TERM PROJECT REPORT

Organization Management

Role of training in increasing the competency of an

individual: Indian Health Sector in preview
Under the guidance of

Professor Vinay Shil Gautam

Submitted By

Kushagra Singhania, 2010SMF6775, kushagra.singhania@dmsiitd.org

DEPARTMENT OF MANAGEMENT STUDIESINDIAN INSTITUTE OF

TECHNOLOGY, DELHI

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Abstract:

Through this paper I seek to review the dynamic capabilities and competencies of the
employees in Indian health industry and how it can be improved substantially. The paper
presents various reasons and their solutions for the poor health services in India. Although the
private sector health services have improved in cities due to large investments in last few
years, the condition in the rural or semi-urban area still remains pathetic. This paper talks
about the lack of competencies in the health professional in these areas and the ways through
which it can be improved.

The health sector of our country has been neglected for decades now. The financing has also
decreased in the past few years.

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Contents

Abstract:........................................................................................................................................2
INTRODUCTION:............................................................................................................................4
Health issues in India:....................................................................................................................6
WHAT ARE COMPETENCIES?..........................................................................................................8
The Need for a Framework:.........................................................................................................10
Problem with Community Health Workers:.................................................................................14
CONCLUSION:..............................................................................................................................16

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INTRODUCTION:
India is a huge nation currently experiencing rapid economic growth, urbanisation and
widening inequalities between rich and poor. It is huge in not only in area terms but also
population size. It is struggling to overcome negative legacies of the past. The economy is
booming with over 8% of annual growth, the purchasing power has increased .There have
been lot of developmental activities that have taken place in past few years but have you ever
thought why is our health sector one of the worst in the developing economies? Why do we
stand at the bottom of the Human development Index year after year?

High Morbidity and Mortality rate substantially contributes to this undesired phenomenon.

Despite being one of the world's fastest growing economies, we have been consistently one of
its weakest performers both in public health provision and in the delivery of medical services
easily accessible to its general population. Why?

Although continuing gap in the health status of the people may be attributed to a number of
factors like

1) Poor infrastructure
2) Lack of skilled professionals
3) Lack of implementation of Govt. Schemes
4) Poor Development of Human Resource for Health.

Although in the past decade there has been a phenomenal increase in Human resources in
health sector yet the gap between the required professional and existing professionals is ever
widening. Poor outcome indicators reflect the need for high level of concern, commitment
and competence among the health personnel responsible for the delivery and management of
health care, primarily the public health care system. Again a lot of training has been provided
in the past but there seems to be a need to examine the status of training that is being
imparted to the individuals in the health care system. It is experiencing a decline in the
amount of government funding for health care and this is a major issue that must be
addressed.

As the country continues to develop economically and socially and moves through the
epidemiological transition – from a predominance of infectious diseases to the emergence
of chronic diseases – its health care systems are experiencing immense pressures from both
increasing and changing demands.

Here infectious diseases of the past sit alongside emerging infectious diseases and chronic

illnesses associated with ageing societies, although the burden of infectious diseases is much
higher in India. Local circumstances are important, especially with respect to the structure
and financing of health care and the implementation of health policy. For example, we have

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huge problems providing even rudimentary health care to our large population of urban slum
dwellers.

In undeveloped societies, mortality is commonly from famine and infectious disease

epidemics (diseases of poverty). As society develops, infectious diseases decline and there is
increasing mortality and morbidity caused by lifestyle factors and chronic illnesses, linked to
increasing life expectancy (diseases of affluence). In particular, diseases of poverty have not
been eradicated but are re-emerging and interact with new infectious diseases (including
HIV/AIDS and SARS), an increasing prevalence of chronic diseases, rapid population
growth, social, economic and geographical polarisation and widening inequalities in health
and health care.

A Basic Diagram of the division of task in Indian Public Health care system

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  Health issues in India:

Historically, we are dealing with large vulnerable populations. Floods and famines were
periodic dangers, as were threats from such sources as earthquakes and cyclones in India (i.e.
the Indian sub-continent at that time), while communicable diseases such as tuberculosis,
typhoid, schistosomiasis or dengue fever frequently reached epidemic proportions. Mortality
rate in India was very high, exacerbated via what has been previously termed systemic
breakdown. Both countries have worked hard to reduce these mortality rates, but by 1965 the
crude death rate in India was still high at 45 per 1000, reducing to 33 per 1000 by 1985. It has
been noted that by 2004 the death rate in India was down to a more reasonable level, at 8.4
per 1000. An Indian baby born today can expect to live twice as long as her great-grandfather
did and the infant mortality rate has been halved, to 68 per 1000. But this is still a very high
rate,

