Article

Human Resource South Asian Journal of Human

Resources Management
Challenges in Indian 3(2) 173–190
2016 SAGE Publications India
Public Health Services Private Limited
SAGE Publications
sagepub.in/home.nav
DOI: 10.1177/2322093716677414
http://hrm.sagepub.com

Nandini Sharma1
A. Venkat Raman2
Sunita Dhaked3
Pawan Kumar4

Abstract
The quality, accessibility and viability of health services depend primarily
on the performance of those who deliver them. Given the strong correla-
tion between the quality of health services and job satisfaction of the health
personnel, this study evaluates the problems faced by primary health care
providers in India. This cross-sectional study was conducted among middle-
level primary care providers operating in the National Capital Region of Delhi,
to assess their perception of various issues and challenges related to human
resources for health (HRH). They identified gaps in human resource (HR)
staffing, training, performance appraisal and compensation, including delays
in recruitment, lack of probationary training and failure to link appraisal and
compensation to performance. This study contributes to the limited literature
on HRH from a broader policy reform perspective, underpinned by stake-
holder perspective.

Keywords
Human resources, stakeholders, public health services, probationary
training, public private partnership, cash incentives as per the minimum
requirement

1
Director Professor, Department of Community Medicine, Maulana Azad Medical College,
New Delhi.
2
Professor, Faculty of Management Studies, University of Delhi, New Delhi.
3
Junior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi.
4
Additional Director, Directorate General of Health Services, Govt. of NCT Delhi, New Delhi.

Corresponding author:
Nandini Sharma, MD, MBA(HCA) Director Professor, Department of Community Medicine, Maulana
Azad Medical College, New Delhi, India.
E-mail: drnandini1@gmail.com
174 South Asian Journal of Human Resources Management 3(2)

Introduction
In India, where a predominant proportion of the population is uninsured,
patients from lower income strata rely largely on government health facilities
which provide free or highly subsidized health care. During the past six dec-
ades, a large network of publicly funded and managed, three-tiered health facil-
ities were created based on population norms (Venkat Raman, 2014). Despite
the existence of a large network of health facilities, the public health system in
India continues to be plagued by many problems, most important of which are
the shortage of staff, resources and non-availability of free drugs. The shortage
of doctors and paramedical staff is more acute in primary care facilities in rural
areas and urban slums. Against the sanctioned strength of 34,750 doctors at
the primary health centres, 9,389 (i.e., 27%) posts are vacant. At community
health centres, the shortage is even more staggering as 84 per cent of surgeons,
76 per cent of obstetricians and gynecologists, 83 per cent of physicians and
82 per cent of pediatrician posts are vacant (Ministry of Health and Family
Welfare, 2015b). There is also a shortage of paramedical staff such as radiogra-
phers, lab technicians and pharmacists.
For several decades, the public health spending remained stagnant at around
1 per cent of the gross domestic product or about 20 per cent of the total health
expenditure (Ministry of Health and Family Welfare, 2005). Much of the public
health expenditure is on account of wages and salaries, leaving little for purchase
of equipment and medicines and meeting maintenance costs. Due to the shortage of
staff and medicines in public health facilities, a large segment of people from the
lower socio-economic strata is forced to seek services from the private sector.
Latest estimates suggest that more than 75 per cent of outpatient services and 60 per
cent inpatient services in India are provided by the private sector (National Sample
Survey Office, 2015). Nearly 80 per cent of health care spending by consumers in
India is private and out-of-pocket leading to debilitating economic consequences
on the poor households (Ministry of Health and Family Welfare, 2009).
For a long time, health experts and policy analysts have advocated for address-
ing this inequitable and anomalous situation confronting the public health system
especially as India is committed to achieving Universal Health Coverage (UHC)
and sustainable development goals (SDGs). A recent research study that carried
out the first global analysis of countries’ progress towards achieving health-related
SDG targets, by an overall SDG index, placed India at a low position of 143 out of
188 countries (SDG Collaborators, 2015). This finding indicates that in order to
achieve SDGs, specifically in relation to maternal and child health, urgent reforms
are required to strengthen the primary care service delivery mechanism.
The need for overall reforms in health system has been recognized and empha-
sized under key policy documents in recent years, namely, National Commission
of Macroeconomics in Health (NCMH) (Ministry of Health and Family Welfare,
2005), the High Level Expert Group (HLEG) (Planning Commission of
India, 2011) and Draft National Health Policy (Ministry of Health and Family
Welfare, 2015a). Some key recommendations under these policy documents
include a substantial increase in resource allocation for public health system,
Sharma et al. 175

renewed emphasis on primary health care, promotion of universal access to

health services and the need to address the HR crisis in public health system on
a priority basis. The need to address HR challenges in health sector, more specifi-
cally in public health system on a priority basis, was emphasized by the World
Health Organization (WHO, 2004, 2006). The WHO reports summarized that the
quality of health services, their efficacy, efficiency, accessibility and viability
depend primarily on the performance of those who deliver them.
The NCMH, while reviewing the health sector in India, highlighted the
importance of HR as one of the key areas for radical reforms as below:

Human resources are the critical variable for the effective implementation of health
programs and delivery of quality health care to achieve the national health policy goals
in India. The availability of an adequate number of health personnel to effectively
and efficiently manage and implement health programs cannot be overemphasized.
(Ministry of Health and Family Welfare, 2005, p. 159)

The report concluded that ultimately it is the attitudes, practices, knowledge,

skills and values of the health care providers, which influence the nature of the
health system and determine how appropriate, rational, efficient and affordable
the health care system is. Thus, attracting, deploying and retaining capable and
motivated health staff in primary care facilities are essential for achieving these
goals. Traditionally, the issues pertaining to HR management (HRM) in the health
sector have looked predominantly from a micro level (i.e., a behavioural or organ-
izational dimension in hospital settings) and not so much from the perspective of
macro-level policy reforms. Reforms of the health care system may not be possi-
ble without taking into account the views and expectations of key stakeholders,
which include inter alia the medical officers. This study attempts to address this
gap by incorporating a stakeholder perspective.

Review of Literature
There is a general consensus that HRH has been a neglected component of
health systems development in low- and middle-income countries (Hongoro &
McPake, 2004). In the developing world, particularly in the South Asian region,
the public health system is plagued with severe challenges with respect to
managing HR in the health sector. More than the shortage of trained health
personnel, the public health system in India is confronted with archaic manage-
ment systems, including traditional civil service rules, poor working conditions,
prolonged postings/transfers to remote areas, insufficient pay or incentives for
better performance, political interference, lack of career progression and oppor-
tunities for upgrading professional skills. This has led to high absenteeism,
low morale, indiscipline, unionization, indifference and corrupt practices
among health personnel (Venkat Raman, 2002). The high absenteeism and poor
service delivery in turn result in an increased dependence of a large portion of
the population on private health care, a trend that has also been reported in
Bangladesh (Khan, Grubner, & Kramer, 2012).
176 South Asian Journal of Human Resources Management 3(2)

Since independence, the Government of India constituted several committees

to review the functioning of health sector in the country. The Bajaj Committee
(1987) indicated that the genesis of HR problems in India’s health sector seems
to be due to a the dichotomous growth of health services (delivery) and HR,
each developing in isolation, without a proper synergy between temporal and
spatial dimensions. The committee observed that there has been a major emphasis
on the development of physical, technical and technological facilities rather
than on managing the manpower or their development. According to Venkat
Raman (2002), issues pertaining to the management of health personnel in the
public health system are rarely viewed from a broader civil service (administra-
tive) reform perspective, which is seen to be more complex having wider ramifi-
cations, and thus no attempts are made to address them. However, evidence
shows that HR drives health system performances (Chen et al., 2004) and that
addressing HR challenges enables the development of health care systems, which
would be more responsive to the expectations and needs of population in the long
term (Dussault & Dubois, 2003; WHO, 2006). Accordingly, developing capable
and motivated health workers may be considered essential for overcoming bot-
tlenecks to achieve national and global health goals. The importance given to HR
cannot be disregarded in the strategic planning and implementation of the health
sector reform process (Rigoli & Dussault, 2003).
Call for reforms in the management of HR in the public sector (i.e., civil ser-
vices) has been ongoing for several years both in India and around the world.
However, advocacy for HR reforms in the public health system gained momen-
tum only in the recent past (Bhat & Maheshwari, 2005; Buchan, 2000;
International Labour Organization (ILO), 1998; Martinez, Collini, & Martineau,
1999; WHO, 2006). While substantial efforts were made in planning and produc-
tion (training and medical education) of HR in the health sector, very little efforts
were made to introduce modern tools for managing health personnel in the public
health system. As a result, despite an increased supply of trained health person-
nel, public health facilities in India are unable to fill vacancies or retain staff.
This bolsters the argument that there is a need for urgent reforms in the manage-
ment of HR in the public health system and the first step in this process will be to
identify the kind of managerial reforms required.
Though measuring the effectiveness of HRM practices through employee
perceptions has been considered to be a crucial factor (Wright, Gardner, &
Moynihan, 2003), the number of studies focused on reviewing the perception of
clinical care providers on management practices in public health system, more
specifically on HRM, is limited.
In 2002, Venkat Raman conducted a survey among primary care physicians
from government health facilities from rural areas of one district, each in two
Indian states. The study identified several HRM issues, related to recruitment, pro-
bation, posting, promotion and transfers, training opportunities, rewards and incen-
tives, etc. The study found most rural primary care physicians seeking radical
reforms in the civil service rules. In 2007, an attempt was made to review the HRM
practices prevailing at the government health establishments across two states in
India (Gujarat and Madhya Pradesh; Central Bureau of Health Intelligence, 2007).
Sharma et al. 177

