Parallel Systems and Human Resource Management in India's Public Health Services: A View from the Front Lines

AuthorGerard La Forgia,Shabbeer Shaik,Shomikho Raha,Sunil Kumar Maheshwari,Rabia Ali
Published date01 December 2015
Date01 December 2015
DOIhttp://doi.org/10.1002/pad.1738
PARALLEL SYSTEMS AND HUMAN RESOURCE MANAGEMENT IN
INDIAS PUBLIC HEALTH SERVICES: A VIEW FROM THE FRONT LINES
GERARD LA FORGIA
1
, SHOMIKHO RAHA
2
*, SHABBEER SHAIK
3
,
SUNIL KUMAR MAHESHWARI
4
AND RABIA ALI
5
1
Health, Nutrition & Population Global Practice, World Bank, USA
2
Governance Global Practice, World Bank, USA
3
Center for Good Governance, Hyderabad, India
4
Indian Institute of Management, Ahmedabad, India
5
Education Global Practice, World Bank, USA
SUMMARY
There is building evidence in India that the delivery of health services suffers both from an actual shortfall in trained health
professionals and from unsatisfactory results of existing service providers working in the public and private sectors. This study
focuses on the public sector and examines de facto institutional and governance arrangements that may give rise to
well-documented provider behaviors such as absenteeism that can adversely affect service delivery processes and outcomes.
We analyze four human resource management (HRM) subsystems: postings, transfers, promotions and disciplinary practices
from the perspective of front-line workersphysicians working in rural healthcare facilities operated by two state governments.
We sampled physicians in one post-reformstate that has instituted HRM reforms and one pre-reformstate that has not. The
f‌indings are based on both quantitative and qualitative measurements. The results show that formal rules are undermined by a
parallel modus operandi in which desirable posts are often determined by political connections and side payments. The evidence
suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities.
These systems appear so entrenched that reforms have borne no signif‌icant effect. Copyright © 2015 John Wiley & Sons, Ltd.
key wordsAsia; India; health systems; governance; human resource management; public management
INTRODUCTION
There is growing evidence from some states in India that the delivery of public and private health services suffers
both from an actual shortfall in qualif‌ied human resources, especially physicians, and from unsatisfactory perfor-
mance of existing service providers. A number of studies using large-scale quantitative data show that there is
widespread absenteeism among medical providers in the public sector (Banerjee et al., 2004, Chaudhury et al.,
2005, Banerjee et al., 2008) and that even though public sector providers are at least as knowledgeable as trained
providers in the private sector, and certainly more knowledgeable than informal sector providers, the low effort that
these providers exert in clinical interactions reduces their eff‌icacy relative to other alternatives (Das and Hammer,
2007; Das et. al. 2012). Although improving health outcomes is linked to a number of factors, supply side delivery
def‌iciencies evidenced by absenteeism, work shirking and low productivity limit the ability of government to im-
prove service delivery and, ultimately, contribute to lagging health outcomes (Misra et al., 2003; Banerjee et al.,
2004; Chaudhury et al., 2005; MOHFW, Ministry of Health and Family Welfare, India, 2005a; Das and Hammer,
2007; Banerjee et al., 2008; Lewis and Pettersson, 2009a, 2009b).
Analytical work on human resources in health in India tends to center on the shortfall in actual numbers of per-
sonnel that public delivery systems require in order to meet the needs of the growing population as specif‌ied in
population-based norms and policies (MOHFW, Ministry of Health and Family Welfare, India, 2005b IPHS,
*Correspondence to: S. Raha, Governance Global Practice, World Bank, Washington DC, USA. E-mail: sraha@worldbank.org
public administration and development
Public Admin. Dev. 35, 372389 (2015)
Published online 2 November 2015 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/pad.1738
Copyright © 2015 John Wiley & Sons, Ltd.