The World Health Organisation (WHO) and official data from the Ministry of Health and
Family Welfare show wide disparities in infant, child and maternal mortality between India's
urban and rural areas. Table below highlights urban–rural inequalities in infant mortality for
the years 1991–2003. India’s, rural–urban variation in infant mortality is not quite marked,
but nonetheless RR ratios are around 1.7 throughout this time period, with indications of
growing disparity in the current century. Lack of hospital births and rural doctors contribute
to these risk ratios, plus an overall imbalance in health expenditure to rural areas compared to
urban ones.

Urban and rural variation in infant mortality rate in India, 1991–2003

Year India Infant mortality (per 1000 live births)

Overall Urban Rural Rural–urban RR

1991 80.0 53.0 87.0 1.6
1995 74.0 48.0 80.0 1.7
1997 71.0 45.0 77.0 1.7
2000 68.0 44.0 74.0 1.7
2001 66.0 42.0 72.0 1.7
2002 63.0 40.0 69.0 1.7
2003 60.0 38.0 66.0 1.7
% decrease over time 25% 28% 24% –

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Most of the in-service trainings in the health departments of different states are either part of
centrally sponsored schemes or projects funded through Government of India. Sequel of this
approach is manifested in terms of several trainings often occurring concurrently for the
same level of professionals. More often, the trainees in these programs are nominated
randomly in compliance to hour. Trainees have to reach to the training venue at a very short
notice. Consequently trainings - which are loaded with lectures with little respect for
continuum of the theme and overall perspective of the program – are compromised with low
number of trainees. Provision of per diem for trainees and remuneration for trainers also
fluctuates from program to program and influence the attendance and spirit of participation.
Profiles of the nominated for training and watching them post-training on work-site often do
not give the signals of capacity development of the concerned health systems. These are well
identified challenges which have remained unmet.
Professional Development Courses (PDC) of ten weeks duration for district level Medical
Officers were initiated as a part of health sector reforms in the beginning of this decade.
Starting from National Institute of Health and Family Welfare, these were taken down to
fourteen institutions throughout the country and more then 900 doctors were oriented in
PDCs over a period of first five years of its launch. In most of these programs, the profile
of the participants nominated remained a matter of debate. Subsequent use of trained
doctors and their contribution to the respective State Health Departments remains a matter of
debate.

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 Here in this paper we will focus on the effects of training in building the competency of the
health professional in the Indian health sector

WHAT ARE COMPETENCIES?

Definitions and terminology surrounding the concept of competency are replete with
imprecise and inconsistent meanings, resulting in a certain level of bewilderment among
those seeking to identify the concept. For example, the general human resources literature
typically refers to competencies through the skills, knowledge, and ability. Competencies
have also been referred to as skills, knowledge, and attitudes (or aptitudes), with ability being
subsumed under skill. Competency from this human resources perspective has been defined
as "a cluster of related knowledge, skills, and attitudes that: 1) affect a major part of one's job
(a role or responsibility), 2) correlate with performance on the job, 3) can be measured
against well accepted standards, and 4) can be improved by training and development" (Lucia
and Lepsinger 1999).

Spencer and Spencer (1993) define a competency as an "underlying characteristic of an

individual that is causally related to criterion-referenced effective and/or superior
performance" in a job or situation. They further posit that a competency comprises five
underlying characteristics--(1) motives, (2) traits, (3) self-concept, (4) knowledge, and (5)
skills--that are developed in a sequenced pattern to optimize job performance. Greater
discussion of the competency concept can be found in Spencer and Spencer (1993), Lucia
and Lepsinger (1999), and Calhoun et al. (2002).

While the exact definition and usage of the term is contested, competencies can be broadly
defined as the knowledge, skills, ability and behaviour that a person possesses in order to
perform tasks correctly and skilfully. There has been substantial focus on identifying
competencies in health, both in India and internationally. This is driven by a range of current
and predicted challenges in the delivery of health care, particularly in remote and rural India.
Competencies are gaining prominence in health as means to increase both the quality and
efficiency of health care services.

High quality health services require health professionals who have up-to-date skills and
expertise, and are trained to be fit for the work that needs to be performed. Health
professionals working in rural and remote areas require unique skills. For example rural and
remote Health professionals frequently work in interprofessional teams, have greater work
responsibility, less management support, reduced access to professional support structures,
and deliver services across broader clinical areas to more culturally diverse populations than

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Health professionals in metropolitan areas. Establishing competencies for practice is one way
of ensuring health care delivered by Health professionals in rural and remote areas meets the
high demands of their work, and that the attainment of these skills is recognised.