The study did not make any attempt to document the perception of medical officers
working in the public health system.
Awareness and suggestions about the HR practices were studied among
health workers in Vietnam (Marjolein, Pham, Le, & Martineau, 2003) where health
workers felt that the appraisal process should be more appropriate and training
process be more transparent. However, this study was limited in the context of job
satisfaction. In another study in Malawi, health workers considered training and
career progression strategies to be inadequate and also felt that they were inade-
quately supervised, with no feedback on their performance (Manafa, McAuliffe,
Maseko, Bowie, Maclachlari, & Normand, 2009). A study from Israel reported
that employees who invest in their jobs expect feedback and recognition from
their managers and there is a likelihood that the employees will produce a better
quality of services if they understand that the ways in which they are evaluated
and rewarded are procedurally fair (Tzafrir & Gur, 2007). Almost all the above-
mentioned studies looked at the perception of care providers in rural settings.
In this article, an attempt has been made to study the perception of primary care
physicians in urban, government facilities.

Research Methodology
The overall objective of the study was to identify and highlight the issues and chal-
lenges in the HRM system, policies and practices as perceived by the physicians
(General Duty Medical Officers or, GDMOs) employed in different government
health facilities, in an urban area. The study was carried out through a survey of
physicians in different primary care facilities (dispensaries) managed by four dif-
ferent government agencies: the Government of National Capital Territory of
Delhi (Delhi government), Municipal Corporation of Delhi (MCD), Employee
State Insurance Corporation (ESI) and Indian Railways (railways). While the
health facilities under Delhi government and MCD are managed as government
departments, the ESI and railways are autonomous government organizations.
However, ESI is managed as a corporation. The respondents, that is, the GDMOs,
are primary caregivers who, besides providing clinical services (outpatient consul-
tations), also hold administrative responsibilities. They are permanent employees,
who have been in service for few years in their respective organizations and are
therefore expected to be familiar with the service rules, HR policies and practices
of their organizations. For the purpose of the survey, the selection of facilities and
respondents was through a purposive sampling method. However, due care was
taken to include a wide representation of respondents from different facilities.
A survey questionnaire was prepared, primarily based on the survey tool used
by Venkat Raman (2002). The questionnaire was then pretested among 12 GDMOs
(3 from each setting) to check for its comprehension, ease of use, relevance,
time taken and other properties. Based on the feedback from the GDMOs, the
questionnaire was edited and moderated. Since the study is exploratory in nature,
the moderated questionnaire was used for collecting data. The health facilities of
Delhi government and MCD were chosen purposively to represent the service
delivery context, that is, in urban slum communities. Since railways and ESI did
178 South Asian Journal of Human Resources Management 3(2)

not have such outreach facilities, the survey was conducted in facilities that had
the maximum number of GDMOs. The respondents were chosen based on the
experience, that is, minimum of two years of experience as GDMOs.
Prior permission was obtained from authorities before the survey could be
initiated. The participation of the respondents in the survey was voluntary.
The questionnaire sought responses on five broad areas of HR systems and
practices, namely, staffing, induction and probation, performance evaluation,
training and development, and compensation, rewards and recognition. The key
questions were related to satisfaction with the staffing pattern based on
workload, their suggestions about attracting talented people for public health,
their views on the utility of the probation period, satisfaction with the perfor-
mance evaluation and suggestions for making it more effective, existing train-
ing programmes and improvement desired, and lastly the satisfaction with and
recommendation for improving the compensation, rewards and recognition.
As the GDMOs did not have any formal training in HRM, the researchers had
to clarify some of the HRM terms used in the questionnaire (e.g., performance
evaluation had to be rephrased as the annual confidential report system). During
their interactions with the researchers, the respondents made informal and
impromptu comments. Though not part of formal data collection, some of these
comments have been presented in the article in order to provide a richer experi-
ence and understanding of the data.

