving them in human resource planning.

As the decision-making in the state is highly centralised, staffing decisions are influenced more by

political and administrative concerns rather than field requirement. It reflects in extremely low

perception of fairness in staffing decision (3.07). Doctors also perceive that most of the selection

processes of hiring people are inadequate in testing the skills of people. Consequently people with

inappropriate skills enter the health sector. Moderate job clarity primarily emanates from primary

focus on implementation of national health programmes that are well spelt out in documents.

Professional growth and career development

As discussed earlier, professional growth and career development opportunities are the most

important issues affecting the commitment of doctors in the state. However the status of most of the

career and professional growth related activity is poor. Opportunities for career growth are extremely

low in the state (2.5), signifying that doctors perceive virtual stagnant career in the state.

Simultaneously the promotions in the state are not perceived fair (2.7). Currently, there is no

promotion policy in this newly formed state. Consequently many doctors are made to officiate at the

district level without having been regularly promoted by the department. In regulating officiating

arrangements seniority of doctors is also often ignored.

Career advancement through role advancement is also moderate (3.25). This, coupled with high

concern for competency development (3.91), leads to lowering of commitment and rising frustration

among the doctors. Similarly, expectations about professional competency development are not being

met through CME. This is a reflection of low developmental environment in the department even

though it is the critical variable to enhance the affective organisational commitment of doctors.

Table 7

Career management and Professional Growth Practices

Career Management Practices Mean

(Scale: 5.0)

Standard

Deviation

Opportunities for promotions and career growth 2.50 1.06

Opportunities for CME 3.21 0.93

Concern for professional competency development 3.91 0.77

Development for higher roles 3.25 0.92

Help for growth and development 3.14 0.74

Fairness and equity in promotion 2.70 0.92

Liking for seniority based promotion 3.35 0.93

Adequacy of selection process 2.88 0.70

Reward Policies

Doctors perceive that there is no relationship between performance and rewards in the state.

Simultaneously, the perception of fairness and openness in appraisal is very low. This is a critical

variable that enhances the commitment of doctors. Rewards in the department do not motivate doctors

owing to perception of little fairness and equity.

The appraisal process does not help in the development of people either, as it is not shared in the

department.

Table 8

Reward Policies and Practices

Reward Policies and Practices Mean

(Scale: 5.0)

Standard

Deviation

Linkage with rewards to motivate high performance 2.91 0.61

Fairness in appraisal 2.68 0.66

Openness in appraisal 2.66 0.65

Role Adjustment based on capability 2.40 0.91

Rewards and performance relationship 2.53 0.72

6. Implications for Reform Processes

The commitment of people working in the health sector would have significant implications for any

sector reform process. The study of health officials at the district level suggests that the sector faces

number of human resource challenges in ensuring professional and organisational commitment of

officials. We propose that effective management of issues, discussed in section 4 and 5 of the paper,

would lead to better implementation of reform processes. In this section we examine and illustrate

selected health sector reforms initiated in number of states in India and based on literature review

attempt to examine which components of human resources initiatives facilitated or hindered the

implementation of each reform. Based on the availability of information and our past studies, we

select the following reforms:

∙Rogi Kalyan Samiti i.e. Patient Welfare Society ( referred as RKS) in Madhya Pradesh and

Medicare Relief Societies in Rajasthan (referred as MRS)

∙User fee policy in West Bengal and Gujarat (referred as UFP)

∙Autonomy to super-speciality departments in hospitals in Gujarat (referred as Autonomy)

∙Public private partnerships in Delhi, Punjab and Rajasthan (referred as PPP)

∙Strengthening regional management of health facilities by creating regional directorates in

Gujarat (referred as RD)

RKS in Madhya Pradesh and Medicare Relief Societies in Rajasthan

The Madhya Pradesh government attempted to address the task of strengthening public hospitals and

improving their performance through a people’s based model of functional autonomy and

decentralised management. This model is based on the establishment of Rogi Kalyan Samiti (RKS) in

the public hospitals and empowering them to take management decisions. The span of control of

RKS, except for the regular budgetary allocations made by the government, is over the non-

budgetary resources generated through user charges, voluntary contributions, grant-in-aids from

government, commercial utilisation of surplus land and donations. The RKS has been empowered to

collect resources and utilise them for the development of the hospital. Similarly the RKS is also

entrusted with the task of promoting popular involvement in the management and administration of

the hospital thereby giving a welfare orientation to hospital management. And last but not the least,

the objective of promoting RKS is to do away with the concept of free-of-charge hospital services for

the people taking into account affordability of facilities.

