Human Resources for Health-Dr T Sundar Presentn

8/3/2019 Human Resources for Health-Dr T Sundar Presentn

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Human Resources for

HealthInitiatives under the

National Rural Health MissionPresentation at NIHFW- WBI Flagship Course January 30th 2008.

Dr. T.Sundararaman, NHSRC.



The main categories of human resource

in health.Four categories of human resource.

Medical doctors and specialists including public health

specialists and health administrators

Nurses, ANMs and allied workers – includes MPWs

Lab techs, pharmacists, and technical support staff

Public health support staff .

The problems in the first three categories are similar but inaddition there are issues that arise out of the strong

professional institutional structure of the medical

profession.



The key issues in HRH:

1. Availability for recruitment: the pool..

there are insufficient institutions in most states.

70% seats concentrated in six states – 30% of seats in rest.

There is in specialists an estimated 10% migration and a large

and increasing private sector preference. (are graduates of public medical education institutions more ready for publicsector jobs….?)

Available pool does not necessarily translate into publicsector recruitment- more so if the expansion is in the private

sector.

There is a reluctance to join if the posting is in remote areas.

The ratio of women doctors joining is even less than of men.



2. Product Does Not Match Requirements: Those who join are not from the underserved areas or social groups- but

relatively privileged persons who see medical education as best way tobreak out of their social class or retain existing class status.

Even those who join with noble motives, change through the educational process into “objective” professionals- more interested in the disease than

in the patient.. There are weak regulatory mechanisms to ensure even agreed to norms.

There no faculty development programmes.

Growth in the private sector is particularly haphazard and of very poorquality..

Skills they learn are not appropriate nor is the quality as desired. Focus is on knowledge and certification – little on skills.

There is often no match between skills required and skills imparted



3. Poor Quality of In- service Capacity

Building … Multiple short duration fragmented training programmes.

Little evaluation of training and no evaluation of whethertraining led to improved service delivery outcomes andincreased capacities to deliver services.

No decentralized planning to ensure that all the facilitieshave the desired skill sets.

no continuing medical or nursing education programmes.

Weak training infrastructure. Little organic links betweenNIHFWs, SIHFWs, RHFWTCs and district training centers.

Human resource planning for training institutions faulty.

poorly functional SIHFWs which are unable to provideleadership.



4. Workforce Issues

Transfers, postings, promotions, disciplinary actions, pensions: ….are they timely, transparent, fair and nondiscriminatory, .. One of the surest indicators of goodgovernance- (workforce management indicators would capture

corruption and capacity and culture…) Issue of incentives…Do those who work more or in more

difficult circumstances get rewarded more… or do theyactually feel penalised and discriminated against!!

Inadequacy of compensation package…. Both financial and

non financial.. Lack of a career path…

Availability of positive role models and team leadership.

Accountability.. …??? And accountability pyramids…



The whys?

Why was HR not planned along with infrastructure…

Why are so many institutions dismantled in the last decade?

ANM training schools? MPW training schools?

Why are SIHFWs and RHFWTCs poorly functional? Why have

district training centers fallen into disuse?

Why this very uneven growth of professional education?

Why are we unable to make ANMs stay in their place of work?



The center – state divide… Health is a state subject and only family planning- (expanded

into RCH) and a few disease control programmes on theconcurrent list.

Central manpower support assumes that the core manpower

issues are managed by state and center needs only supplementmanpower occasionally in relation to some of itsprogrammes.

States constrained by lack of funds and most state fundsbeing deployed for salaries and establishment.

With diminished programme planning role… states lose their imagination…. And public health becomes confined to RCHand disease control which accounts for only 19% of allmorbidity….



Case study:the male health worker (MPW)- A health sub-center has two staff – one female – paid for by the center

and one male – paid for by the state.

Poor understanding of what is their work role- weakly seen as lookingafter all non RCH disease control programmes- or as fetch and carryassistance for the female MPW. Or as epidemic control

No training programmes in place. No recruitment guidelines. Nostandardization of roles or pre-service training content.

Almost all training schools in the nation for the male worker has closeddown – yet recruitment being emphasized…

No 6 month training before promotion…unlike for females MPWs

Yet promoted into supervisor roles easier. Solutions sought: Declare it as a dying cadre. Promote them into

supervisors, replace this by a female..

But they are there.. With all the problems… and will probably come back…



Other possible answers to “ the whys?” Medical professional interests influence HR

policies/fail to correct them – widespread conflict of interest situations.