Results
A total of 200 questionnaires were distributed, out of which responses were
received from 180 medical officers, yielding an excellent response rate of 90 per
cent. A brief summary of the respondent profile is given in Table 1.
Of the 180 GDMOs who responded to the survey, 60 were from Delhi govern-
ment, 40 from MCD, 48 from ESI and 32 from the railways. The mean age of the
respondents was 42 years (± 8.74), and it was similar across different facilities.
This indicates that most of them have had a minimum of 10–15 years of experience,
a right time for them to have experienced the HR issues and reflect on them
candidly. Out of 180 respondents, 110 (61%) were male and 70 (39%) were females.
Respondents from railways had the highest median years of experience, followed
by medical officers from ESI, MCD and Delhi government. The mean number of
promotions for the respondents was 1.4 for 10 years of experience from all types of
health facilities. The higher mean number of promotions in railways and ESI implies
quicker promotions for GDMOs employed in such organizations, as compared
to their counterparts in MCD and Delhi government. This indicates slower career
progression in government organizations than that in autonomous undertakings.
A majority of the respondents (71%) possessed basic medical graduation
(i.e., MBBS) and were not specialists with post graduate medical degrees (i.e., MD
or MS). Therefore, the respondent group (GDMOs) and the care setting (dispensa-
ries) clearly captured the perception of primary care providers.
In the following sections, the perception of GDMOs on various HR policies,
systems and practices are analyzed further.
Sharma et al. 179

Table 1. Profile of Respondents from Different Health Facilities

Delhi Govt MCD ESI (N-48) Railway Total

Variables (N-60) n (%) (N-40) n (%) n (%) (N-32) n (%) (N-180) n (%)
Less than 30 4 (6.7) 1 (2.5) 2 (4.2) 0 (0.0) 7 (3.9)
30–34 19 (31.7) 5 (12.5) 7 (14.6) 3 (9.4) 34 (18.9)
35–39 12 (20.0) 12 (30.0) 13 (27.1) 3 (9.4) 40 (22.2)
Age

More 25 (41.6) 22 (55.0) 26 (54.2) 26 (81.2) 99 (55.0)

than 40
Mean ± SD 40.7 ± 9.8 39.8 ± 7.6 37.9 ± 9.1 46.3 ± 7.8 42.0 ± 8.7
Male 38 (63.3) 22 (55.0) 34 (70.8) 16 (50.0) 110 (61.1)
Avg. years of Gender

Female 22 (36.7) 18 (45.0) 14 (29.2) 16 (50.0) 70 (38.9)

Median 10 11 15.50 18 12.50

experience

(Q1–Q3) (5–23.3) (11–16) (7.3–20.8) (11.3–26.8) (7.0–21.0)

Graduate 39 (65) 32 (80) 35 (72.9) 22 (68.7) 128 (71.1)

Qualification

Post 20 (33.3) 8 (20) 13 (27.1) 10 (31.3) 51 (28.4)

graduate
Super 1 (1.7) – – – 1 (0.5)
specialist
No. of promotions 1.35 1.34 1.50 1.45 1.41
in current
organization
per 10 years of
experience
Source: Empirical data collected by the first investigator.

Staffing
The perception of doctors about issues related to staffing revealed that nearly
half of them (44.5%) were dissatisfied with the volume of workload and the
sanctioned staff strength at their health facilities. The most common reason for
the staffing gap identified by more than half of the respondents was failure to
recruit staff in time. Non-attractiveness of public sector (government) job and
low salary were stated as reasons by 28 per cent and 18 per cent, respectively.
However, nearly half of the respondents expressed satisfaction with the
screening methods followed for recruitment and with the transparency of
hiring process.
More women (72.2%) respondents expressed greater dissatisfaction with
the staff deployment and resultant workload due to the shortage of manpower as
compared to men (52.7%). This perceived high workload and consequent
dissatisfaction among women doctors could be due to the fact that a majority of
patients who seek services from primary care facilities (dispensaries) are
180 South Asian Journal of Human Resources Management 3(2)

women, who prefer being examined by female doctors, thus increasing their
workload.
In recent years, health policy analysts have been advocating for the use of
morbidity-based (i.e., epidemiological data) staffing norms for the planning
of HR (e.g., Lopes, Almeida, & Almada-Lobo, 2015). This means that if a
geographical location or a community faces a greater risk of maternal deaths, the
health facility serving that community (or area) should have an obstetrician and
support staff who can provide maternal health services. But most governments
across the world, including India, rely only on creating health facilities according
to the population norms and HR planning according to the health facility staffing
norms. The exact methodology for arriving at estimates using such techniques is
still evolving. Though nearly 31.7 per cent (one-third) of the respondents felt
that staff estimates should be based on bed capacity (which is true in hospital
settings), 22 per cent felt that morbidity-based estimates would be more
appropriate.

