Is the Annual Confidential Report system effective? A study of the government appraisal system in Gujarat, India.

BACKGROUND Effective performance appraisal systems can not only motivate employees to improve performance but also be important for the performance of organizations. However, the appraisal systems in civil services called the Annual Confidential Report (ACR) systems can be ineffective and do not contribute to employees' learning and development. With this background, the current study aimed at understanding the ACR system and assessing its effectiveness. The research aims to contribute in filling the knowledge gap in the existing literature on the need as to why the ACR system in civil services is an important human resource management (HRM) function. METHODS The analysis is based on policy review to understand the extant appraisal-related rules and policies. Nineteen in-depth interviews with medical officers (MOs) working with the government health department of Gujarat, India, were conducted. The main objective of the research was to assess the effectiveness of the actual appraisal system called or referred to as the ACR as perceived by MOs. Thematic framework approach was used to analyze qualitative data using NVIVO 9. Themes were built around five features of an effective appraisal system, i.e., purpose, source, feedback quality, link of the ACR system with other human resource functions, and administrative effectiveness. RESULTS The five features of the effective appraisal system studied in the current research (purpose, source, feedback quality, link of ACR system with other HRM functions, and administrative effectiveness) indicate that the overall appraisal system is ineffective. The overall appraisal system was perceived to be subjective and one directional in character by the study respondents. Furthermore, respondents perceived the appraisal system to be a ritual and where MOs hardly got to know about their performance, especially good performance. Hence, the feedback loop, an important feature for an effective appraisal system, was absent. The overall ACR system functions in isolation with no link to other HRM functions such as training and counselling, and a weak link with salary administration and promotion. CONCLUSIONS Addressing the five features or domains of an effective appraisal system can lead to improved perceived fairness MOs have on the current appraisal system which may further influence the satisfaction and motivation positively. Improved motivation and satisfaction with the appraisal system can influence two important human resource for health-related outcomes, i.e., performance and retention

Human Resources and the Success of Health Sector Reform

Though reforms in the health sector have recently been common around the world, their success has, for a variety of reasons, been mixed. The paper aims to examine and explain the importance of human resources (HR) to the success or failure of health reforms using case studies from Russia, Zambia and the United Kingdom. Health sector reform often focuses on changes in financing or organisational structure, but neglects a key resource - the staff. This may result in inappropriately skilled staff for new tasks, poorly motivated staff, or even serious opposition to the reforms. Though reforms present many challenges in relation to the management of human resources, they also provide opportunities for alleviating long-standing staffing problems - such as the management of staff performance. Better staffing will contribute to the success of health reforms. The complexity of managing staff is greatly increased at times of reforms and the reasons for failure to meet challenges and take up opportunities are many. However, based on experience of reforms around the world the authors suggest that the root of the problem is in the general lack of experience and relevant skills around managing HR in the context of reforms. The priority actions proposed are: 1. Awareness raising: creating better understanding of policy makers and managers of human resource management and planning, especially in relation to reforms. 2. Capacity building: creating the structures and capacities to implement appropriate HR strategies to support health reforms. 3. Adequate preparation of the workforce for changes due to reforms - especially where conditions of employment are affected

Initial posting-a critical stage in the employment cycle: lessons from the experience of government doctors in Gujarat, India.

BACKGROUND With the critical shortage of government doctors serving in rural health centers in India, understanding the initial posting policies, processes, and practices become important from a retention point of view. The initial posting is a very critical stage of an employment cycle and could play an important role in influencing the key human resource for health outcomes such as turnover and performance. The current study aimed at exploring a rather unknown phenomenon of the initial posting-related processes, practices, and perceptions of Medical Officers working with the Public Health Department in Gujarat, India. METHODS This was an exploratory study carried out in the state of Gujarat, India, that used qualitative methods first to document the extant initial posting policy with the help of document review and five Key Informant interviews; next, 19 in-depth interviews were carried out with Medical Officers to assess implementation of policies as well as processes and systems related to the initial posting of Medical Officers. A thematic framework approach was used to analyze qualitative data using NVIVO. RESULTS The results indicate that there is no formal published or written initial posting policy in the state, and in the absence of a written and formal policy, the overall posting systems were perceived to be arbitrary by the study respondents. In the absence of any policy, the state has some unwritten informal practices such as posting the Medical Officers at their native places. Although this practice reflects a concern towards the Medical Officer's needs, such practices are not consistently applied indicating some inequity and possible implications over Medical Officers' retention and motivation. CONCLUSIONS Initial posting is a critical aspect of an employment cycle, and the perceptions and experiences of MOs regarding the processes and practices involved in their initial posting can be crucial in influencing their performance and turnover rates. If long-term solutions are to be sought in addressing the availability and distribution of Medical Officers in the state, then there is a need to have clearly laid down initial posting-related policies that reflect the equity and consideration towards Medical Officers in placement-related matters

Issues and challenges in recruitment for government doctors in Gujarat, India.