The Institution of RKS consists of two bodies - the General Body which is policymaking and

decision-making role and the Executive Body focusing on implementation of decisions. At the state

directorate level, a senior officer is responsible for monitoring RKS in addition to shouldering a host

of other responsibilities. This officer routinely collects information on the income and expenditure of

the RKS. Although, no comprehensive review of the performance of RKS has yet been done, but

available evidences indicate that the model has been successful in generating sufficient resources to

meet the routine needs of the patients attending the hospital and maintain hospital infrastructure and

working environment. In many places we find that hospitals have been able to develop and implement

comprehensive hospital management information system. This has also strengthened the capacity of

hospitals to prepare and implement long-term development plans. Overall the effort has led to a

number of managerial innovations in running of the public hospitals.

The structure of RKS is less bureaucratic and more professional. This enables the facility managers to

come up with a well-designed, needs-based programme for the development of the facility and for

improving its infrastructure and facilities. Participation of hospital staffs in the constitution of RKS

plays a critical role. The power and authority to encourage proper representation and control over

resource generation and utilisation of the facility is vested at the facility level. RKS generally gets

full responsibility for the management of the hospital including all clinical services. However, the

control over government budgetary allocations is not within the purview of RKS.

The implementation of RKS provided a sense of empowerment among the doctors. Some of the

doctors in MP stated, “RKS is a boon to us. We have been able to independently upgrade the facilities

here. We have improved the physical environment which was in extremely poor condition earlier. We

can buy medicines and hire pathological services. We get the satisfaction of providing healthcare in a

way of our professional liking. As better services result in enhanced preference for our facilities, we

tend to earn more through RKS by improving the quality of our services.”

Involvement of local community in the executive committee of RKS has brought it closer to the

beneficiary group. One of the doctors remarked: “We need not go to state headquarter for the approval

of our plans. We get them approved locally in the executive committee. We find this process

extremely fast and transparent.”

The effective implementation of RKS in some of the hospitals has provided visibility to doctors in

those settings. In one of the district hospital the doctor said, “We have been extremely successful in

improving the hospital through KRS. People have visited us to write cases. I have been invited at

national and international workshops and seminars to share our experiences.”

This signifies that RKS provided empowerment, a sense of professional contribution, recognition,

professional development through seminars and conferences in some cases, and a better place to

work. The process was perceived to be fair and equitable.

In 1995, the Rajasthan state government decided to grant autonomy to public hospitals with more

than 100 bed capacity by setting-up autonomous Medicare Relief Societies. The societies are

autonomous bodies registered under the Rajasthan Societies Act. The objectives of the societies are:

provide diagnostic services at cost price; free medical services to families living below the poverty

line, widows, destitutes, freedom fighters, orphans, prisoners, senior citizens above 70 years and

emergency patients; obtain donations; provide measures to conserve resources by adoption of wards,

opening lifeline fluid stores (low cost drug stores). At present, 72 societies are functioning in the

state. Hospital societies in Rajasthan were able to generate Rs. 123 million through various schemes,

which also included user fees (Lubhaya, 2000). All the families living below the poverty line have

been issued Medicine Relief Cards by the government which entitles them to free treatment. Freedom

fighters also carry identity cards. For other categories, means testing is informal and discretionary.

On an average 15 to 20 per cent of users get free care. Funds collected by the societies are deployed

mainly for purchase of new equipment, repair and maintenance, consumables, contractual services for

maintenance and cleanliness, and drugs and medicine (25% funds are to be kept for medicines for the

poor). The use of funds is decided by the societies which have evolved their own purchase and

expenditure procedures which are transparent and flexible. Cost recovery in Rajasthan has varied

from 4 to 25 per cent across various facilities.