Competency frameworks serve many purposes in the delivery of quality health care. They are
frequently employed as a tool to determine staff skills against the requirements of a position.
They are also used to support staff development, as a tool to facilitate individual performance
review, and to identify the ongoing professional development needs of individual employees.
At the organisational or institutional level, competency frameworks allow for the
identification of skills and knowledge necessary to achieve an organisation’s strategic
agenda. In terms of health management and leadership, Baker suggests that most importantly
competency frameworks ‘provide a language for talking more precisely about leadership
knowledge and skill. They offer a way to deepen current conversations about the specific
knowledge and skills necessary for leaders, and provide a mechanism for measuring these.
Identifying competencies also has the potential to allow for the development of new work
roles in health and increased efficiency of the healthcare workforce. Job re-design that
includes using skilled workers in roles beyond the traditional scope of their work, is seen as
one way of addressing future challenges in health care delivery. Health assistants in rural and
remote areas working under the supervision of Health Professionals are an example of this;
they have the potential to increase work efficiency by increasing caseload throughput

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The Need for a Framework:

The recent discussion and debate involving core competency development for health
management practice may ultimately be productive. However, while numerous research
efforts have been undertaken to develop competency models, there exists little evidence to
suggest that any competency model may be more useful to the field than others. Much of this
research has been hampered because a common shared framework for competency
development does not exist. Lacking a common framework, competencies proposed in
different studies have been idiosyncratic and fundamentally non-comparable. In describing
the efforts of the six Association of University Programs in Health Administration (AUPHA)
faculty forum task forces' attempts to identify core competencies.

An important question for identifying competencies is to determine the context from which
they are derived and in which they should be applied. Unfortunately, there has been
considerable variability with respect to this aspect of competency development.
Competencies are derived from his experience in recruiting healthcare executives. AUPHA
and NCHL have attempted to identify competencies that have some support in the literature
and validate these by seeking consensus from individuals they viewed to be expert
stakeholders, in addition, most previous competency development activities have relied
almost exclusively on the perspectives of nominal experts and on the literature that exists in
the field. While there is some value in reflecting salient perspectives that exist within a
particular context, competencies that are not embedded within a framework are likely to be of
little lasting value. Typically, what has been identified are broad competency domains, such
as leadership or professionalism, that are removed from specific contexts and actual
behaviours and thus have almost no meaning in terms of how they relate to important
behavioral outcomes. A general competency statement such as professionalism is comparable
to an overarching aim or goal of training that provides little direction as to what the specific
objectives of training should be. The goal of competency research is to change healthcare
management practice and education for the better; however, competencies configured as
broad domains are likely to have little translational value.

 The four phases of the competency development process used in the study (data collection,
analysis, and results) are described in the sections that follow.

Phase I: Generation of Critical Healthcare Issues

In phase I, 12 healthcare executives, comprising both men and women, from different types
of healthcare organizations (hospitals, health systems, health maintenance organizations,
preferred provider organizations, health insurance, medical group practice, consulting,
employer health coalition) were convened for a nominal group technique (NGT) meeting and
were asked to identify the critical environmental issues facing practicing executives. The

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NGT is a highly structured meeting during which participants individually respond to a
specific question, present their responses one at a time to the group, and anonymously
prioritize what they perceive to be the most salient responses. Ideally, an NGT meeting
involves between eight and twelve participants.

Before the actual elicitation process, participants were provided with a brief explanation of
the issue being addressed and a rationale for their participation. They were then presented
with the question, "What are the most critical issues facing healthcare industry today?" and
asked to work individually for approximately five minutes to develop a list of concise
responses to the question. To help ensure that a comprehensive array of responses was
developed, participants were encouraged to avoid evaluative self-censoring and to think
broadly about the issue. Participants were then given an opportunity to individually present
their responses one idea at a time to the group. The sequential presentation of ideas to the
group continued until all participants had contributed their entire list of responses. This
format was used to ensure that everyone had an equal opportunity to nominate their
responses. To promote open discussion and increase response volume, participants were
informed that it was unnecessary to state rationale or justification for their responses. They
were also asked to avoid any evaluative discussion of others' responses.

Each brief response was recorded on a flip chart. As the flip chart pages became full, they
were hung on the walls to help participants keep track of all previous responses. When the
group was unable to generate additional responses, a brief discussion for clarification
purposes--not evaluation--took place to ensure that all responses were understandable from a
common perspective. From that discussion, some minor response elaboration and new
responses were added to the list.

