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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.
Human resource issues: Implications for health sector reforms
Ramesh Bhat
Sunil Kumar Maheshwari
Indian Institute of Management
January 2004
Human resource issues: Implications for health sector reforms
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
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
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
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
Continuity and holes
Provisions for Private Practice
Characteristics of Reforms
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
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
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:
Professionally committed doctors
Team spirit among the officials
Liking for job-security among doctors
Appreciation for community-based health
Lack of autonomy and
experimentation in the field
Lack of transparency and fairness
Lack of performance orientation
Lack of skilled manpower and
Interferences of political leaders
High concern among doctors to improve
health services
To develop fresh policies and strategies
Financial help owing to being a new state
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)
(Scale: 5.0) N
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
Table 2
Dependent Variable: Affective Organisational Commitment (Adjusted R square = 0.58)
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
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
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)
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
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
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
Authority driven
Bureaucratic behaviour
Influence driven
Benevolent leadership
Pro-social behaviour
Coordinating abilities
Customer sensitive
Centralised decision-
High power distance
between different levels
Long hierarchy
Empowerment at
lower levels
Low power distance
between different
Short hierarchy
Democratic decision-
Equitable power
Medium hierarchy
behind the
structural design
Do not trust people
unless proven worthy
Do not leave things to
Trust people unless
proven unworthy
Neither trust them not
mistrust them, be open
to evaluation every
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
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,
Broken Hierarchy
little influence to steer the programme and its
lack of clarity on linkages and resource flows
strategic policy and planning role inadequate
considerable gaps in capacities
inadequate decentralisation to address needs of
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)
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)
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
Table 8
Reward Policies and Practices
Reward Policies and Practices Mean
(Scale: 5.0)
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
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
***** *** ***** *** ****
7. Adopting means to improve the
perception of fairness in training
*** * **** * *
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.
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.
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
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
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
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
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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Technical Report
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A number of state governments in India are in the process of developing and implementing user fees policy for their public health facilities. There are other state governments which has reviewed the implementation of their existing policies. For example, the government of West Bengal, which implemented the revised rate structure of charges for hospital services in 1995, has reviewed its implementation. The government of Orissa has implemented the user fees policy at district level hospitals for diagnostic services, special rooms, and ambulance services. The government of Rajasthan created autonomous Medicare Relief Societies in each tertiary hospital and secondary hospital having 100 or more beds. One of the objectives of these societies has been to implement user fees policy for various services in these hospitals. Madhya Pradesh government has also established Rogi Kalyan Samiti (Patient Welfare Society) in the public hospitals and empowering them to generate revenue by charging user fees for the services provided and by other means thereby removing resources constraints for improving the quality of services. There is growing trend to introduce 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 the revenue generating potential of user fees in health facilities. The effective implementation of user fees policy also needs to ensure that there are effective mechanisms in place making the policies consistent with the patient's ability to pay and do not become barrier to accessing the health care facilities. 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 the revenue generated for improving the quality of care, and having an appropriate policy framework on incentives. There are a number of trade-offs in implementing the user fees policy and these need critical examination. This paper discusses the experiences in implementation of user fees policy in five states: West Bengal, Rajasthan, Gujarat, Madhya Pradesh and Orissa. The second section of the paper describes the macro policy context and significance of user fees policy and implications for resource mobilization and efficiency. The third section discusses the management issues in implementing the user fees policy. A detailed case study of implementation of user fees policy is presented in section four. The last section discusses the implications of this study from the viewpoint of strengthening the referral system, quality of services, and implications for developing appropriate financial management practices.
Performance evaluation of salespeople is examined from an attribution perspective in a field study involving sales managers. Findings support the presence of an attribution bias. Effort significantly influenced sales managers’ evaluations, but task difficulty had no measurable effect on performance appraisal.
The authors address a fundamental gap in understanding how sales performance and job satisfaction are determined in an investigation of the sales force of a direct-selling organization. Results indicate a direct positive effect of work-related effort on job satisfaction that is not mediated by sales performance. This is inconsistent with commonly accepted theoretical models and suggests that the perspective of work as a “terminal value” (i.e., an end in itself, rather than strictly a means to an end) has been underemphasized in models of work behavior. As such, either (1) measures of sales performance should be broadened to encompass the terminal value perspective on the psychological value of work or (2) conceptual models should be revised to reflect that narrowly defined measures of sales performance do not completely mediate the effect of effort on job satisfaction. The authors conclude with a discussion of managerial implications of these findings.
This research proposes an integrative model of the antecedents and consequences of salesforce role stress, with particular emphasis on two outcomes important to sales reps and firms alike: salesforce performance and satisfaction. Drawing on data from 196 sales representatives for five major industrial firms, the linkages in the proposed model are tested with path analysis procedures. The model is sufficiently comprehensive that it provides a basis to replicate and extend, in one study, much of the key research on the sales representative's role environment, especially as it relates to role conflict, role ambiguity, and their relationships with job performance and satisfaction. Implications of this research for sales managers and researchers in the sales area are given.
A model of the turnover process is developed by synthesizing three turnover models: those of Price (1977) and Mobley (1977), and the model which has developed around the organizational commitment variable. This model is tested via path analysis and is generally supported. An attempt to cross validate the new model provided moderate support for it.