70239 Volume I Number I Supportillg Evide11ce-based Policies alld Imp/em elltatioll TACKLING HEAL HI HUMAN RESOURCE CHALLENGES IN INDIA: INITIAL OBSERVATIONS ON SETTING PRIORITIES FOR ACTION Peter Bcmmn' . Shomikho Rah'I', Krishna D. Rao' INTRODUCTION More compl ex approaches try to incorporate populati on Human resources arc the largest component of health care hea lth needs to estimate service requirements and to deli very in India, o ft en accounting for sevcnty pcrcent of consider the behavior and preferences of patients and state government health expenditure. National polic ies and service users that generate demand for services . BUI health programs, likc thc Nati onal Rurall-lealth Mission (N RHM), systems are complex. They produce a wide variety o f have recognized thai meeting the challenges of assuri ng services to meet needs spread across the whole burden o f sufficie nt numbers o f we ll-trained and motivated health disease. Users' behavior responds to service-spec ific as well workers is essenti al for improving hea lth outcomes for as system-wide facto rs. These more complex analytica l India 's poor. approaches requ ire much more information about whi ch But what exactly arc those challenges - numbers, location, there can be great uncertainty. In addition, whi le workforce knowledge and skills, motivation - all of these things? The requirements can be esti mated and projected based on such Joint Lea rn ing Initiative fra mework, referred to in recent calcu lat ions, link ing the numbers of workers to their NRJ-IM reports, lists ni ne key areas for action: numeric distribution, effecti veness and ultimately health impact also adeq uacy, ski ll mix , soc ia l outreach, sati sfacto ry requires consideration of factors that affect the quality of remunerati on. workplace environment, system support , what workers do and their capabil ities and motivation to appropriate skills, trai ning and lea ming, and leadership and work active ly and properly. entrepreneurship. These are linkcd to three "workforce Another app roach would be to prioritize action strategies on obj ecti ves" - coverage, moti vation, and compctcnce. HRH , by foc usin g on health system performance Clearly all are rclevant, eve n important. But change takes improvement. As described in Roberts et al (2004), to time. Skills and capaciti es to create and manage reform are devel op performance improvement strategies. reformers limited. Where should policy and planning focu s attention? should follow a diagnosti c journey which begins with health The notes that constitute this first vo lume of India Health system outcomes which need improvement and analyzes a Beal attempts to address this question. chain of causat ion determining poor outcomes. This chain o f causation posits whi ch health system clements, such as APPROACHING PRIORITY SETTING FOR HRH ACTION I-IRH , explai n short fall s in perfo mlance framed in ternlS of Pl anners of I·hunan Resources in Health (HRH) have used outcomes such as access to care, quality, and effi ciency. di ffe rent ap proac hes fo r determinin g work fo rce In deve loping a diagnosis, hypotheses and assumptions requirements. The simplest of these are based on explicit about the contributi on made by determinants such as HRI-J norms - for example setti ng requirements for numbers o f numbers, location, moti vation, knowledge and skills to the workers of d iffe rent types requ ired fo r a given population causes ofullsatisfactory outcomes, should be made exp licit. size or setting staffing nonllS for speci fic types of hea lth So should assumpti ons about the effi cacy and cost of faci lit ies so that the total numbers and types of staff needed strateg ies to improve these determinants. Working through arc calcu lated based on the mix of fac il it ies in an area. Staff this kind o f d iagnostic journey can help set pri oriti es for requirements could also be detennined based on average action in terms of emphas is on different types of hea lth productiv ity in providi ng services and associated norms for workers and which detenninants may be most li kely to service deli very targets. These approachcs foc us attention generate improvements in health system results. on the suppl y of workers and the human inputs needed to produce a suppl y o f services. Pri ority setting grounded in an analysis of perfomlance t The World Brlllk, Wflshington DC; , The World Bank, New Delhi, India; . The Publ ic Health Foundation o f India. New Delh i understand best the feasibility of different interventions and their potential impact. tn India, this is likely to be administrators and HRH stakeholders at state and di strict level. We can s till s umma rize so me pre liminary observations from our studies wh ich may guide in setting priorities as well as topics for furt her investi gation and analysis. These arc: • For most MDG-re lated health outcomes, the higher clinical ski ll s of physicians as front-line service providers are not req uir e d . Evidence suggests that recruiting and retaining phys icians to serve in lower level health fa ci liti es in rural areas will be vcry difficu il given both the physical conditions in those areas and the expectations and altitudes of medical grad\Jates. Doctor at health calliI' ill Bik(/ller district. Rajasthall (Febmmy 2007) Efforts to add ress num er ica l improvement strategies is especially important in situations ad equ acy and relention of ElRH in rural areas should where the resources and capacities to refonn HRH systems nol foc us pr im a rily on p hysicians.I While non- arc lim ited - i.e. almost everywhere! In contrast, the norm- physicians like G Ms are more receptive to government based approaches tend either to emphasize only numbers and rural postings. their