User fees policy

A number of state governments in India have developed and implemented user fees policy for their

public health facilities. For example, the state of Gujarat had implemented the user fees policy in

1974. The government of West Bengal introduced user fees policy in teaching and secondary

hospitals during the late 80’s. The government of Orissa has implemented the user fees policy at

district level hospitals for diagnostic services, special rooms, and ambulance services. Many state

governments are introducing the concept of pay clinics and introducing the options of private public

collaborations having implications for user fees policy.

Among other things, the implementation of user fees policy in most places has been identified as an

important instrument in raising revenue for future growth and development. Other goals include

influencing health-seeking behaviour and improving the efficiency of resource use. The introduction

of user fees, however, gives rise to a number of questions about its revenue generating potential in

health facilities. Effective implementation of user fees policy also needs to ensure that there are

efficient mechanisms in place making the policies consistent with the patient's ability to pay. It

should not become a barrier to accessing healthcare facilities; and should develop an ability to attract

high-strata patients who could not only pay but may also donate funds to the hospital. The attraction

could be achieved by perception of better quality among the beneficiary groups.

The management of user fees policy also critically hinges on the extent to which user fees reinforces

desired patterns of referral; the flexibility and autonomy granted to the revenue generating institutions

to use it for improving the quality of care, and, having an appropriate policy framework for

incentives.

Finally, the implementation of user fee did not provide any incentives to the doctors in terms of

empowerment, professional achievements, working conditions, recognition and professional

development. All these factors affected the commitment of people managing these facilities in the

implementation of this reform. Hence, user fees policy failed to generate adequate revenue or improve

efficiency of majority of the hospitals.

Autonomy to super-speciality departments in public hospitals in Gujarat

The Government of Gujarat has granted autonomy to a number of teaching hospitals offering super-

speciality services in the state. The study of these autonomous departments suggests that granting of

autonomy has helped them address many of the general management and HR issues affecting the

performance of the health facilities (Bhat 2001). Autonomy has influenced the following practices in

these hospitals.

∙Concerns of employees

∙Contracting out of services

∙Focussing on consumers services and quality of care

∙User fees

∙Financial management and generation of resources

Through this autonomy, the departments have been able to improve working conditions. Their

positive influence on employees has improved their productivity. The employees are assured that

they will not be transferred without adequate reason and prior consultation. Regarding grievances of

employees, one of the senior doctors stated, “It is easy to manage services since all the employees

now report to the Director. It is easy to handle their grievances and other HR issues.”

Promotion and other career prospects of employees are locally decided by the hospital. . A doctor

said, “The job descriptions are well specified. The staffing decisions are primarily local and

transparent now.” The personnel department plays an important role in designing appropriate policies.

These autonomous centres have developed mechanisms to contract out various services. The hospital

has also evolved mechanisms and systems to address consumer concerns. The hospital has set up a

Counselling and Liaison Office. Social workers have been appointed in this office which provides

counselling services to the patients. The office also offers guidance and information on financial

benefits available to the users. The hospitals have developed standards of care which help the patients

to know whether they would be admitted to the hospital. The institutions are able to ensure good

quality of care by developing treatment protocols. They provide free treatment to all patients whose

income is less than Rs. 1000 per month. One of the autonomous centres has found that 70 per cent of

the patients get free treatment. Generally the patient requiring free treatment has to obtain a

certificate about her/his income from the public representative. The user fees charged are significantly

lower than what is charged in private facilities. The autonomous institutions receive 100 per cent

grant for all its recurring expenses. The grant is also adjusted against the revenues the hospital

generates from user fees. The government provides budget support only to the extent of

recompensing deficits and recurring expenditures. Some of these facilities have raised funds through

donations. These funds are used to meet research requirements and capital expenditure. The hospitals

prepare the budget and it is discussed in the governing board. The governing board has a government

nominee on it and once the budget is approved it gets clearance from the government as well. Most

of the purchase decision are discussed in a purchase committee and later presented to the governing

board for approval. In all cases the institutions follow the cash basis of accounting. The cost

accounting systems are however not adequate and hospital lack mechanisms to control the costs.

