By Aarti Sahasranaman, Vice President, Interventions – ICTPH
Although India is home to 17% of the world’s population, human resources for delivering health (HRH) to this population have remained woefully inadequate and this is one of the main reasons that our country has managed to achieve only moderate health outcomes. To work towards solutions for health workforce issues, the Public Health Foundation of India (PHFI) and Swasti, a health resource centre working in South and South-east Asia, are partnering to implement “The People for Health Project”, a three-year initiative funded by the European Union to advance HRH in India. As part of the “People for Health: Advancing Human Resources for Health in India” Seminar Series, a one-day seminar on “Recruitment Processes in Human Resources for Health” was held at New Delhi on November 29th, 2011. Speakers at the seminar included representatives from state and central government human resource agencies, civil society members, members of the private sector, and researchers studying health workforce issues.
The first session of the day focused on “Improved Practices for Addressing Factors Leading to Reduced Recruitment of Doctors, Nurses, and Frontline Workers”, and was co-chaired by Dr. P.K. Hota, Director Emiretus of the Norway India Partnership Initiative, and Dr. Saroj Pachauri, Distinguished Scholar, Population Council. As this session progressed it became evident that the current recruitment processes for medical personnel by government agencies are at best, utterly indifferent and inefficient. For example, the time that elapses between the appearance of a recruitment advertisement for a doctor in a newspaper and the actual appointment of a doctor can range anywhere between nine months to one year! This session, therefore, focused on HR innovations that could potentially strengthen recruitment processes. The most-touted HR innovation was from the government of Haryana where walk-in interviews of doctors were being conducted to fill positions within one month or so, instead of almost a year. Given my rather simplistic understanding of HR issues, the very idea that something as ubiquitous as a walk-in interview might be considered an “HR innovation” was somewhat surprising. However, the fact that it is considered an innovation by the government is testament to the protracted manner in which change is embraced and implemented by our public institutions. Now, whether walk-in interviews are the best way to recruit medical personnel is open to debate, and whether this mode of recruitment will have an impact on health outcomes in Haryana remains to be seen. One of the most interesting speakers of the first session was Dr. Vandana Prasad, National Convener, Public Health research Network, who gave us the civil society perspective of recruitment of HRH. As we strive to build a system where our SughaVazhvu RMHC staff will be accountable to patients, it was useful to hear Dr. Prasad’s contention that people in the health system are not answerable to patients. To quote her verbatim, “The health professional exists to run the system, not cure the patient”. She suggested that the importance of the patient and his/her rights should be raised during the recruitment process itself. Furthermore, institutionalising patient feedback as a metric to monitor physician performance could help to foster a sense of accountability towards patients. Strengthening our customer satisfaction audit process and using these audits to enable our RMHC staff to constantly improve their performance will take us a lot closer to achieving our vision of patient-centric care.
The second session of the day focused on “Strengthening Research and Training for Improved Recruitment Processes”. This session was an eye-opener to me in terms of the kind of HR-related research being done in our country. It was particularly interesting to listen to Dr. Krishna Rao, Senior Health Specialist, PHFI talk about his research on various state strategies to increase recruitment and retention of medical personnel in rural areas. His work has revealed that simple incentives such as a higher salary are not enough to motivate doctors with an MBBS degree to work in rural areas. What works instead is a combination of incentives – for example, educational interventions such as reservation of seats in post-graduation programmes for those who perform rural service, combined with a higher salary was found to increase willingness of doctors to serve in rural areas. Dr. Rao is also engaged in some interesting work on assessing the impact of task shifting on rural healthcare. For example, his group has undertaken a comparative study of the performance of AYUSH physicians, rural medical assistants (RMAs), and medical officers (MOs) with an MBBS degree. When the “competence score” of these different medical personnel was determined, it was shown that RMAs are just as competent as MOs, and that clinics manned by RMAs are accessed just as often as those manned by MOs. Interestingly, clinics manned by AYUSH physicians were accessed most often. Given Dr. Rao’s interest in task shifting and our desire to objectively determine the effectiveness of our trained AYUSH physicians, it might be worthwhile for us to consider collaborating with his group.
For someone who is a novice when it comes to HR practices and health workforce-related issues, attending this day-long seminar opened a window into how recruitment of HRH is structured. As we expand in Thanjavur from four to 10, and eventually 20 RMHCs, we are hitting the gas pedal where recruitment of AYUSH physicians and health extension workers (HEWs) is concerned. This recruitment drive has been preceded by “perspective planning”. Knowing how our health system will grow over the next year or so, we are in a position to determine the resources, human and others, we need to meet these requirements. For our vision of rural primary healthcare to be realised, it is very important that our frontline workers be aligned with our philosophy for delivery of healthcare. While physicians and HEWs can most definitely be trained, we need to ask ourselves precisely what qualities we are looking for in interviewees. Are we looking only for clinical skills to the exclusion of everything else, including people/social skills? While passion and motivation are not necessarily qualities that we might be able to ensure as we scale up, are these also not important qualities we should look for when we recruit new staff members? How important is attitude when we recruit our RMHC staff? Given that we train AYUSH physicians in allopathic medicine and expect them to adhere to our protocols and not their years of learning, I believe that the attitude of interviewees will be an indicator of their performance in our system. Interviewees must also be given a very clear sense of purpose, i.e precisely what do we expect them to accomplish. Besides their clinical roles, we should share with them our vision of physicians as community organisers in a sense, who have a pulse on the health needs of the communities they serve. An organisation is only as good as its people. The first step to building a successful organisation, then, is to recruit the right people. Spending time getting our recruitment processes right will definitely enable us to build a stronger organisation where individual values are all directed towards the achievement of a common goal.