Health systems development programmes ignore(?)manpower issues – treating them as agiven…..beyond innovation.

From the nineties – investment in public health plummets and the „keeping government small‟agenda takes its toll..

From the nineties -Search for solutions that do notrequire internal human resource.. The hope of the

private sector partnership….



THE NRHM initiatives in HR

1. Creating the norms: The IPHS( Indian

Public Health Standards)

two ANMs per sub-center and one male MPW. Three nurses/ANMs per PHC plus two medical

officers.

Adding ayush staff into available pool.

Nine nurses per CHC plus 5(11) specialists and 3 to

4 medical officers .



2. NRHM initiatives :Expanding available skilled human resource

More medical colleges- government andprivate and through public privatepartnerships.

More government seats in private medicalcolleges

More nursing schools & nursing colleges.

More technical and paramedical courses.

Reviving ANM and MPW training centers.



Case Study: two ANMs…

The case for two ANMs:

ensure better coverage of the villages

Ensure that sub-center is functional on all days..

Sub-center was designed as a two person center- butdue to defunct male MPW becomes effectively oneperson center!!

Ensure that there is at least one ANM there… ondays of training, vacation,

Ensure that residency criteria is applied to selectionand posting….



Case – study : two ANMs.. West Bengal:

Decision to appoint married woman, resident in thatpanchayat.

All sub-centers co-located with gram panchayat.

Selection by board under leadership of local panchayat.Selected and sent for training.

Revised sub-center building with state putting up two thirdscosts.

Established 31 new training schools plus existing 18 underPPP arrangements where the state pays for the salary of thefaculty to the private hospital. 3527 out of 10,000 needed areunder training.



3. NRHM Initiatives: Increasing

availability in priority areas..

1. Compulsory rural postings- pre- post graduation – eg Orissa,Chhattisgarh and after graduation e.g. Tamil nadu

2. Contractual appointments made to the facility- “contractualmode as a form of beating the pressure to transfer to urban areas – the

residency criteria...” 1. Eg Additional ANMs nurses in bihar, west bengal, tamil nadu etc.

2. Eg specialists in madhya pradesh.

3. fair transfer policy- rotational postings… tamil nadu..

4. Incentives for difficult areas: eg Himachal and Orissa.

5. „Pooling‟ of medical officers: West Bengal, Bihar, Jharkhand.



PPP options as HR solutions

6. Contracting-in options.

1. Madhya Pradesh for specialists:

7.

Contracting-out options.1. Arunachal Pradesh; of PHCs to Karuna trust..

2. Bihar: Of PHCs; of diagnostics, of district planning..

3. Gujarat: PHCs, CHCs and a district hospital.&

CHIRANJEEVI:4. Punjab: village level dispensaries

5. Sewa Mandir Rajasthan / Haryana maternity hut



Increasing availability of skilled in priority

areas..

8. Multi-skilling existing staff to play more tasks.

1. Medical officers to play specialist roles: emergency

2. Ayush doctors for medical officer roles.

3. Nurse practitioners to fill in for doctors

4. Pharmacists providing curative care.

5. Male multi purpose workers into male multi-skilled

workers to provide a set of support services of the PHC.9. ANM schools in under-served areas.

10. Will three year courses help?



Case study: multi-skilling for specialist

skills..

Chhattisgarh produces 4 anesthetists per year and

two of them would join state service.

A total of 156 are needed, but only 20 available in

public health system… a gap of over 136.

The shortest time it would take to expand post

graduate seats qualified anesthetists would be five to

seven. years. Multi-skilling is not a choice ..it is a compulsion.



The results in Chhattisgarh Attempted to close gaps for emergency obstetric care in 64 FRU centers

over three years

Could manage to start C-section in 11 centers over three years About 50% lost due to governance issues- mainly transfers, lack of key

equipment or failure to complete repairs etc.

About 30% lost due to poor training outcomes

About 30% lost due to poor follow up support- lack of enabling environment.( overlap between the three factors)

But in about 70% improvement in number of institutional deliveries andthe management of complicated deliveries improves.

Need to have a very good follow up and enabling system in place – other

than solving all problems of training and while preparing for legalchallenges ahead.

Corollary Case Study: The curious incident of multi-skilling in Uttar Pradesh.