These institutions have also started using computers in a major way to store data and financial

information. Given this autonomy, they have also explored the possibility of developing alternative

financing mechanisms such as development of insurance systems. In one case we found that one of

the hospitals has taken initiative to develop an insurance scheme. However, they have not received a

good response. The hospitals currently do not have capacities to handle such tasks, for it would

require considerable marketing effort to promote the new mechanisms.

The study of this reform shows that it provided empowerment, a sense of professional contribution,

and a better place to work. The process was perceived to be fair and equitable. Employees’ issues

relating to growth and development, rotation between departments and grievances were dealt with

locally on merit. It enhanced the commitment of employees for the implementation of reform and thus

the quality of healthcare.

Public-private partnerships

With the shrinking budgetary support and growing fiscal problems, most of the state governments are

finding it difficult to expand their public facilities to cater to the growing healthcare needs of their

population. In terms of resource allocation, the most affected areas are secondary and tertiary care.

The difficulties experienced in providing medical services specifically in these areas have compelled

many state governments to explore alternative options. Having experienced significant growth in

private sector at curative primary and high-tech secondary care, some of the state governments are

exploring the options of promoting the public-private partnerships in the health sector. Most of these

options are being explored in the areas of curative and tertiary care, and also in provision of medical

services in remote places.

The public policy goals for having private initiatives have not been discussed and debated. There is

always a great deal of trade-off in policy goals involving equity and protecting poor patients,

efficiency (technical and allocational), and quality of services. For example, the focus of previous

initiatives to protect the poor has produced insignificant results. Targeting the poor is a difficult

process. There has not been enough emphasis on strengthening the mechanisms to ensure it. Some

questions that have not been addressed adequately are (a) does the public initiative of promoting

private sector arrangement fit the local circumstances? (b) is the regulatory environment in the

country suitable for promoting public-private partnerships in health? (c) does the reform respond to

the concerns of those affected? and (d) how does one handle the ills and undesirable consequences of

private sector growth in health?

Most of these concerns relate to high cost and lack of standards and inadequate regulation of quality.

In order to strengthen the public-private partnerships, and in general the role of private sector, it is

important to identify areas of intervention to make it more responsive towards public goals and to

minimise the unintended consequences of private sector growth. The lack of monitoring mechanisms

and absence of appropriate regulatory instruments raises doubts on the effectiveness of public-private

partnership approaches.

The process and institutional mechanisms to handle public-private partnerships plays a critical role in

the process of developing these initiatives. Private sector health providers interested in participation

have to make a number of decisions that would involve a complex process of information search and

analysis. In the absence of appropriate mechanisms for information sharing, the private provider

incurs high transaction cost. This makes these partnerships vulnerable to inefficiency and high cost.

Policy initiatives did not provide sufficient information on various aspects of the proposed

partnerships and thereby generated high uncertainty that affected the investment by private providers.

Besides information sharing processes, other important issues in these partnerships have been the

absence of appropriate mechanisms to involve all stakeholders (including community and user

groups) and transparency in the process.

Implementing private initiatives involved considerable amount of co-ordination across different

departments of the government. Experiences suggest that mechanisms to handle the complex

interfaces across the departments such as making amendments in certain statutes and co-ordination

with various implementing agencies were not considered before the start of the process. The

development of these approaches has been top-down. Proposals have not taken into account

stakeholder views because the involvement of various stakeholders was not considered important in

this process. There has been little interaction and involvement of concerned departments in

promoting such initiatives. The processes also lack mechanisms to consider viewpoint of various

stakeholders, largely consumers. Public litigation has been one of the direct outcomes of these

factors. Inadequacy of appropriate mechanisms to monitor the performance of the proposed

partnerships has been another concern. This is a direct outcome of not having clarity about the public

goals of these initiatives.

The development of private initiatives in health will need significant institutional development work.