The last part of the meeting involved having each participant select and rank order three
responses from the overall list that they perceived as most salient. Individual rank orderings
were aggregated across participants to derive a group result.

Phase II: Perceptual Assessments of Issues

The critical issues identified by the healthcare executives in phase 1 were then assessed for
their perceived importance using a card-sorting task and a perceived importance scale that
subsequently were administered by mail to a nationwide representative sample of 750
healthcare administrators affiliated with ACHE. The sample was further selected from those
working in freestanding hospitals, system hospitals, and corporate headquarters, managed
care, and consulting firms.

The card-sorting task was used to elicit healthcare executives' judgments about the
similarities of the identified critical issues in healthcare. Participants were instructed to
consider the meaning of the NGT-generated critical healthcare issue that was printed
individually on each card and then use their own criteria to sort cards into an unspecified
number of card piles that could contain any number of perceptually similar cards. Thus, the

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critical healthcare issues that were sorted into piles together can be assumed to be more
similar than issues that were sorted into other piles. Executives were also asked to rate their
perceptions of the importance of each critical healthcare issue using a Likert-type rating
scale. Completed assessments (survey and card sort) were obtained from 227 of the 750
sampled healthcare executives, resulting in a response rate of 30.3 percent. This contrasts
with typical response rates to ACHE-administered surveys of approximately 50 percent
following two administrations of a survey. The current survey, however, was not presented as
coming from or being endorsed by ACHE; it was administered once, and it required subjects
to complete not only a survey but a card-sorting task as well

Phase III: Mapping Analysis

Individual sorting of critical healthcare issues was aggregated across all participants to
indicate how often a particular issue was sorted together with other critical issues. This
aggregation formed a group co-occurrence matrix that identified the overall group's
perception of the similarity for any pair of issues. The frequency of co-occurrence of issues
can be thought of as a perceptual distance. The more frequently a pair of issues was sorted
together, the shorter the distance, and vice versa. The group co-occurrence matrix was
analyzed using multidimensional scaling and hierarchical cluster analyses. These analyses
completed phase 111 of the study and enabled derivation of a map-like representation to
quantify a framework depicting how healthcare executives collectively organized the 38
healthcare issues. Clusters of similar issues were weighted by the average perceived
importance for the set of issues defining each cluster. This map provided information about
(1) how the critical issues were grouped, (2) perceived relative importance of the healthcare
issue groups, and (3) relative importance of the specific issues within each group.

The cluster analysis produced five clusters or groupings of the critical healthcare issues --that
is, the critical issues within each cluster were perceived as being more related, or more
similar, to each other than they were to critical issues in other clusters. The related issues
within each cluster were examined for underlying themes and commonality of meaning.
Because no assumptions can be made about the distribution of the data used in this analysis,
well-developed and accepted statistical tests for assessing the adequacy of fit have yet to be
developed. A subjective decision was made to interpret a five-cluster solution. This decision
was informed by examining the pattern in the agglomeration coefficients indicating which
critical issues were joined together in the clustering sequence. This sequencing of cluster
formation obtained from hierarchical cluster analysis was also graphically depicted using
dendrograms and icicle plots (Aldenderfer and Blashfield 1984; Statistical Package for the
Social Sciences [SPSS] 2002), which are generally provided in most statistical software
packages

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Phase IV: Competencies to Address Healthcare Issue Groups

The five clusters of perceived critical healthcare issues were used as a framework to guide
healthcare executives in generating the specific behavioral competencies perceived to be
required by those entering the field.

Each of the five healthcare issue clusters was presented to the panelists on a worksheet. Using
the worksheets, panelists were asked to list the specific behavioral competencies needed by
those entering the field of healthcare administration to address each critical issue cluster.
Using the NGT procedure employed in generating the critical healthcare issues (a group
information elicitation and prioritization exercise for each of the five critical healthcare issue
clusters), an exhaustive listing of associated competencies that were perceived to be germane
to each critical issue cluster was generated. The panelists generated a mean of 20
competencies that they perceived were necessary to allow new entrants to the field to perform
effectively within the critical healthcare issues framework. The highest-ranked competencies
within each cluster, and the number of votes for those competencies were received from the
panel. Generally, as indicated by the assignment of votes, there was a relatively high degree
of consensus among panelists regarding the relative importance of individual behavioral
competencies within each critical healthcare issue cluster.