4. NRHM initiatives :

Community level service providers

1. ASHA: 4 lakh ASHAs- major and one of most visible components of NRHM.

2. Anganwadi worker- increasing hereffectiveness as health care provider.

3. The RMP: Would training them help?

4. The traditional birth attendant: continuingrole for the TBA where institutional deliverylevels are low.

5. Community midwifes and maternity huts.



5. NRHM initiatives:Strengthening Capacity building activity…

Strengthening SIHFWs.

Developing an integrated training approach.

IMNCI plus skilled birth attendance as focus of

increasing skills for the ANM and PHC- poorlyintegrated with family planning.

Reviving ANMTCs and MPWTCs.

Moving towards DTCs.

Need to redefine the role of SIHFWs/NIHFWs asapex of a pyramid of institutions that ensure that allthe necessary skills required for quality servicedelivery are in place.



6. NRHM initiatives.. Improving

workforce performance..

Putting an accountability framework in place: Hospital development committees.

Community monitoring programme.

Involvement of PRIs.

Linking funds for new contractual appointment to filling upof regular vacancies…..

Untied funds to enable local health care providers…

Bringing in a cadre of health managers and data managersand financial managers.

Introducing health management courses and promoting healthmanagement certification for key posts.

Insisting on public health qualifications for key public health posts…!?!



Questions about the “new”HR strategies:

Areas for study to define policy further..

Cross state comparisons could help us understand :

Does increasing medical/nursing colleges help reduce public sectorvacancy? At what terms could this be optimised?

Does public or private nature of such expansion affect availability?

What is impact of expansion on the availability of specialists? What is potential availability in each specialty for each state - at least for

EAG states- Is it even theoretically possible to close within a ten yearperiod.

What is the experience of three year courses – in the recent past and in thepresent (Chhattisgarh)

What is the experience with “pooling of medical officers “ where it has been done like in West Bengal or Jharkhand…

With contractual doctors as compared to permanent employment- are thebenefits of contractual appointment real – and what are the costs?

Does incentivisation work? What are the bottlenecks?



Increasing availability with quality..

9. How do we get a live register going? So that currently available pool can be recorded and updated…

10. Would different approaches to recruitment through decentralized,facilitated, flexible processes make a difference?

11. Could we have special pre-service programmes that provide preferentialaccess for women in underserved areas into ANM and nursing courses?

12. What is the potential of private sector partnerships to close human resourceavailability gaps- does a model like Chiranjeevi help?

13. What Specific skills needed in public health system is not provided bycurrent medical/nursing/technical education? Is it faulty curricular design?Or poor educational quality or poor evaluation/certification process?

Different approach to revision of curriculum – easier done for technicaleducation.

14. What are the institutional mechanisms that safeguard quality of educationfor each category?

15. What is the availability of faculty development programmes?



Improving workforce performance..

16. Can the pyramid of training centers be charged withmaximizing the service outcomes from availablehuman resource- not merely the delivery of trainingprogrammes.

17. What are the tools of Measuring motivational levels – and what are the enabling factors. What processescould lead to its improvement? Both larger policychanges and immediate tools like appreciative

inquiry.18. What systems are needed for managing change once

a workforce management reform policy is agreedupon.



D. Improving work force management

19. What is Current position on core workforce managementissues- recruitments, postings, transfers, service conditionsincluding compensation packages. What are the possibilities

for change? Would cross state comparisons help evolve bestpractice and good governance parameters in these ?

20. How to match skilled workforce needs with service rules andcadre rules. What are the current and possible careerdevelopment path for each cadre? What are the bottlenecks?

21. Do public health specialists as administrators make adifference? Does having a public health (administrative )cadre make a difference? Comparing the two …..



Questions on the multi-skilling and task shifting

route …

23. In a district today what is the incremental increase inservices that it is possible to garner through multi-skillingand task shifting alone? (Without fresh recruitments). And

what is the gap between requirements and present positionthat cannot be met by recruitments and needs multi-skillingto complete?

24. What are the issues in the deployment of Ayush doctors toperform role of medical officers ?What are the legal and

quality of care issues related to multi-skilling and task shifting?



Basic questions.25. Is it possible to use district level human resource

management planning as a vehicle to address allthese issues simultaneously? Could we use it tomaximise gains within available policy boundaries.

26. Would decentralisation of ownership/employmentto district or block panchayats help solve theproblem- or would it merely shift the problem?

27. What are the “boundary conditions” which

determine the choice between “contracting in of human resources” or “contracting out of facilities”or “ making the public provider work‟ which is – more effective, more efficient.



Thank You

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Human Resources for Health-Dr T Sundar Presentn