GOI, 2007; MOHFW, 2008). In contrast, understanding the high incidence of absenteeism, low productivity and
low quality of service delivered by providers already in the system draws less attention. Moreover, there are
relatively few studies that have examined the institutional workings of states that may contribute to provider
behaviors and performance.
This research addresses an important gap in the health human resource literature. It attempts to carefully mea-
sure how front-line physicians in the public sector view the workings of the delivery system in terms of human re-
source processes and practices. This study analyzes current systems of management and governance, identifying
the gap between formal rules and de facto practices. We provide direct evidence on what doctors feel about the
management of their careers, transfers and postings. We uncover a system that is essentially parallel to what exists
on paper. We show that this system is the governing arrangement in a state that suffers from low human develop-
ment indicators and in a state that is perceived as doing much bettergiven higher levels of human development.
We raise several hypotheses of the impacts of parallel systems on service delivery.
This study focuses on understanding the institutional environment, in particular the policies, rules and processes
that govern human resource management (HRM) in the public health system. We analyze four HRM subsystems:
postings, transfers, promotions and disciplinary practices from the perspective of front-line workersphysicians
working in primary care facilities and hospitals operated by state governments in rural areas. These functions are
considered major determinants of human resource performance (Meyers and Allen, 1991; Sims, 2002; Burke
and Cooper, 2005). The ways in which these four HRM functions are conducted in practice provide evidence of
underlying accountabilities and incentives that can affect service delivery performance. To our knowledge, this
is the f‌irst study that systematically examines HRM in a developing countrys health sector with a focus on the
de facto practices as described by those whose livelihood and careers depend on them.
Analytical framework and key arguments
Conceptually, we work from the premise that HRM practices and performance are determined by the institutional
environment in which they are embedded (Manning et al., 2000; Bana and McCourt, 2006). The framework is
illustrated in Figure A1. This environment, which is inf‌luenced by worker preferences and external pressures, con-
tributes to organizational performance (e.g., accountability, results focus, organizational discipline and employee
morale), which in turn impacts service delivery performance. Our approach emphasizes de facto institutional and
governance arrangements, as well as parallel systems, that inf‌luence organizational performance and lead to behav-
iors that further perversely affect service delivery processes and outcomes (Burke and Cooper, 2005; Devarajan,
2008; Lewis and Pettersson, 2009, a,b; Wild et al., 2012; Fukuyama, 2013). Although not directly measured in this
study, service performance consists of HR behaviors (e.g., absenteeism and low effort) that mediate actual service
provision. We hypothesize the effects of the institutional environment on provider behaviors and, ultimately,
downstream service performance.
Four f‌indings contribute to understanding the institutional environment in India and its potential impact on pro-
vider behaviors. First, HRM practices are undermined by a parallel modus operandi in which key functions are often
determined by political connections and side payments. Parallel systems refer to well-known and widely practiced
informal processes that deviate signif‌icantly from formal policies and rules governing HRM. These systems appear
to be controlled by senior administrators and politicians. Second, we conf‌irm what is well-known anecdotally: these
parallel systems are widespread and predictable. Third, the occurrence of parallel systems in a pre-reformstate that
has yet to formalize many HRM processes are no different from a post-reformstate that instituted HRM reforms in
the public health service. Parallel systems are so embedded in the institutional fabric that reforms appear to have had
little impact on what happens on the ground. Finally, parallel systems are open to manipulation by all participants
administrators, politicians and physiciansfor their benef‌it, whether monetary or non-monetary.
Our f‌indings suggest an institutional environment in which formal rules of accountability are trumped by infor-
mal systems that respond to a different set of accountabilities and incentives. Parallel systems are detrimental to the
link between better performance and rewards (whether through promotions, betterpostings or even higher
salaries) and instead create alternate margins for doctors to focus their attention. For example, if a better posting
373
PARALLEL SYSTEMS AND HRM IN INDIAS PUBLIC HEALTH SERVICES
Copyright © 2015 John Wiley & Sons, Ltd. Public Admin. Dev. 35, 372389 (2015)
DOI: 10.1002/pad

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