Induction and Probation

Induction and formal orientation of new employees is an important stage of an
employee’s career. Incoming employees not only need to be acquainted with
the job responsibilities but also with the organizational culture, people and
work context. This allows both the employee and the organization to test their
mutual “fit”. It is obvious that probationary training enhances work place
adaptability, thereby improving performance and efficiency. Unlike the
probationers in more prestigious civil services (e.g., Indian Administrative
Service or Indian Police Service), the probationary period is a mere formality
for medical officers in the Indian public health system, with no attention paid
towards their grooming or orientation to the community they serve or work
place culture. They are expected to “learn the ropes” all by themselves. Further,
the absence of probationary training leads to an inadequacy of adaptability
among the doctors, especially those serving in rural areas or in urban slums.
As a result, doctors who are posted in public health facilities are often socially
and culturally alienated from the community they are expected to serve (Venkat
Raman, 2002).
The respondents were asked: Whether this probation period could be turned
into an effective mechanism for induction and thereby improve performance?
The results show that an overwhelming majority (95.6%) favours probationary
training. More than half of the respondents were of the opinion that probationers
who perform poorly during this period should not be confirmed. A significant
proportion (63%) of respondents did not consider that the current format of
the probationary period objectively assesses their ability to serve in a public
health facility.
One of the respondents commented:

[W]hen we are hired, we are simply asked to report to a health facility and meet a
particular officer; we do not know the people we are going to work with or work for;
Sharma et al. 181

we do not know what clinical skills and social skills are needed to work in a dispensary
in a slum community; although we did our extension work, but much of it was for few
days in a month.

Performance Evaluation
In government health departments, the appraisal system (commonly called as the
annual confidential report) has generic evaluation parameters and is highly subjec-
tive in practice. The appraisal system varies in its format, objective and content
across the four organizations mentioned. The appraisal system in MCD is most
rudimentary. Allegedly designed in the 1970s, the format contains four pages
of information containing appraisal criteria such as “quality of work,” “quantity of
work” and “job knowledge.” Although the appraisal form of Delhi government is
more elaborate, both MCD and Delhi government system are invoked primarily for
the purpose of promotion decisions, that too only to verify for any adverse remarks.
The appraisal forms of ESI and railways are more contemporary in its format
wherein all the appraisees are required to fill in the self-appraisal form prior to
supervisor’s assessment and are therefore well versed with the current performance
appraisal parameters. As is the case with most other organizational settings, the
appraisal system in this case too is subjective and is susceptible to biases.
Despite the archaic system of the performance evaluation process, a majority
of the respondents expressed satisfaction with the frequency of the appraisal
(79%), evaluation parameters (63%) and transparency of the system (70%). More
than one-third (40%) of the respondents were of the view that the performance
appraisal process lacked follow-up measures, in terms of providing additional
skills or competencies to overcome any performance deficiencies, thus indicating
that the basic purpose of the appraisal was not being fulfilled. A majority of
respondents (57%) felt that the current appraisal system has not made doctors
complacent in performance and that most doctors are performing to their best
abilities. The remaining respondents (43%) felt that the current performance
appraisal process lacks incentives for good performers. A contentious issue in
performance appraisal is the perception of bias, which often leads to dissatisfac-
tion and even legal wrangling. Although half of the respondents (49.4%) felt that
the performance appraisal process is riddled with bias, almost an equal proportion
of respondents (47%) did not agree.
In government organizations, while the self-appraisal forms are submitted to and
reviewed by a reviewing officer, the appraisal is carried out solely by the superior
officer. In contrast, most private organizations follow a system of joint consultation
between the appraiser and appraisee, in addition to self-appraisal. The respondents
were asked whether there was a need to change the current system of reporting.
They were also asked to suggest a better evaluation system. A majority of the
respondents did not feel a need for change. Only 11 per cent of respondents
suggested that a more comprehensive appraisal system be put in place, where the
evaluation is carried out by superiors, subordinates as well as the patients.
It is interesting to note that, although there is certain dissatisfaction with the cur-
rent system of performance appraisal, the doctors do not seem to be in favour of
182 South Asian Journal of Human Resources Management 3(2)

implementing any changes that may lead to a wider scrutiny of performance

(by patients, subordinates, etc). As reflected in the following comments, this is mostly
due to a sense of resignation and frustration over current working conditions:

[G]iven the working conditions in which we are working, how can you ask for more
performance; … what do we gain from better performance? Same increment, same
promotion? … here there is no one who bothers how hard you work; In fact if I work
hard I am likely to be given more work.