BACKGROUND India faces a critical shortage of government doctors in rural and underserved areas. Several measures have been introduced to address the shortage, but significant problems still remain. The main aim of the current research was to understand the existing recruitment-related policies and systems in place for government doctors in Gujarat and to identify issues that prevent effective recruitment of doctors that could have implications for doctors' shortage in the state. The research also aims to fill the knowledge gap in the existing literature on why recruitment in civil services is an important HR function to address the shortage of doctors. METHODS The study aimed at identifying the existing recruitment policies and practices for government Medical Officers (MOs) from Gujarat state in India. The analysis is based on document review to understand the existing policies, 19 in-depth interviews with MOs to understand the systems in place for recruitment of MOs, construction of job histories from interviews to understand various nuances in the recruitment system and five interviews with Key Informants to understand recruitment policies and their actual implementation. Thematic framework approach was used to analyse qualitative data using NVivo. RESULTS While the state has general recruitment guidelines called the Recruitment Rules (RRs), these rules are very wide-ranging and fragmented. The MOs were neither briefed about them nor received copies of the rules at any time during the service suggesting that RRs were not transparent. The recruitment system was considered to be slow and very sporadic having possible implications for attraction and retention of MOs. The study results indicate several other system inefficiencies such as a long time taken by the health department to provide salary benefits and service regularization that has a negative effect over MOs' motivation. The study also found unequal opportunities presented to different categories of MOs in relation to job security, salary benefits and in recognizing their previous work experience leaving MOs unclear about their future thereby influencing the attraction and retention of MOs to government jobs negatively. CONCLUSIONS If long-term solutions are to be sought, the health department needs to have an effective recruitment system in place with the aim to (1) address the slow and sporadic nature of the recruitment system (that is likely to attract more doctors and prevent loss of any doctors during recruitment) and (2) address the job insecurity issue that MOs have which also influences their other employment benefits such as salary, pension and recognition for the years of service they have given to the health department. Addressing these issues can improve motivation among doctors and prevent loss of doctors through voluntary turnover leading to better retention

Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention

<p>Abstract</p> <p>Background</p> <p>Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making.</p> <p>Methods</p> <p>This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review.</p> <p>Results</p> <p>The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies.</p> <p>Conclusion</p> <p>There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.</p

Health systems research in fragile and conflict affected states: a qualitative study of associated challenges.

BACKGROUND: High quality health systems research (HSR) in fragile and conflict-affected states (FCAS) is essential to guiding the policies and programmes that will improve access to health services and, ultimately, health outcomes. Yet, conducting HSR in FCAS is challenging. An understanding of these challenges is essential to tackling them and to supporting research conducted in these complex environments. Led by the Thematic Working Group on Health Systems in FCAS, the primary aim of this study was to develop a research agenda on HSR in FCAS. The secondary aim was to identify the challenges associated with conducting HSR in these contexts. This paper presents these challenges. METHODS: Guided by a purposely-selected steering group, this qualitative study collected respondents' perspectives through an online survey (n = 61) and a group discussion at the Third Global Symposium on HSR in September 2014 (n = 11). Respondents with knowledge and/or experience of HSR in FCAS were intentionally recruited. RESULTS: Of those ever involved in HSR in FCAS (45/61, 75%), almost all (98%) experienced challenges in conducting their research. Challenges fall under three broad thematic areas: (1) lack of appropriate support; (2) complex local research environment, including access constraints, weak local research capacity, collaboration challenges and lack of trust in the research process; and (3) limited research application, including rapidly outdated findings and lack of engagement with the research process and results. CONCLUSIONS: This study shows that those familiar with HSR in FCAS face many challenges in gaining support for and in conducting and applying high-quality research. There is a need for more sustainable support, including commitment to and long-term funding of HSR in FCAS; investment in capacity building within FCAS to meet the challenges related to implementation of research in these complex environments; relationship and trust building among stakeholders involved in HSR, particularly between local and international researchers and between researchers and participants; and innovative and flexible approaches to research design and implementation in these insecure and rapidly changing contexts

