Human Resources for Health

Initiatives under the

National Rural Health Mission

Presentation 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 in addition 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 public sector jobs.?) Available pool does not necessarily translate into public sector 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 to break 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 poor quality.. 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 whether training led to improved service delivery outcomes and increased capacities to deliver services. No decentralized planning to ensure that all the facilities have the desired skill sets. no continuing medical or nursing education programmes. Weak training infrastructure. Little organic links between NIHFWs, SIHFWs, RHFWTCs and district training centers. Human resource planning for training institutions faulty. poorly functional SIHFWs which are unable to provide leadership.

4. Workforce Issues

Transfers, postings, promotions, disciplinary actions, pensions: .are they timely, transparent, fair and non discriminatory, .. One of the surest indicators of good governance- (workforce management indicators would capture
corruption and capacity and culture)

Issue of incentivesDo those who work more or in more difficult circumstances get rewarded more or do they actually 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 the concurrent list. Central manpower support assumes that the core manpower issues are managed by state and center needs only supplement manpower occasionally in relation to some of its programmes. States constrained by lack of funds and most state funds being deployed for salaries and establishment. With diminished programme planning role states lose their imagination. And public health becomes confined to RCH and disease control which accounts for only 19% of all morbidity.

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 looking after all non RCH disease control programmes- or as fetch and carry assistance for the female MPW. Or as epidemic control No training programmes in place. No recruitment guidelines. No standardization of roles or pre-service training content. Almost all training schools in the nation for the male worker has closed down yet recruitment being emphasized No 6 month training before promotionunlike 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 a given..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 not require 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 and private and through public private partnerships. More government seats in private medical colleges 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- but due to defunct male MPW becomes effectively one person center!! Ensure that there is at least one ANM there on days of training, vacation, Ensure that residency criteria is applied to selection and posting.

Case study : two ANMs.. West Bengal:

Decision to appoint married woman, resident in that panchayat. 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 thirds costs. Established 31 new training schools plus existing 18 under PPP arrangements where the state pays for the salary of the faculty to the private hospital. 3527 out of 10,000 needed are under training.

3. NRHM Initiatives: Increasing availability in priority areas..

1. 2.

Compulsory rural postings- pre- post graduation eg Orissa,

Chhattisgarh and after graduation e.g. Tamil nadu

Contractual appointments made to the facility- contractual

mode as a form of beating the pressure to transfer to urban areas the residency criteria...
1. 2.

Eg Additional ANMs nurses in bihar, west bengal, tamil nadu etc. Eg specialists in madhya pradesh.

3. 4. 5.

fair transfer policy- rotational postings tamil nadu.. Incentives for difficult areas: eg Himachal and Orissa. Pooling of medical officers: West Bengal, Bihar, Jharkhand.

PPP options as HR solutions

6.

Contracting-in options.
1.

Madhya Pradesh for specialists: Arunachal Pradesh; of PHCs to Karuna trust.. Bihar: Of PHCs; of diagnostics, of district planning.. Gujarat: PHCs, CHCs and a district hospital.& CHIRANJEEVI: Punjab: village level dispensaries Sewa Mandir Rajasthan / Haryana maternity hut

7.

Contracting-out options.
1. 2. 3.

4.
5.

Increasing availability of skilled in priority areas..

8.

Multi-skilling existing staff to play more tasks.

1. 2. 3. 4. 5. Medical officers to play specialist roles: emergency Ayush doctors for medical officer roles. Nurse practitioners to fill in for doctors Pharmacists providing curative care. Male multi purpose workers into male multi-skilled workers to provide a set of support services of the PHC.

9.
10.

ANM schools in under-served areas. 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 and the 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 legal challenges ahead.

Corollary Case Study: The curious incident of multiskilling in Uttar Pradesh.

4. NRHM initiatives : Community level service providers

1.

2.

3. 4.

5.

ASHA: 4 lakh ASHAs- major and one of most visible components of NRHM. Anganwadi worker- increasing her effectiveness as health care provider. The RMP: Would training them help? The traditional birth attendant: continuing role for the TBA where institutional delivery levels are low. 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- poorly integrated with family planning. Reviving ANMTCs and MPWTCs. Moving towards DTCs. Need to redefine the role of SIHFWs/NIHFWs as apex of a pyramid of institutions that ensure that all the necessary skills required for quality service delivery 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 up of regular vacancies.. Untied funds to enable local health care providers Bringing in a cadre of health managers and data managers and financial managers. Introducing health management courses and promoting health management certification for key posts. Insisting on public health qualifications for key public health posts!?!

Questions about the newHR strategies: Areas for study to define policy further..
Cross state comparisons could help us understand : Does increasing medical/nursing colleges help reduce public sector vacancy? 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 year period. What is the experience of three year courses in the recent past and in the present (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 the benefits of contractual appointment real and what are the costs? Does incentivisation work? What are the bottlenecks?

Increasing availability with quality..

9. 10. 11. 12. 13.

14. 15.

How do we get a live register going? So that currently available pool can be recorded and updated Would different approaches to recruitment through decentralized, facilitated, flexible processes make a difference? Could we have special pre-service programmes that provide preferential access for women in underserved areas into ANM and nursing courses? What is the potential of private sector partnerships to close human resource availability gaps- does a model like Chiranjeevi help? What Specific skills needed in public health system is not provided by current 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 technical education. What are the institutional mechanisms that safeguard quality of education for each category? What is the availability of faculty development programmes?

Improving workforce performance..

16.

17.

18.

Can the pyramid of training centers be charged with maximizing the service outcomes from available human resource- not merely the delivery of training programmes. What are the tools of Measuring motivational levels and what are the enabling factors. What processes could lead to its improvement? Both larger policy changes and immediate tools like appreciative inquiry. What systems are needed for managing change once a workforce management reform policy is agreed upon.

D. Improving work force management

19.

20.

21.

What is Current position on core workforce management issues- recruitments, postings, transfers, service conditions including compensation packages. What are the possibilities for change? Would cross state comparisons help evolve best practice and good governance parameters in these ? How to match skilled workforce needs with service rules and cadre rules. What are the current and possible career development path for each cadre? What are the bottlenecks? Do public health specialists as administrators make a difference? Does having a public health (administrative ) cadre make a difference? Comparing the two ..

Questions on the multi-skilling and task shifting route

23.

24.

In a district today what is the incremental increase in services that it is possible to garner through multi-skilling and task shifting alone? (Without fresh recruitments). And what is the gap between requirements and present position that cannot be met by recruitments and needs multi-skilling to complete? What are the issues in the deployment of Ayush doctors to perform role of medical officers ?What are the legal and quality of care issues related to multi-skilling and task shifting?

Basic questions.
25.

26.

27.

Is it possible to use district level human resource management planning as a vehicle to address all these issues simultaneously? Could we use it to maximise gains within available policy boundaries. Would decentralisation of ownership/employment to district or block panchayats help solve the problem- or would it merely shift the problem? 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