Developing capacities to handle these initiatives require financial analysis capabilities, efficient

monitoring and evaluations systems and capabilities to analyse various options. One of the major

concerns about private initiatives would be the policy perspective of the government. There is no

uniform view on what should be the private-public mix of healthcare. Policy frame on public policy

towards private sector is yet to be developed. There is little clarity on the amount of subsidies and

incentives being channelled to the private health sector. The appropriateness of existing mechanisms to

channel these needs discussion. Other policy concerns relate to development of mechanisms to protect

funding to government institutions while promoting private initiatives. It should not displace other

sources of funding as has happened in some programmes sponsored by the central government.

There is a potential problem of private initiatives leading to unequal standards of clinical care across

public and private sectors. Private initiatives would create two different standards of healthcare

delivery systems providing different quality of care to different clientele. This problem would further

aggravate as a result of less allocation of government resources to public facilities. In the process,

ultimately, the poor will suffer. The private sector would displace the resources of the public sector,

attracting qualified personnel from it further aggravating the problem in public sector. The

implications of these on public goals of health policy are less than understood.

Given the experiences in private initiatives, organisation mechanisms have assumed significant

importance in implementation. Recent experiences suggest that governments are vulnerable in

proposing and handling these initiatives themselves. Given that implementation requires considerable

amount of expertise and time and the monitoring of these initiatives is critical, creation of a separate

organisation (outside the ministry) could be considered for effective performance. . It is also

important that other aspects as discussed above are adequately addressed in the process.

The study of this reform shows that structural discontinuities were not addressed and information flow

between care providers in the two sectors remained a challenge. The top-down approach did not

provide a sense of empowerment. The reform process did not contribute neither to professional

advancement, betterment of workplace, nor professional growth issues. Investigations reveal that the

partnership carried high potential for professional growth through sharing cases and professional

knowledge. However, the implementation process would need to bridge the structural discontinuity

and create opportunities for mutual learning and growth.

Strengthening regional management of health facilities by creating regional

directorates in Gujarat (RD)

The government of Gujarat has developed structures to implement decentralisation strategy in the

health sector. For the purpose of managing health facilities, particularly the hospital sector, Gujarat

state has been divided into six regional zones. Regional offices were created in each zone in 1986, ,

which among other things, look after the hospitals in each region. Each regional office is headed by

Regional Deputy Director (RDD) and is assisted by an assistant director. The regional offices have an

important role in monitoring the health of the region. For this purpose the Department of Health and

Family Welfare (DoHFW) has developed MIS. Each hospital is required to submit a statement every

month to the RDD. The RDD generally holds monthly meetings to review the progress of the

programmes. The meeting also discusses technical and administrative functioning of hospitals and

takes decisions to implement programmes and deal with any other problems. The general experience

is that most of the problems related to functioning of the health facilities are sorted out at the level of

regional offices.

While implementing this intervention, resource allocation decisions and staff transfer and promotions

have not been delegated to regional offices. Earlier regional offices were given the authority to

transfer and promote the personnel in their regions but it was later withdrawn. Most of the decisions

of transfer and promotions are now handled at the level of the DoHFW. To maintain discipline and

effective functioning of the facilities, the RDD can issue a memo to an erring employee. However,

since they cannot take any follow-up action, the RDDs feel that it is not very effective. Staff unions

are active in each region. The general experience of the regional offices has been that they have not

posed any major problem in implementing programmes.

The regional offices have also the responsibility of ensuring good performance from hospitals. For

this purpose, the regional offices make surprise and scheduled inspections of hospitals. The officers

from regional office spend one day in each health facility. For this purpose they use a prescribed pro-

forma. The regional office is supposed to inspect each hospital once a month. But, due to staff

problems there are sometimes delays in carrying out inspection. There are surprise visit for Primary

Health Centre (PHC’s) and CHC’s once in every three months. Some disciplinary actions are

initiated after these inspections. There are instances when the inspection committee has asked an

employee to go on leave without pay or has issued memo.