training and sk ills and and di stribution of personnel or to treat all HRH -rclated profess ional status arc not today well-suited to their detemlinants as equally feasib le, urgent, and important. The functioning as independent clinical providers and HRH field is very comp lex with different types of workers, a service managers. Stra tegies to increase R RH using range o f many types of services provided public sector hea lth carc systems, and a number of determinants of performancc. When capa citi es for improvemcnt are scarce, lack of critical thinking about which determinants arc more important will diffuse efforts and effectiveness. THINKING ABOUT PRIORITIES BASED ON OUR INITIAL STUDIES OF HRHININDIA The work described in the following notcs (nos 2-6) isn' t suffic ient to develop a comprehensive diagnosis for setting priorities for HRI-I act ion to improve hea lth system perfonnance in India. It is unl ike ly that a single diagnosti c analysis wou ld be sufficient to address the compl exity of health prob lems and I-IRH -related ca uses of poor performance. In addition, this work reall y s ho uld be done in Nurses undergoing First ReJerml Ulliffraillillg lit District Headquarters HoslJita/. co llabor a ti o n w ith those who Erode. Tamil Nadll (Julie 2008) [)\I)[A [ [I AI I II HI \ I . \()lulll~' [ • \Jumhl"f I (August 2()()Y) non-physicians as provid ers a nd ma nagers need to do more th an just foc us on recruitment a nd retention. New types of wo rkers ma y be needed whi ch wo uld require developi ng new training p rog ram s , ca dre r ul es , a nd pr o f e ssion al inst ituti o n s. Address ing th is requi res a broader a p proac h than j ust expa nd ing co ntract worke r opportu nities , increas in g sanctio ned posts, or bu ilding nursing schools. • Inadequacy in support func tions like facil ity management , supp lies and log ist ics manage ment , accounting, and publi c hea lth pl anning at state, district, and block level are a major constra int to more effective service provision. HR H stra tegies should not foc us on in creaSing 1-1 RH se r vice providers only or even Palients qllellil/g III' 10 see (f doclor ill OPD o/ GoI'emmelll HosI'ilal Pal/nlli, p ri marily. Stat es need to cou ple Dislricl Cllddalore. Ttllllil Nadll (December 2008) efforts 10 increase service provid ers with cO lllmitt ed efforts to develop HRH strategies for transparency and accountabi lity in public service 111 s UI)pOr l functio ns. hea lth . These are important priorities as we ll , and amenab le to research and dia loguc_ • I-IRH issues need to be addressed primaril y at state and district level, si nce states have the prim ary responsibil ity for I-IRH in the sector. The institutional e nvironment for plann ing and dec ision mak ing for HRH is dysfunctional in many slates, espec iall y in the lagging states. In vest ment in stn Hegies to iml)rove HRH in st ates needs to incl ud e ~lI1al ys i s of in stitution al as pects an d to cou ple incr c:lsing resou rces fo r production, recruitmen t, lll1d retention to address HRH need s with incenti ves lind co nditions for bringing a bout in stituti onal ch ange. State-spec ific analyses and strateg ies shou ld be developed . These cou ld be based on the pcrfonnance im provement approaches sketched out above. • Earl ier research has emphasized the importance of governance-rela ted fae lors in dctemlining human resource performance. Stud ies have reported high levels of absenteeism in government hea lth facilities and weak cnforccmcOI orthe labor contracts of government hea lth carc providers. T here arc wi dcsprcad reports of sizab le infonnal paymcnts fo r prefcrred postings and transfers in many states. Many officia ls compla in about how these undennine efforts to establi sh a merit-based reward system. Our studies have ca lled atlention to the necd for formal insti tut iona l reform. But these problems go beyond those of fo nnal in stituti ons_ Addressing them will req ui re stTong leadership and enhancing a culture of I:\[)IA til \1 I II BI \1. \'olullle I • 'Jumbl'r 1 ( \ugU\' .:!OIl'J) • Emergency obstetric services may be an important exccption to this. Public-private partnerships, like the Chiranjeevi scheme in Gujarat or hnani in Bihar. may provide an altcmative approach (see references for links). REFERENCES Roberts, M., Hsiao. w., Bemlan, P. and Reich, M. (2004), Getting Health Refoml Right: A Guide to Improving Perfonnance and Equity, Oxford, U. K. Chiranjeevi Yojana: gujhealth.gov. in/C hiranj eevi%20 Yoj a na/M index.htm lanani, Bihar: www. janani.org/home.htm For further information on "Tackling health human resource cha llenges in India: Initial observations on sett ing priorities for action" visit http://www.ph fi. org orcontact Kri shna D. Rao, Public Health Foundation of India. New Delhi at kd. rao@phfi.org Editors: Gerard La Forgia, Lead Special ist. HNP Unit. The World Bank, New Delhi : and Krishna D. Rao, Public Hea lth Foundation of India. New Delhi India Health Beal is produced by the Public Health Foundation of India and the World Bank's Health. Nutrition and Population unit located in Dclhi. The Notes arc a vehicle for disseminating policy-relevant research, case studies and experiences pertinent to the Indian health system. We welcome submissions from Indian researchers and the donor community. Enquiries should be made to Nira Singh (nsingh2@worldbank.org). Disclaimer: The views, findings , interpretations and conclusions expressed in this policy note arc entirely of tile authors and shou ld not be attributed in any manner to the World Bank, its affiliated organizations, members of its Board of Executi ve Directors, the countries they represent or to the Public Hea lth Foundation of India and its Board of Directors.