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Problem with Community Health Workers:

In order to respond to the unique barriers present in a given community, community health
workers must play a dynamic role in effectively engaging
both community members and health service personnel. Fulfilling this role and realizing the
potential contribution of community health workers services relies upon community
participation and ownership as well as support from the health system. Historically in India,
however, both have been lacking, and past experiences with community health workers
suggest significant challenges in making theory a reality. For example, although community
health workers may serve multiple roles in providing integrated preventive care interventions,
they often lack the ability to deliver curative services, such as infectious disease treatment
and first aid, and therefore struggle to gain the trust of the community. As a consequence,
their roles in community mobilization
towards immunization uptake may be jeopardized. Furthermore, if community ownership is
not perceived by either community health workers or the
communities that they serve, then community health workers often become viewed as mere
extensions of the health system, instead of trusted community members. In anticipation of
these challenges, community health workers must be carefully selected through an informed
process for identifying reputable individuals who are invested in the community, and their
roles in the health system must be clearly articulated. Within the Indian health system, a

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strong hierarchical culture and pressure from upper management has driven other health
functionaries to blame community health workers for obstacles faced in achieving target
levels of immunization coverage. Under these conditions, community health workers may
believe that they are unable to share valuable information about community-level barriers
with their supervisors for fear that these explanations will be perceived as excuses for
inadequate performance. To address these issues, emphasis must be placed on supportive
supervision for community health workers and strong coordination among health personnel.
Otherwise, a strict focus on achieving numeric targets for immunization coverage may
predominate at the expense of attention to quality and equity of services. The role of
community health workers in identifying local barriers to immunization, like other
community health workers activities, must be clearly delineated and understood by other
health functionaries in order to establish an expectation that open channels for
communication are maintained.

An understanding of the positioning of CHWs at the interface between communities and the
rural health system must be incorporated into implementation of CHW programs. Regarding
selection of CHWs, for example, it has been widely accepted that communities must play
integral role in the process to ensure the acceptability, quality, and sustainability of CHW
services. However, a recent comprehensive review of CHW programs found that no
consensus exists on how this process should be carried out and that meaningful community
participation is often lacking, particularly in large scale programs. The most common
approach involves the formation of village health committees. In the context of India,
substantial political, religious, and caste heterogeneity in rural settings highlight the need to
understand community dynamics to appropriately facilitate the process of selection of CHWs.
True representation of the breadth of the community can be undermined by patronage
selections for health committee membership by powerful community groups. Furthermore,
even among health committees with broad representation, dominant committee members
can often guide the selection process resulting in patronage selections for CHW positions. An
alternative approach outlined in India’s NRHM requires officers at the block level to appoint
field-based facilitators from local NGOs, trusted community groups, or civil societies to
mediate the selection process at the community level. Specifically, facilitators conduct focus
group discussions with community members in order to become sensitized to potential biases
of caste and socio-political divisions. They then generate a list of three CHW candidates from
which community residents finalize a selection. Prior to the conception of the NRHM, the
state-wide Mitanni Programme in Chhattisgarh launched in 2002, trained 54,000 CHWs
offering a model for the implementation of this CHW selection strategy on a large scale.
Successful community participation in CHW selection in this program has been attributed in
part, to a strong social mobilization phase that preceded selection and raised community
awareness of the CHW program through popular media and local theatre groups. While
participation was not universal among communities, and local elites exerted significant
influence on the selection process in some villages, the use of facilitators represents an
important mechanism to promote community participation in the selection process. The
selection process should also consider factors related to retention of CHWs. Whenever
possible, facilitators must work with communities to expand selection criteria beyond the
basic qualifications for CHWs under India’s NRHM. For example, the basic guidelines for
the selection of native female residents with an education up to the 8th class can be enhanced
by specifying a preference for women over 25 years of age, married women, and women with
grown children to avoid foreseeable personal obligations which have been shown to
contribute to increased rates.

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CONCLUSION:
As seen from the above mentioned details, it is clear that Trainings play a significant role in
increasing the motivation and hence shaping an employee’s competency and capabilities but
these should be properly dealt with by the senior management i.e. the management has to
identify the weak areas of an employee and then engage him or her in that specific field of
training rather than forcing him to attend all the trainings. Ignoring these may lead to a
demotivated individual which affect his competency in a negative way and can lead to
varying results, which might not be in the prosperity of the organization.

Also, evidence supports the effectiveness of training in increasing the competencies of the
health worker in rural India and further suggests that it may have a greater impact when
compared to other strategies for expanding basic health services.

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