Under each regional office there are five to six district hospitals. In some places under each district

hospital, some departments have been granted full autonomy (for example, the cancer department in

Civil Hospital of Ahmedabad). Similarly, Civil Hospital in Baroda has a department of urology

which is now autonomous. These autonomous departments receive grants-in-aid from the DoHFW

and are also allowed to raise resources through donations and other grants. The regional offices

monitor these departments and make recommendations to the DoHFW for extending their grants. The

autonomous departments have governing bodies in which representatives from the DoHFW are ex-

officio members.

Each hospital is expected to constitute a management committee. The members of this management

committee are selected from community, public representatives and health officials. The regional

offices recommend the constitution of these committees. However, over the years the functioning of

these committees has not been effective.

The implementation of this structural reform shows that managerial decisions, primarily relating to

HR, continued to be centralised at state headquarters. The intervention has only tightened the control

and monitoring of health units in the field and has not contributed to empowerment, professional and

career growth, recognition, and perception of fairness in HR decisions. Consequently, the reform has

failed to add to the commitment of the people.

Comparing these reform initiatives

These initiatives were independently assessed by both the authors on different dimensions of HR

issues that were found to be related to commitment. The authors assessed them on a scale of five.

Both the authors had high similarity in their evaluation. They deliberated upon their disagreements on

some of the items to reach to a consensus (Table 9).

Table 9

Assessment on different HR factors in implementing reforms

Variable that affect commitment RKS UFP Autonomy PPP RD

1. Helping doctors for growth and

development **** * **** * *

2. Providing opportunities for CME and

professional growth **** * **** * **

3. Increasing training intensity *** * **** * *

4. Supporting local training initiatives **** * *** ** **

5. Providing opportunities for promotions

and career growth * * ***** * ***

6. Providing opportunities for

development for higher roles and

responsibilities.

***** *** ***** *** ****

7. Adopting means to improve the

perception of fairness in training

opportunities

*** * **** * *

8. Adopting means to improve the

perception of fairness in selection,

appraisal and promotion

*** * ***** * *

9. Empowering the health facility

managers ***** * *** * **

10. Linking rewards and recognition with

performance ***** * *** * **

11. Helping them stay longer in clinical

settings **** * *** * **

12. Providing freedom to interact with

superiors and patients ***** * **** * ****

Effective (E) or not-effective (NE) Policy E NE E NE NE

The table indicates that wherever reforms could integrate HR issues in their implementation they were

effective in their outcome. It suggests that the reforms that could integrate HR issues in their

implementation will be / can be expected to be effective in their outcome. It suggests that states will

have to rethink and reorient their implementation of reform agenda to integrate structural HR issues.

In the absence on such integration, it is unlikely to achieve the millennium developmental goal of

health for all by 2015.

Annexure 1

Profile of the State

Chhattisgarh is the 26th state of the Indian Union created on 1st November 2000 by bifurcating Madhya Pradesh.

The state comprises of 16 districts and 146 community development blocks. The state occupies 135,194 square

kilometre area. Nearly half of the state’s population, about 21 million, is classified as socially underprivileged.

The state has low urbanisation of 17.4 percent as compared to 28.5 percent for all-India. Out of 20308 villages

in the State 18076 villages are electrified. There is one medical college, one Ayurvedic college and two

homeopathic colleges in the State.

Economy of the State

According to quick estimates for the year 2002-03, total revenue of the state was Rs. 53844 million. Tax

revenue is 67 percent of the total revenue.

State Finance (2002-03: Quick Estimates) Amount (Rs. in Million)

Revenue Receipts

Tax Revenue 36092.90

Non-Tax Revenue 8733.90

Grants From Central Government 9017.80

Total Revenue 53844.60

Revenue Expenditure

Non-Plan 44679.80

Plan 14120.20

Total 58800.00

Net State Domestic Product at current prices 241420.00

Source: Revenue Department

The economy of the State is predominantly agricultural as about 85 percent of the population is engaged in

agriculture. Nearly 43 percent of the total land area is cultivated. However, only 12 percent of the total

cultivable land is irrigated; rest of the cultivation depends on rain fed canals. Forest accounts for 45 percent of

the total land area.