Training/Continuing Medical Education (CME)

In the health sector, training is widely and frequently used to upgrade the technical
skills of health staff (i.e., clinical skills). Training in public health (i.e., non-
clinical issues such as sanitation, nutrition, community mobilization and disease
prevention programme) is provided only if a new national or provincial-level
health campaign or programme is launched or whenever a health crisis (such as an
outbreak of an epidemic) occurs. Training on clinical skills for doctors is usually
called the CME programme. Most physicians do not get training in management/
leadership development till they reach a level of seniority and/or occupy an
administrative position. Such programmes are on general management rather than
focused on any specific management domain such as HRM.
A majority of the respondents (81%) viewed training and CME to be highly
important. A large number of respondents (43%) felt that all the deserving people
were not sent for training. As stated by some respondents:

(“… people who are sent to the training are those who are easily dispensable people”;
“…. you ought to have good relations with your boss to be nominated for a ‘good’
training program” as stated by couple of respondents).

Despite these reservations, most respondents (82%) felt that their knowledge
levels had improved after attending the training programmes. It must be noted
that many short duration, off-site training programmes are awareness creation
programmes focused on imparting knowledge (e.g., new diagnostic protocols for
tuberculosis), whereas most CME programmes are focused on imparting clinical
skills. A majority (66.7%) of the respondents indicated an improvement in their
skills, whereas many (62%) also believed that their performance had improved
after attending the CME programmes. Many respondents (63%) stated that the
training programmes, especially behavioural skills programmes, helped them to
improve their attitude towards their work and improved their perspective towards
others (colleagues and patients). Benefits of the programme in terms of the
acquisition of skills and attitude towards work and others were significantly
higher among doctors from Delhi government as compared to others.

Compensation: Non-practicing Allowance (NPA)

In some states in India, government doctors are prohibited from private practice
and are given a NPA as part of compensation, whereas in some other states the
Sharma et al. 183

government doctors are allowed private practice instead of NPA. All the respond-
ents in this study receive NPA and are not allowed private practice.
A majority of the doctors (over 60%) felt strongly that the NPA should be
uniformly applicable for all government doctors across the states and private
practice should be discouraged as is the case in some states. However, nearly half
of the respondents (46%) felt that NPA is not an adequate compensation and
therefore additional revenue earning options should be permitted by opening private
wards in government hospitals.
Some comments in this regard are given below:

“… when we joined the government service, we knew well that the salary and perks are
going to be less than our friends who joined the private sector. But NPA is no compen-
sation to what one can earn additionally.”

“… there is no second opinion that government doctors should not be allowed

private practice. But when NPA is pittance, doctors would be tempted to indulge in
moonlighting.”

“… incentivize our work. Let the doctors who want to do private practice, do it inside
the government hospital. Open private wards and private clinics. Let’s share the patient
fee; hospital will also earn money.”

It is apparent that all doctors, irrespective of gender, are not satisfied with the
NPA alone, with differing views based on seniority. A significant proportion of
respondents (40%) felt that private practice among government doctors should be
legalized. Many doctors (43%) felt that doctors should receive monetary incen-
tives in relation to their performance. These findings indicate a desire for higher
earning in addition to the security of a government job.
This is not a surprising finding. Debate on the compensation package for profe-
ssionals, like doctors, in government services has been raging since the 1980s in
India. Due to the rapid growth, the compensation package in the private health
sector has multiplied several times, compared to a highly regulated and structured
government system. The government health system is no more an attractive place
for a large section of medical graduates. Doctors are hired on short-term contracts,
at lower wages, with no guarantee of regularization. This is compounded by the
fact that medical education (especially in private sector) has become highly
expensive. Previous studies (Central Bureau of Health Intelligence, 2007; Venkat
Raman, 2002) have indicated that doctors would not mind existing salary struc-
tures, but would prefer better perks, benefits and incentives.

Perks and Benefits

Respondents were asked about their satisfaction with respect to the various
perks and benefits available to them. Questions on perks and benefits include
allowances and provisions, such as house rent, leave, children education and
financial assistance schemes (housing loan, provident fund). A majority (67%) of
the respondents expressed satisfaction with various provisions governing leave.
More men (69%) appeared satisfied with leave provisions as compared to women
184 South Asian Journal of Human Resources Management 3(2)

