Abstract
Health care is considered as one of the fundamental rights of every individual. At the same time, efficient and effective delivery of health care service requires pro-active management of health care professionals. The purpose of this article is to highlight human resource issues and challenges faced by health care professionals in South Asia and identify suitable strategies for better management of health care professionals. By using data from a pilot study in Pakistan’s public health sector in the province of Punjab, the article explores ways of implementing productive reforms to upgrade human resource management system in the public health care sector in South Asian countries.
Introduction
Internationally, there has been a growing focus on health care workforce for improved health outcomes (Drafke, 2002). The quality of health workforce plays a vital role in the performance of health care systems but very little attention has been given to its composition, training and performance in both developed and developing countries (Beaglehole & Dal Poz, 2003). Hence, serious efforts from national and international agencies are required to rebuild the public health workforce. Human capital is the backbone of every organization and public health system is no exception. The functioning and growth of health care sector is highly dependent on availability and quality of health workforce as well as its well-being and satisfaction for timely and efficient execution of tasks (WHO, 2006). However, research shows that human resource for health (HRH) has been a highly neglected element of health care delivery system in South Asian countries (Jamison et al., 2006).
In most countries, public health care system is one of the main sources that provide subsidized health care services. The government expenditure on health sector plays a pivotal role in the efficient delivery of public health care services which ultimately leads to positive impact on human capital and economic growth (Akram & Khan, 2007). However, South Asian countries including India, Bangladesh, Pakistan and Sri Lanka have not paid sufficient attention to health care facilities and health care providers. Health care financing in these countries is considered suboptimal as compared to minimum standards, that is, 1.3 per cent of gross domestic product (GDP), as prescribed by the World Bank (Akram & Khan, 2007). The public health care expenditures reported are: India 1.2 per cent, Bangladesh 1.1 per cent and Pakistan 1.0 per cent (The World Bank, 2012).
Majority of the South Asian countries lack the human resources needed to deliver essential health interventions for a number of reasons, including low health care budget, shortage of health care professionals, poor training and development facilities, inadequate compensation and benefits for health care professionals and migration of health workers from public to private and overseas health care organizations due to dissatisfaction with facilities and condition of work in the public health care sector (Gupta & Dal Poz, 2009).
The purpose of this article is to explore some of the issues faced by health care professionals in South Asian Countries from the human resource management (HRM) perspective. First, the human resource issues and challenges in Sri Lanka, Bangladesh, India and Pakistan are outlined as representative cases of the general situation prevalent in South Asia. Second, data collected from a pilot study of public health sector of Pakistan is presented. The article then discusses some of the limitations of the pilot study and provides directions for future conduct of research in the subject area.
HRM Issues and Challenges in Public Health Care System in South Asia
Sri Lanka
A major constraint in health care delivery in Sri Lanka has been the non-availability of funds and the allocations made to provincial councils. Moreover, it is aggravated by lack of planning and technical competencies and deficiencies in human resources in the provincial health system (Ministry of Healthcare and Nutrition, 2011). Human resources for health (HRH) in the country faces several challenges including absence of administrative cadre, unorganized recruitment and selection, lack of decentralization, geographic inequity, less number of teaching and training hospitals, disparity in job performance and training facilities and lack of efficient health care providers (Ministry of Health of Sri Lanka, 20011).
A study conducted by Sheriff (2005) reveals that Sri Lanka has been struggling to develop human resource for health care industry since 1950s. To cater to the needs of expanding health care system, the government has increased the number of health care workers but in an unorganized manner. The health care providers, employed in the public health sector, are highly dissatisfied resulting in the shortage of nurses and other medical staffs (Sheriff, 2005). Research also shows that training is offered on an ad hoc basis, and it is not based upon a formal process of assessing staff needs nor is it linked to the organizations’ key priorities and changes in the health sector and health practices (Ministry of Healthcare and Nutrition, 2011). Although training is a formal component of the organization and linked to staff and organizational needs, it is not available for all staff, nor is it evaluated for results.