Rich in mineral resources, Chhattisgarh has the world famous reserves of iron-ore in Bailadila. Coal, limestone,

dolomite, bauxite, tin, gold and diamonds are the other valuable minerals found in the State. Chhattisgarh earns

about Rs. 3950 million annually from the mining sector.

Major Health Indicators of the state

The following table provides broad health indicators of the State.

Indicators

Total Fertility Rate (1997) 3.60

Couple Protection Rate (Sterilisation - %) 29.5

Birth, Death & Infant Mortality Rates 1999

Birth Rate Total (Per 1000 Population) 26.9

Rural (Per 1000 Population) 29.3

Urban (Per 1000 Population) 23.6

Death Rate Total (Per 1000 Population) 9.6

Rural (Per 1000 Population) 11.3

Urban (Per 1000 Population) 7.0

Infant Mortality Rate (Per 1000 live birth) 78

IMR in Rural Areas (Per 1000 live birth) 95

IMR in Urban Areas (Per 1000 live birth) 47

Infrastructure : in units

District Hospitals 6

Urban Civil Hospitals 17

Community Health Centres 114

Urban Civil Dispensaries 23

Primary Health Centres 512

Sub-Primary Centres 3818

T. B. Hospital 1

Leprosy Sanatorium & Hospitals 3

Polyclinic 1

Beds 6822

The Structure

Operationally, like in other states, Chhattisgarh state health system is rule-based and procedures are important in

the administration of health services. Decision-making is highly centralised and most of HR decisions are taken

at the level of the minister. The structure of the Department of Health and Family Welfare is as described below:

The Principal Secretary is responsible for formulating and implementing policies for all public health and family

welfare programmes. The Secretary (Family Welfare) is in charge of the family welfare programmes and other

related projects and Commissioner (Health) is in charge of health programmes. At the operational level, there is

a Directorate, consisting of five Directors, one each for Medical Services, Public Health & Family Welfare; IEC

and Communicable Diseases.

The state has been divided into ten health divisions with a Joint Director as incharge to facilitate health

administration. In the administrative hierarchy, the Joint Directorate (Division) is a link between the state head

quarters (i.e., the Directorate) and the district medical and health administration. The Joint Director co-ordinates

and monitors the programmes in the districts under his/her jurisdiction, and reports to the concerned director.

Two officers, i.e., the Civil Surgeon-cum-Hospital Superintendent and the Chief Medical & Health Officer

(CMHO), mainly look after the health administration at district level. The Civil Surgeon-cum-Hospital

Superintendent is primarily responsible for management of district hospital (DH). The CMHO is mainly

responsible for management of healthcare setup in rural areas of the district, which includes Community Health

Centres (CHCs), Primary Health Centres (PHCs), and Sub-Centres (SCs), and also Civil Hospitals (CHs).

The CMHO heads the district health management team and is supported by District Health Officer, District

Family Welfare Officer, District Immunisation Officer, District Leprosy Officer, District Tuberculosis Officer,

District Prevention of Blindness Officer, District Public Health Nurse Officer, and District Education and Media

Officer. Thus, for the functioning of health system, the district is an important unit.

The districts are divided into a number of administrative blocks conforming to the area of Panchayat Samiti. At

the block level, the medical officer in charge of the block PHC is responsible for implementing all national

health programmes, family welfare and reproductive, health and curative services in the block area through the

network of PHCs and SCs.

From the administrative point of view the block PHC compiles all the performance reports sent by CHCs and

PHCs. At the PHC level the designated medical officer is responsible for implementing all the programmes in

his PHC area and is supported by a team of para-medical personnel. At the village level, an Auxiliary Nurse

Midwife (ANM) manages the Sub-Centre. She is responsible for implementing all the programmes in the SC

area, which usually covers 4-6 villages.

Unlike other states in India, the government of Chattisgarh allows private practice to the doctors. . All the

doctors in medium and large sized towns have some form of private practice.

Annexure 2

Item Mean Std.