Being a midwife is being prepared to help women in very difficult conditions”: midwives’ experiences of working in the rural and fragile settings of Ituri Province, Democratic Republic of Congo

Introduction: Maternal and neonatal health is a core focus area in fragile and conflict-affected states and midwives are key actors. But there is currently very little evidence on midwives’ experiences, the challenges that they face and coping strategies they employ in the challenging and fragile rural areas of Ituri region in the North-Eastern Democratic Republic of Congo. This understanding is critical to developing strategies to attract, retain and support midwives to provide vital services to women and their families. This study aims to explore midwives’ work experiences and challenges through time from initial professional choice to future career aspiration in rural Ituri Province, North-eastern DRC. Methods: A qualitative approach using life history interviews with 26 midwives and 6 ex-midwives, and 3 focus group discussions with 22 midwives in 3 health districts of Ituri Province (Bunia, Aru and Adja) was conducted in 2017. Purposive sampling was used to recruit research participants. The transcripts were digitally recorded, and thematically analyzed using NVivo. A lifeline framework was deployed in the analytical process. Results: Problem solving, child aspirations and role models were the main reasons for both midwives and ex-midwives to join midwifery. Midwives followed a range of midwifery training courses resulting in different levels and training experiences of midwives. Midwives face many work challenges: serious shortage of qualified health workers; poor working conditions due to lack of equipment, supplies and professional support; and no salary from the government. This situation is worsened by insecurity caused by militia operating in some rural health districts. Midwives in those settings have developed coping strategies such as generating income and food from farm work, lobbying local organizations for supplies and training traditional birth attendants to work in facilities. Despite these conditions, most midwives want to continue working as midwives or follow further midwifery studies. Family related reasons were the main reasons for most ex-midwives to leave the profession

Additional file 2: of Health systems research in fragile and conflict-affected states: a research agenda-setting exercise

An online survey used during stage 2 of the study to consult on health system research needs in Fragile and conflict-affected states (FCAS). The survey was developed and distributed via the Bristol Online Survey tool

Health systems research in fragile and conflict-affected states: a research agenda-setting exercise

Background: There is increasing interest amongst donors in investing in the health sectors of fragile and conflict-affected states, although there is limited research evidence and research funding to support this. Agreeing priority areas is therefore critical. This paper describes an 18-month process to develop a consultative research agenda and questions for health systems research, providing reflections on the process as well as its output. Methods: After a scoping review had been conducted, primary data was collected from August 2014 to September 2015. Data was collected using a mixture of methods, including an online survey (n = 61), two face-to-face group sessions (one with 11 participants; one with 17), email consultation (n = 18), a webinar (n = 65), and feedback via LinkedIn. Two steering committees of purposively selected experts guided the research process - a core steering committee (n = 10) and broad steering committee (n = 20). The process moved from developing broad topics and lists of research needs to grouping and honing them down into a smaller, prioritised agenda, with specific research questions associated to each topic. Results: An initial list of 146 topics was honed down to 25 research needs through this process, grouped thematically under transition and sustainability, resilience and fragility, gender and equity, accessibility, capacity building, actors and accountability, community, healthcare delivery, health workforce, and health financing. They were not ranked, as all health system areas are interdependent. The research agenda forms a starting point for local contextualisation and is not definitive. Conclusions: A wide range of stakeholders participated in the different stages of this exercise, which produced a useful starting point for health systems research agenda setting in fragile and conflict-affected states. The process of engagement may have been as valuable for building a community of researchers as the product. It is now important to drive forward the research agenda. Without both a higher profile and deeper focus for this area, there is a real risk that fragile and conflict-affected states will continue to fall behind in global health and development goals. 2016 The Author(s).sch_iih14pub4455pub

Fragile and conflict affected states: report from the Consultation on Collaboration for Applied Health Research and Delivery

Fragile and Conflict Affected States present difficult contexts to achieve health system outcomes and are neglected in health systems research. This report presents key debates from the Consultation of the Collaboration for Applied Health Research and Delivery, Liverpool, June, 2014