However, after the implementation of HRM reforms by Sri Lanka’s government, the country is now ranked 94th in Human Development Index (Malik, 2013). They have introduced better recruitment and selection practices and frequent training opportunities and increased salaries for health professionals. Consequently, satisfaction of health care workforce and quality of health care services have increased.
Bangladesh
The health care system of Bangladesh faces acute shortage of required number of human resources in the form of physicians, medical technologists, nurses and other paramedical staff (Ahmed et al., 2011). According to Mahmood (2012) other related HRM problems such as absenteeism, poor service delivery, inefficiency and corruption are also deep rooted in the public health care sector of the country. Owing to these problems, a large portion of the population depends on private and informal health care systems for their health issues (Khan, Grübner & Krämer, 2012).
India
The main challenges faced by the public hospitals in India are deficient infrastructure, deficient manpower, unmanageable patient load, equivocal quality of services and high out-of-pocket expenditure (Bajpai, 2014). There is unwillingness of doctors and other health personnel to serve in rural areas, while in urban areas there is disproportional supply of health care professionals between private and public sectors. Lured by better wages and working conditions, health care professionals prefer to work in the private sector leaving the public sector health organizations with insufficient and underqualified health care workers (Labonté et al., 2015).
Raut and Mukhopadhyay (2007) examined human resource for health practices in two states of India (i.e., Madhya Pradesh and Gujarat). Findings show that there was no formal mechanism in place for recruitment and selection. In spite of having large workforce, the directorates of both states did not have a specialized HR department. The study further showed that there was immense dissatisfaction among health care professionals regarding compensation, benefits and promotion procedure. Junior doctors suffered from lack of training facilities. There was hardly any system of induction training for medical officers of the primary health centres when they joined the government health system.
Further, studies suggest that the human aspect of care is missing in most training programmes. Medical colleges increasingly focus on high-technology and private medicine rather than on community oriented primary care (Rao et al., 2011). Nursing and paramedical education have deteriorated due to lack of resources, leadership and rapid expansion without attention to quality.
Pakistan
There are 74 medical colleges and 32 dental colleges in Pakistan which produce 9,000 doctors and 2,000 dentists annually (Sheikh & Sabatinelle, 2011). There are 8 physicians for every 10,000 people in Pakistan as compared to 24 in the USA and 25 in UK (OECD, 2009). In the urban areas, this ratio is 14.5, whereas it is 3.6 in the rural areas (World Health Organization, 2012). This health workforce is likely to remain stagnant or may get depleted as these medical professionals consider migrating out of Pakistan for better opportunities and job security in other countries (Safdar et al., 2010).
Hafeez et al. (2010) conducted a cross-sectional survey on Pakistan’s Human Resource for Health Assessment with the help of World Health Organization (WHO). The results for a sample size of 3,549 health care professionals show that the satisfaction of private health care sector workforce is better than that of public health care workforce. The employees in public health sector are dissatisfied because of inadequate salaries, lack of career growth and poor work environment. The major problem in recruitment and selection is that majority of the posts are vacant due to lack of trained staff or because of procedural delays in appointing staff. Therefore, the public health care system only provides out-patient services, and even that is not up to the desirable standards of health care. According to Mavalanka (2003), the major reasons for these problems are due to government and bureaucratic influence in hiring, delayed appointments of health care staff and a general lack of accountability in the public system.
As the pilot study reported in this article relates to Punjab province in Pakistan, we give below a brief overview of the health care sector in this region.
With the average population of 396 persons per square kilometres, Punjab is the most populous province of Pakistan. There are three ways in which doctors are appointed in the public health sector in the province of Punjab. First, Punjab Public Service Commission hires doctors in grade 17 after conducting written exams and interviews. Second, the hospitals also hire doctors to fill urgent vacancies. Third, the Punjab government also appoints doctors on contract or on ad hoc basis.
