Human resource issues and its implications for health sector reforms

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.

Implications of Human Resource Practices and Other Structural Factors on Commitment of Public Medical Professionals in India

In this paper we focus on often neglected issue and inadequately studied area of commitment of public sector health professionals and some of the issues surrounding human resources as its determinants. The paper argues that success or failure of new initiatives in health sector critically hinges on the commitment of the staff. This paper is based on the questionnaire study and focused group discussion of 175 doctors working as district medical officers at district level and holding key administrative positions at state level in four states in India. These four Indian states account for nearly 22 per cent of India’s population. The findings provide some important insights that would be useful in drawing future agenda of strengthening health sector and involving all stakeholders in implementation process. The study finds critical linkage between human resource (HR) practices and commitment of doctors working in the government. Specifically, following HR practices are found critical in influencing organizational commitment: transparency in selection/postings, supportive training and capacity strengthening climate, recognition of performance and regular performance feedback. Further, results suggest that certain work environment and structural factors facilitate these practices. Health officials’ roles need to be redefined and given complexity of coordination at various levels, officials need to be allocated higher responsibilities. There is also a need to improve interpersonal relations within departments and coordination among agencies and officials at various levels. It is also observed that the structural rigidities in the system leading to obstruction in information sharing across various levels needs to be addressed to ensure effective healthcare delivery. This study highlights the criticality of administrative and structural issues for reforms of healthcare sector in India. Addressing human resources issues is critical for ensuring commitment from staff in implementing new initiatives or health reform agenda. National Rural Health Mission (NRHM) also identifies the human resources and capacities as an important challenge. Institutions that are critical vehicles to implement the NHRM would remain weak owing to low commitment of people. It would be important to focus on HR issues before any new initiative is proposed and implemented. The departments of health across states need to broaden and deepen the understanding of HR management and planning issues. For this purpose they may need to set-up HR division having appropriate competency and skill-mix to address the issues and work towards making the right changes. The papers discusses that these changes will be required at both strategic and operational levels.

Provision of Reproductive Health Services to Urban Poor through Public-Private Partnerships: The Case of Andhra Pradesh Urban Health Care Project

Andhra Pradesh had initiated the Urban Slum Health Care Project to provide basic primary healthcare and family welfare services to urban poor living in slums in 2002. As of now, the project has established 192 Urban Health Centres (UHCs) in 74 municipalities of the state through contracting-out process to the NGOs. These UHCs cover population of about 3 million. State government has played pivotal role in creating capacities to monitor and supervise the functioning of these UHCs. This project was started with the World Bank support and the state has effectively managed the transition from a donor-funded project to government programme and at the same achieving demonstrable impact on health status among its target population. The scheme ensures people’s participation in management of the UHCs and placing the power for identifying the health priority in the hand of the community. The case study identifies emerging challenges in the scheme implementation relating to (a) involvement of NGOs as partners in service delivery, (b) financing and financial management system, and (c) need to reposition the UHCs in view of changing epidemiological scenario. Some of the areas needing attention to address the challenge include: need to refine the service mix to better respond to the health needs of the population served; evolving a financial management practices to increase efficiency in disbursement; motivating NGOs to actively participate in the scheme; developing management capacity and competencies of both partners; and repositioning relationship between the state and non-state actors away from a contractual basis to an effective partnership.

Contracting-out of Reproductive and Child Health (RCH) Services through Mother NGO Scheme in India: Experiences and Implications

Partnership with NGOs in delivering and provision of Reproductive and Child Health (RCH) services through mother NGO (MNGO) in the un-served and under-served regions is one of the important initiatives in India. The scheme involves large number of contracts between government and the NGOs. As of April 2006, 215 MNGOs were working in 324 districts of the country. In addition to this there are about 3 to 4 Field NGOs attached with each MNGO in a district. This paper discusses this scheme with an objective to understand the make up of the partnership and the development of management capacity in the system. MNGO scheme is a central sponsored scheme. This scheme faces management challenge to implement it in all states in India. Further, the case study of three states presented in this paper suggests that this challenge emanates several factors. Inter alia, these include delay and uncertainty of funding and contract renewal, lack of partnership orientation in the scheme, lack of trust among the key stakeholders, capacity constrain in the district and state health system, weak monitoring system, procedural delays and multiple points of authority and reporting relationships. It is also observed that the capacity of field NGOs to deliver in the programme is constrained due to non-availability of financial and human resources. The scheme demands a strong leadership at local levels and ownership from the state health system. This can be achieved through effective decentralisation, flexibility in decision-making and creating adequate accountability systems. Regional Resource Centres has to play an important role in coordination between state/district RCH society and the NGOs and strengthening their capacities. The central government instead of focusing on micro-management of the scheme at state level should focus on developing and strengthening the enabling environment and capacity of various stakeholders to implement the scheme. Also, they need to address various systemic issues including development of accountable and performance oriented system, ensuring financial autonomy and decentralisation, delegation of authority, building trust and accountability in the system, effective integration, continuity of the scheme and fostering true sense of partnership between the state and non-state sector.

Public-Private Partnership, Contracting Arrangements and Managerial Capacity to Strengthen RCH Programme Implementation

Strengthening management capacity and meeting the need for Reproductive and Child Health (RCH) services is a major challenge for the national RCH programme in India. Central and state governments are working through multiple options to meet this challenge, responding to the complexity of issues in RCH which cut across social, cultural and economic factors, as well as reflecting the immense geographical barriers to access for remote and rural populations. Other barriers are also being addressed, including lessening financial burdens and creating Public - Private Partnerships (PPP) to expand access. For example, the NRHM has been initiated with particular focus on rural population. However, there are a number constraints faced by departments of health in implementing these initiatives. In this paper we focus on one key area: the development of management capacity for working with the private sector. A synthesis of the learning from three case studies of public-private partnerships in the RCH area is discussed. Two case studies pertain to state level initiatives in Gujarat and Andhra Pradesh and third study focuses on the national level mother NGO scheme. The objective of these case studies was to investigate how management capacity was developed through the implementation of these three public-private partnerships initiatives and contracting out of RCH services. The case studies also focused on the partnership in service delivery setting by examining the structure and process of partnership experiences, understanding the management capacity and competency in make-up of various public-private partnership initiatives in RCH, and identify pathways towards developing management capacity of partners to address key challenges in implementation.