respondents (63%). Satisfaction with children’s educational assistance was low

among all respondents (40%). Even doctors in railways who were otherwise
found to be most satisfied on all parameters were dissatisfied with regard to the
children’s education assistance. Although railways have dedicated schools for
the wards of employees, officers posted in cities tend to send their children to
private schools, and the unsubsidized fee could be a matter of concern. Another
factor could be due to the transferability of railway officials affecting their chil-
dren’s education. Only 61 per cent of women doctors indicated satisfaction with
maternity benefits from their employers.
Although a large number of government doctors are provided with government
accommodation, satisfaction with residential accommodation was found to be
considerably low (32%). This may be due to the fact that the residential accom-
modation provided by the government is in short supply in Delhi and/or the rental
costs of private accommodation are very high in a city like Delhi. Some of them
do not avail the government accommodation due to their own housing and they
tend to compare the rental value of their accommodation vis-à-vis the house rent
allowance they receive. This is evident from the fact that only half of the respond-
ents (55.6%) are satisfied with house rent allowance.
Provident fund is a uniform, statutory provision for all government employees,
but only 54% of them were satisfied with the provident fund scheme. Only 47 per
cent of doctors expressed satisfaction with conveyance allowance, whereas satis-
faction with pension benefits were even lower (46%). In recent years the govern-
ments have moved away from employer-(in this case, the government) supported
pension scheme to voluntary (privately managed) pension fund scheme evoking
dissatisfaction across employees who recently joined government services. This
disaffection could be higher among the younger employees.
As indicated earlier, professionals in government services apparently are
willing to accept a grade-based salary system, but wish to receive more/better
perks and benefits. Unlike corporate employees, whose perks and benefits are
monetized (expressed as cost to the company), in government services several
perks and benefits are indirect and not monetized and therefore the employees
are unable to comprehend the real value of the perks and benefits (for example,
government accommodation in a prime location of the city could fetch a rental
value much more than the gross salary). High satisfaction level on account of
leave provision is not surprising considering the liberal provision of leave for
government staff, compared to corporate employees.

Table 2. Respondents’ Recommendations for Improvement

Items Suggestions Percentage (%)

Staffing
Suggested ways to Walk-in interviews 40.6%
speedily overcome Decentralized hiring 35.6%
the shortage of
Campus placement 21%
Doctors
Using placement consultants 6%
Sharma et al. 185

Items Suggestions Percentage (%)

Probation period
Make it more Exposure to public health management 88%
effective Assigning mentors during the probation period 80.6%
Performance evaluation
To include following Quality of work 97.2%
criteria Team spirit 96.1%
Communication skills with the patient, 92.8%
creativity and innovation
Quantum of work 92.3%
In-service training 91.7%
Leadership 88.9%
Link the appraisal to Promotion 47.2%
Training programmes 43.8%
Transfer/posting 23.3%
Increments 5.5%
Termination/Suspension 14.4%
Evaluation should Superiors, subordinates and patients 40.5%
be conducted by Consultative evaluation with reviewing officer 15.5%
Training/continuing medical education
To make it more Unbiased selection of trainees 47%
effective Skilled trainers 23%
Non-practicing Allowance (NPA)
Suggested changes NPA should be uniformly applicable 66.7%
Monetary incentives in relation to their 43.0%
performance
Legalization of private practice 40.0%
Compensation suggested by doctors
Performance linked bonus 61%
Separate pay commission for health staff 44%
Provision of greater non cash incentives 38%
Removal of upper limit to the pay package 35%
Suggested benefits for attracting people to public health service
Dedicated fellowships 52.2%
Access to internet and electronic journals 50.6%
online
Seed money for research 47.2%
Sabbatical 37.2%
Club membership 35.6%
Video conferencing/teleconferencing for CMEs 31.7%
Source: Empirical data collected by the first investigator.
186 South Asian Journal of Human Resources Management 3(2)

Recommendations for Reforming Public Sector HR

System in Primary Health Care
Major changes in the existing HRM practices, especially for government depart-
ments such as MCD and Delhi government, are considered to be urgent and
imperative. However, effecting changes in government systems are time con-
suming and slow process. Resistance to change is more forceful among govern-
ment departments compared to autonomous government bodies. It is equally
important to seek the views of the government employees, in this case GDMOs,
to identify the scope and areas for reform.
The respondents were asked about the type of changes they would like to recom-
mend for improving the HR management systems, policies and practices, in order
to improve the functioning of government primary health care system. Table 2
presents some of the recommendation for improving HR systems in public sector
health care system.

Discussion and Conclusion

The research referred to in this article aimed to understand the perceptions of
middle-level medical officers, providing primary health care services, in urban
settings about the manner in which HR are managed in their respective organi-
zational context. The study also sought to measure the degree of satisfaction of
these officers, about the existing HR practices, and sought specific feedback on
how to improve the management of HR. In a developing country context like
India, primary care settings are resource deficient, overcrowded and located in
highly demanding physical locations. Motivated staff, with skills and competen-
cies commensurate to the demands of the work situation, is key to the success of
any community-based organization underscoring the importance of effective
HRM system.
The article contributes to our understanding of the perception of primary
health care providers regarding various components of the existing HRM prac-
tices and identifies solutions to improve the system. The respondents perceived
a regular shortage of staff and considered delay in recruitment as the reason for
this. This implies the need to find other ways for effectively filling the staff
vacancies (especially doctors) in time, instead of excessive dependence on the
public service commission, as is presently the case. The age distribution of
the health workforce can be an indicator of how frequently younger health
personnel are hired (renewal of personnel). In our study the average age of
primary care physicians was more than 40 years, which may be indicative of a
low rate of renewal given the long drawn recruitment process. The gender
dimension is crucial to a comprehensive assessment of HR in health systems.
In some contexts, access to female providers is an important determinant of
woman’s health service utilization patterns (Gupta & Dal Poz, 2009). In the
present study, it was found that women doctors felt their workload was higher as
compared to male doctors. It is important to recognize these social and cultural
Sharma et al. 187