A report prepared by Cyan and Young (2009) on Punjab Government’s Efficiency Improvement Program shows that a large share of the contract employees was recruited at entry-level positions. Among the survey participants, 95.12 per cent of the individuals were employed on fixed term and had not been promoted to senior positions. In addition, it was also found that contract employees were less motivated as compared with regular employees as the former had not been given benefits as provided to the latter. There are no provisions for leave, pension and other benefits for contract employees contributing to their dissatisfaction.
At the turn of new millennium, Punjab faced enormous challenges about its human resources for health. There are 36 districts in Punjab and the doctors are unevenly distributed in each district (Hafeez et al., 2010). Some of the health facilities (especially in rural areas) have been closed in certain districts because there is no one to run them. Doctors in Punjab are highly dissatisfied with their contractual appointments, inconsistent promotion mechanism and low pay scale (Khan, 2007). Current human resources for health policies are not responsive to the needs of the population as there is no standard human resource development plan (Human Resource for health in Public sector in Pakistan, 2006).
Pilot Study on HRM in Public Health Sector of Pakistan
The author conducted a pilot study to provide some empirical data about human resource practices in the health care sector in Pakistan. Data was collected from a sample of 20 respondents comprising doctors, hospital administrators and government officials working in public health care institutions in Lahore, one of the largest metropolitan cities located in the Punjab province of Pakistan. Purposive sampling technique was used for the selection of respondents based on minimum employment period of 3 years for junior doctors, 10 years for senior doctors, 5 years for hospital administration staff and 2 years for Health Secretariat staff. Semi-structured interviews were conducted with the respondents. The interview questions covered a wide range of issues pertaining to human resources for health, including recruitment, training, compensation, career prospects, working conditions, health care reforms and overall HRM policies and procedures.
“Thematic analysis” approach was employed for understanding and interpreting qualitative data (Braun & Clarke, 2006). Statements from the transcriptions are presented as evidence to illustrate the actual reality of the phenomenon using logical inferences from the data collected. Data was collected from many sources providing different perspectives. First, doctors were interviewed from different public hospitals in Lahore. Later, Hospital Administration and senior management staff were interviewed to obtain in-depth information about human resource management issues in the health sector.
The major findings from the thematic analysis of the data collected for this study are provided below:
While recruitment through public service commission is favourably viewed by majority of the respondents, there is considerable dissatisfaction with contract or ad hoc appointments. Contract employees are less motivated due to lack of long-term career incentives. The major flaw identified from the analysis was “Sifarish Culture”. Sifarish culture is generally described as hiring or promoting a person based on personal references and contacts rather than on merit. In other words, placements and other favours granted to employees based on nepotism are generally referred as “sifarish culture”. The existence of sifarish culture is evident in every institution of Pakistan but public sector is especially notorious for it. Literature suggests that there is strictly hierarchical, centralized and corrupt system along with high level of gender discrimination in administrative roles in public sector organizations in Pakistan (Islam, 2004).
Respondents in our study repeatedly referred to the existence and detrimental effects of sifarish culture. For example, according to a Professor in a medical hospital, “There are 100 seats for 3,000 applicants and these seats are allocated only to the people who have some reference or Sifarish.” To address this problem, a Registrar suggested that “the recruitment criterion should be made more transparent and standardized.”
Our analysis showed that a major flaw in the workforce management is non-availability of seats that hindered further career progression. Most of the doctors work honorary during their House job and Postgraduate training which makes it difficult for them to support themselves and their families. As pointed out by a post-graduate trainee, “due to lack of seats, the government appoints doctors on contract and on ad hoc (basis).” This was supported by a Deputy Medical Superintendent:
I have been working on contract for 17 years and have not been promoted due to lack of available seats. Many doctors are working on the same pay scale in which they were inducted 20 or more years ago … there is no time bound promotion.
The study also revealed that government trainee doctors are underpaid and overburdened with work. They typically have very long working hours, without appropriate facilities, and inadequate security conditions. As pointed out by a medial superintendent, “A young doctor is treated like a donkey and he is expected to do as much work as he can. However, there are fixed timings for the senior cadres, such as professors.”