Dynamics of Team Teaching and Research in a Management School: Learning and Imperatives

This paper discusses the experience of team teaching to address the issues of integration of academic inputs by bringing multi-disciplinary perspective together and thereby enhance learning experience of participants. The paper delves on the process, events and outcome of team teaching by four faculty members at IIM Ahmedabad who collaborated in teaching, writing cases, and doing research for a period of more than three years. The experience has been summarized using the following dimensions: need for team-teaching, existing mechanisms and barriers, opportunities and potential, imperatives, fall-outs and challenges experienced in the process. The cohesion, trust and mutual respect are key imperatives. The other factors contributing to the success of team-teaching are strong felt need by the members for integration in programmes, complementary skills and experiences of team members, frequent programmes with integrated components that provided continuous opportunities for learning, co-location of the instructors, and off-site programmes that provided opportunities for close get-togethers. The autonomy granted by the institution to instructors and co-coordinators to design and execute learning opportunities was also instrumental in the success. In an environment where the rule of the game is individualism, forming teams creates fears of loss of importance and recognition. The experience shows that the competency of the members and the overall effectiveness of the tasks are strengthened if the team believes in “reciprocating interdependence”. This can be possible only if members allow themselves opportunities to experiment, improvise and review

Treating HIV/AIDS patients in India with antiretroviral therapy: a management challenge

India stands at a critical junction of HIV pandemic. Controlling spread of HIV is critical. Ignoring this will lead millions of Indians in grip of this pandemic. Ever since HIV/AIDS was acknowledged as a problem, the strategies to address the issue have focused on prevention, treatment and research. This paper discusses the treatment aspect. With currently available antiretroviral agents, eradication of HIV infection is not likely. The aim of treatment is thus to prolong and improve the quality of life by maintaining maximal suppression of virus replication for as long as possible. Brazil has shown how to implement antiretroviral therapy programme. India has embarked upon an ambitious programme to introduce antiretroviral therapy in six high prevalent states and the national capital. The paper discusses the technical, management and financing challenge in implementing this intervention.

Maternal Health Financing – Issues and Options: A Study of Chiranjeevi Yojana in Gujarat

Government of Gujarat announced a “Chiranjeevi Yojana” in April 2005. The objective of this scheme is to encourage private medical practitioners to provide maternity health services in remote areas which record the highest infant and maternal mortality and thereby improve the institutional delivery rate in Gujarat. The scheme was finally launched as a one year pilot project in December 2005 in five districts viz., Banaskantha, Dahod, Kutch, Panchmahal, and Sabarkantha. The private empanelled providers are reimbursed on capitation payment basis according to which they are reimbursed at a fixed rate for deliveries carried out by them. The payments are made for a batch of 100 deliveries. This is expected to take care of case-mix differences (i.e., normal or complicated deliveries) and help the providers to keep the costs below the reimbursed amounts. The scheme proposes to use a voucher system to target the people living below poverty line. The objective of this paper is to document the experience in implementing this scheme and discuss the issues in up-scaling it further.

Human Resource Practices and Commitment of Senior Officials in Health System: Reflections from a Progressive State in a Developing Economy

It is widely recognised that the commitment and competencies of people working in the health sector has significant bearing on sector performance and its reform process. The current paper attempts to analyse the commitment of the health officials and its implications for HR practices in Maharashtra. The study suggests that the district health officials do not share a strong emotional bond with their department. The state needs to reform its Human Resource Management practices to effectively strengthen the functioning of the health system. The study shows that there is a need to involve senior doctors in staffing decisions that affect their work units. There is a need to develop a proper tribal/remote area posting plan for the health officials, failing which creates a sense of frustration among the health officials. The study also suggests investing in development of multiple strategies for the growth and career development of health professionals. Finally the study advocates the need to develop areas of public private partnership and community participation in making the public health programme successful.

Third Party Administrators and Health Insurance in India: Perception of Providers and Policyholders

The advent of Third Party Administrators (TPAs) is expected to play an important role in health insurance market in ensuring better services to policyholders. In addition, their presence is expected to address the cost and quality issues of the vast private healthcare providers in India. However, the insurance sector still faces challenge of effectively institutionalising the services of the TPA. A lot needs to be done in this direction. Towards this the present paper describes the findings of a survey study, which was carried out with the objective to ascertain the experiences and challenges perceived by hospitals and policyholders in availing services of TPA in Ahmedabad, Gujarat. The major findings from the study are: (i) low awareness among policyholders about the existence of TPA; policyholders mostly rely on their insurance agents; (ii) policyholders have very little knowledge about the empanelled hospitals for cashless hospitalisation services; (iii) TPAs insist on standardisation of fee structure of medical services/procedures across providers; (iv) healthcare providers do experience substantial delays in settling of their claims by the TPAs; (v) hospital administrators perceive significant burden in terms of effort and expenditure after introduction of TPA and (vi) no substantial increase in patient turnover after empanelling with TPAs. However, there is an indication that hospital administrators foresee business potential in their association with TPA in the long-run. There is a clear indication from the study that the regulatory body need to focus on developing mechanisms, which would help TPAs to strengthen their human capital and ensure smooth delivery of TPA services in emerging health insurance market.