factors, while determining the composition of the workforce being deployed in

the primary care facilities.
The challenges in managing HR in health care organizations, as found in the
current investigation, are also faced in other countries of the South Asian region.
The strategies suggested by the respondents in our study to overcome these chal-
lenges (for instance, providing career development opportunities for those serving
in remote and rural areas) are similar to the ones outlined in the World Health
Organization’s report (WHO, 2014).
Compensation plays a significant role in determining the attractiveness of a
workplace. Physicians in the private sector tend to earn considerably more than
their counterparts in public facilities. In the Indian context this situation is not
uniform. In Madhya Pradesh, doctors in government health facilities were per-
ceived to receive better remuneration than their counterparts in the private sector,
whereas in Gujarat it was the reverse (Central Bureau of Health Intelligence,
2007). Through this study, it can be seen that in Delhi the doctors perceive that
remuneration in government health services is not attractive. Inequities in access
to health service utilization result from absence of policies to encourage provid-
ers to work in remote areas. A report by the World Health Organization (WHO,
2014) recommends development of strong HR policies, provision of better living
conditions, continuation of professional career development and better remu-
neration for doctors in the South East Asian region who work in disadvantaged
areas. The report also mentions that in Myanmar, doctors in such areas are given
twice the regular salary leading to better retention. In the studies from Gujarat,
Madhya Pradesh and this one from Delhi, it is evident that physicians want mon-
etary benefits and incentives to work in primary care settings in rural areas and
urban slums. Motivation in health staff is influenced not only by specific incen-
tive system, but by a range of reforms that would affect organizational culture,
reporting structures, channels of accountability, etc. (Bennett & Franco, 1999).
In the present study too the medical officers have recommended a range of
reforms, including decentralizing hiring, setting up a separate pay commission
for health staff and de-freezing the upper limit of salary. Medical officers in
this study indicated dissatisfaction with the performance appraisal system and a
perceived lack of transparency in the training programmes. They expressed satis-
faction with the frequency of supervision, but not with the quality and transparency
of performance feedback. A similar finding was reported by Marjolein, Pham, Le,
and Martineau (2003). Induction training or probationary training is another
major area of concern for government doctors.
It is well established that effective management of care providers in high
intensity human service delivery settings, such as clinical care, old age care, etc,
influences the clinical outcomes. Effective management of HR not only depends
on designing appropriate policies and systems but also how they are implemented.
There are both direct and indirect ways to measure the effectiveness of HRM
system. Perceived effectiveness of the HRM system by employees is one such
measure. Research studies confirm that the policies and practices in managing
HR in the public health system continue to be archaic and are perceived as such
by the doctors providing primary health care. In a country like India, where a
188 South Asian Journal of Human Resources Management 3(2)

large proportion of primary care services are sought in the private sector, even by
the poor households, due to the inadequacies of the public sector, there is an
urgent need to reform the manner in which government attracts, motivates, develops
and retains doctors in its health facilities.
The ability to attract, deploy and retain skilled and motivated health staff in pri-
mary care facilities is directly related to the quality of HRM policies and practices.
This is more so for professional health staff such as doctors. Unless the existing,
archaic civil service rules (or HR policies) are thoroughly reviewed keeping in mind
the perceptions and suggestions of the primary health care providers, and keeping
in view the competitive market for talent, and HR practices in other health care
settings, it is unlikely that the government will be able to provide health care ser-
vices to a large section of the population. Strengthening the service delivery capacity
of the public health system through reforming the way it manages its workforce is
critical for ensuring UHC, which is one of the SDG of the United Nations. One key
step in this direction could be creating dedicated HR department within the
Directorate of Health Services in every state, staffed with HR professionals, who
could identify and effectively handle the complexities of managing a wide range of
employees varying from super-specialists in a tertiary care hospital to village-level
health workers. In many countries, governments have embraced such initiatives
termed as New Public Management (NPM). Such initiatives require the willingness
and support of governments at all levels (federal, state and local).

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