The House Officers, Post Graduate Trainees and Medical Officers complained about low pay. The families of these doctors are not entitled for health benefits. The promotion structure for doctors is defined on paper but it is not implemented properly. Unavailability of seats and vacancy-based promotions are the major flaws of promotion process. As pointed out by one of the respondents, in Punjab, the government has not set up any new hospital since 1996. This has made it impossible to implement time-bound promotions. As a result, unlike employees in other public sector agencies, health care employees do not get promotions and higher salary despite long years of service. The following statements are representative of the bitterness among respondents on this aspect:
If we compare the doctors with civil servants, the doctors have higher education, tough training, long working hours and much more sensitive job responsibilities. However their salaries and benefits are less as compared to civil servants. (Professor of Cardiology) Salary of a young doctor has no comparison with other government servants. The basic salary may be equal but the incentives and facilities which bureaucrats get have no comparison with what is offered to the doctors. (Professor of Surgery)
Further, respondents reported that the major causes behind human resource management problems in public health sector were low priority given to this sector and a lack of will from the government to improve HRM in the health care sector. Though doctors are administrative head of the hospitals, they are powerless and subservient to the bureaucracy in all matters. Pointing to these administrative flaws, a Professor of Surgery stated:
Bureaucracy runs the entire public health care system. Although there are written rules and procedures, the administration is reluctant to implement them properly. Both the government and bureaucracy are reluctant to bring human resource reforms in health sector. In fact, health has never been a priority of any government.
This view was further supported by an Assistant Professor of Surgery: “Pakistan has a culture of feudalism. Bureaucrats have always been enjoying control over the medical community and other public sectors. (As a result) doctors have to go to the bureaucrats for every petty issue.”
Discussion and Conclusions
Our pilot study on the health sector of Pakistan provides further support to existing literature (e.g., Abid, 2012; Islam, 2004; Khan, 2007). The study reveals that doctors in the Punjab province of Pakistan are highly dissatisfied with their contractual appointments, inconsistent promotion mechanism and low pay scale. Most of the doctors work honorary during their house job and Postgraduate training due to lack of financial resources and unavailability of seats. Salaries of junior doctors are woefully inadequate even to fulfil their basic needs. Doctors have a defined eight working hours per day; however, they work much more than eight hours without compensation. The promotion policy is not implemented properly due to lack of sufficient seats and vacancy-based promotion system.
The practical implication of this research is that the recruitment and selection process must strictly follow the set rules and regulation of Punjab Public Service Commission. Structured training must be provided in both public and private hospitals. Salary of junior doctors should be equivalent to other public sector organizations, so that they do not feel discriminated. Regular promotion avenues need to be created for the doctors according to the written rules of Public Service Commission.
This article adds to the growing literature on the human resources for health, especially in South Asian countries by extending our understanding of the key issues and challenges across the region. It underscores the critical importance of human resource for health as one of the essential pillars of the health care system. For the successful implementation of health interventions, adequate numbers, quality, well-being and satisfaction of health work force are very important.
In order to further understand and address the complex issues of health care delivery in the public sector of South Asian countries, longitudinal and multi-methods studies with larger sample size and broader coverage of population should be conducted to make an assessment of the changes and new opportunities provided in the public health sector. This study was conducted in the public health care organizations only. A study of both the public and the private health care sectors will provide us with a holistic picture of health care services and institutions in South Asia. This will not only help us compare differences in the two sectors but also show how both the public and the private sectors could complement and supplement services provided to health care clients.
Footnotes
Acknowledgements
The authors would like to acknowledge the extensive revisions and improvements made to the earlier versions of the paper by Professor Mohan Thite and Professor Sudhir Saha and thank them for their editorial support. We would also like to acknowledge the help of Suhail Ahmad, Past District Governor, Rotary International 3270, and Atiqa Maryam, PhD scholar at Department of Management, Faculty of Business and Economics, Monash University, Australia, for their contribution to this article.