Deviation

AGE 48.13 6.74

Experience in the medical profession 22.55 7.72

Experience in the department in the State 19.42 9.52

Early role clarity 3.54 0.84

Training adequacy 3.28 0.83

Adequacy of training intensity 2.20 0.57

Support for training 3.37 0.83

Fairness in training 3.01 0.83

Role in training Process 2.95 0.91

Role clarity 3.69 0.58

Empowerment 2.88 0.69

Satisfaction about clinical settings 3.97 0.87

Satisfaction about administrative settings 3.49 1.02

Willingness to assume higher responsibilities 4.19 0.51

Importance of financial returns 2.79 0.69

Concern for fringe benefits 2.74 0.79

Pay according to ability 3.57 0.82

Value for competence in the profession 3.51 1.06

Expectation for compensation for ability 2.95 1.09

Importance of opportunities for CME 4.07 0.49

Importance of respect and recognition 4.01 0.46

Expectation on responsibility and independence at work 3.83 0.49

Expectations of interesting work 3.93 0.60

Expectations about comfortable working conditions 3.15 0.71

Concern about hours of work 3.64 0.80

Expectations on sound policies and practices 4.11 0.49

Importance of job security 3.71 0.80

Nature of supervision 3.93 0.67

Importance of respect for self 3.88 0.56

Satisfaction with income 3.43 0.71

Satisfaction with recognition 3.88 0.58

Time with family 3.23 1.02

Risk free environment 2.86 0.99

Professional growth provided 3.26 1.00

Independence provided 3.06 0.97

Freedom to deal with community 2.67 0.92

Freedom to seek resources 2.71 0.78

Freedom to plan work 2.68 0.90

Freedom to interact with superiors and patients 3.02 0.84

Freedom to interact with other departments 2.98 0.98

Freedom to reward subordinates 3.06 1.01

Annexure 3: Rotated Component Matrix (Cumulative variance: 53.3 %)

Factor 1: Professional growth and developmental climate

Factor 2: Autonomy

Factor 3: Capability based staffing

Factor 4: Willingness for higher responsibility

Factor 5: Role in staffing of subordinates

Factor 6: Willingness to stay in clinical settings

Factor 7: Willingness for competence based assured pay

Factor 8: Satisfaction with recognition and reward

Component 1 2 3 4 5 6 7 8

Help for growth and development 0.82

Fairness in training 0.81

Linkage with rewards to motivate high

performance

0.76

Training adequacy 0.75

Support for training 0.70

Opportunities for CME 0.68

Fairness in appraisal 0.66

Empowerment 0.64

Rewards and performance relationship 0.63

Fairness and equity in promotion 0.57

Testing skills in selections 0.51 0.43

Concern for development for higher roles 0.48

Opportunities for promotions and career

growth

0.48

Professional competency development 0.42 0.42

Openness in appraisal 0.42

Freedom to seek resources 0.81

Freedom to interact with other departments 0.78

Freedom to plan work 0.75

Freedom to reward subordinates 0.68

Time with family -0.68

Role adjustment based on capability 0.62

Adequacy of selection process 0.45 0.62

Adequacy of training intensity 0.61

Expectation on responsibility and

independence at work

-0.55

Value for job vs. worthwhile work -0.51

Willingness to assume higher responsibilities 0.71

Concern on hours of work 0.56

Importance of financial returns -0.53

Expectations on sound policies and practices 0.52 0.47

Expectations towards comfortable working

conditions

-0.48

Role clarity 0.40

Consultation in staff postings 0.71

Job clarity 0.60

Consultation on manpower planning 0.54

Fairness in staffing decisions 0.44 0.52

Nature of supervision -0.43 0.47

Willingness to stay in clinical settings 0.65

Freedom to interact with superiors and patients 0.61

Importance of respect for self -0.54

Component 1 2 3 4 5 6 7 8

Importance of worthwhile work -0.48

Importance of respect and recognition -0.48

Pay for ability 0.67

Importance of job security 0.61

Value for competence in the profession 0.52

Concern for fringe benefits -0.45

Satisfaction with recognition 0.71

Expectation for compensation for ability 0.60

Professional growth provided 0.57

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