Posting and Transfer: the experiences of public sector doctors in two Indian states.

Posting and Transfer (PT) refers to deployment of the health workforce in ways that ensure appropriate numbers and distribution. Although PT is a crucial aspect of health workforce governance, it remains under-researched from the viewpoint of implementation, health workforce and governance. The aim of this paper is to examine public sector doctors' experience of their initial postings, in the context of local policy from two Indian states. We carried out a review search for policy documentation. A total 61 in-depth interviews were conducted in both states with 33 doctors, as subjects of the study. There were 28 key informant (KI) interviews of health administrators and other policy actors to understand their perspectives of PT policies and implementation. Thematic analysis was used to analyse data. Job histories were constructed from the doctors' interviews to track their experience with the PT system, and analysed using location, duration and postings. Despite search for state policy for PT, we were unable to identify any policy documentation. However, participants referred to PT practices that suggested expectations of what the poliy meant to them. These expectations were corroborated by KI, and the job histories and interview data enabled the authors to construct a series of norms, interpreted as evidence of implied policy. The main norms identified relate to service need, native place, request, gender and posting duration. The norm related to state need had strong face validity, while other norms based on request, gender and duration were less consistent in application. In the absence of documented policies, the construction of norms from the qualitative data proved useful to examine the dynamics of health workers' interactions with the initial PT systems This construction of norms provides a methodological innovation allowing health policy and systems researchers to compensate for the absence of documented policy in exploring PT functions.

Measuring management practices in India's district public health bureaucracy.

Weak management is widely recognised as a key impediment to scaling-up coverage of health interventions and ensuring health systems are responsive to population needs. Yet there is scant evidence linking management practices in the public administration to effective health service delivery. We report on the development of a tool to measure management practices in India's district health bureaucracy. We first developed a conceptual framework based on a review of the literature and qualitative interviews with district public health managers. Across 16 management practices, we then drafted and piloted questions to be used with a scoring grid to evaluate process-orientated management practices. We implemented the tool in 34 districts of Maharashtra between April and July 2016, interviewing up to three district public health managers per district (n = 99). Using rigorous psychometric methods, we assessed the acceptability, reliability and validity of the tool. We present three key findings. First, the tool was feasible to implement, response rates were high, and there were no missing data. Second, internal consistency of the tool was high and test-retest reliability was comparable with other management tools used in the literature. Third, there was evidence of validity. The number of staff with a management qualification was positively associated with better management practices. Factor analysis showed that one principal component loaded positively on all the management practices although there was little support for management sub-scales. These findings provide novel evidence on the psychometric properties of a tool designed to measure management practices in the public administration of a developing country. Our framework and tool provide the basis to examine associations between district health management practices and health service delivery, and test the effectiveness of management strengthening interventions in India's public health sector.

Role stress among auxiliary nurses midwives in Gujarat, India.

BACKGROUND: Understanding Role Stress is important as health service providers, especially nurses experience high levels of Role Stress which is linked to burnout, poor quality of care and high turnover. The current study explicates the concept of Role Stress and assesses the Role Stress experienced by the Auxiliary Nurse Midwives (ANMs) working with rural government health centres from Gujarat, India. METHODS: The study included 84 ANMs working with government health centres from one district in India. A structured instrument with established reliability and validity was used to measure 10 dimensions of Role Stress namely: Inter-role distance, role stagnation, role expectation conflict, role erosion: role overload, role isolation, personal inadequacy, self-role distance, role ambiguity and resource inadequacy. The study instrument was based on 5 point Likert rating scale that contained 50 unidirectional negative statements, 5 for each dimension. Kolmogorov-Smirnov and Shapiro-Wilk test were carried out to assess if the data were normally distributed. Cronbach's alpha test was carried out to assess reliability of the instrument. The study data was analyzed using descriptive statistics mainly using mean scores with higher scores indicating higher Role Stress and vice versa. The data was analyzed using SPSS version 19. RESULTS: Kolmogorov-Smirnov and Shapiro-Wilk test indicated that the data were normally distributed. Cronbach's alpha test indicated values of 0.852 suggesting high reliability of the tool. The highest Role Stress among ANMs was experienced for resource inadequacy. Role overload, role stagnation and inter-role distance were among the other important role stressors for ANMs. The study results suggests that ANMs frequently feel that: they do not have adequate amount of resources, facilities and financial support from the high levels authorities; people have too many expectations from their roles and as result they are overloaded with work and have very limited opportunities for future growth. CONCLUSION: The current study has the potential to provide a useful and a comprehensive framework to understand the Role Stress among the health service providers that could be further useful in designing interventions specifically aimed at reducing Role Stress in order to prevent burnout thereby addressing the productivity and retention.

Opening the black box of transfer systems in public sector health services in a Western state in India.

BACKGROUND: Limited research on Posting and Transfer (P&T) policies and systems in the public sector health services and the reluctance for an open debate on the issue makes P&T as a black box. Limited research on P&T in India suggests that P&T policies and systems are either non-existent, weak, poorly implemented or characterized by corruption. Hence the current study aimed at opening the "black box" of P&T systems in public sector health services in India by assessing the implementation gaps between P&T policies and their actual implementation. METHODS: This was a qualitative study carried out in Department of Health, in a Western State in India. To understand the extant P&T policies, a systems map was first developed with the help of document review and Key Informant (KI) Interviews. Next systems audit was carried out to assess the actual implementation of transfer policies by interviewing Medical Officers (MOs), the group mainly affected by the P&T policies. Job histories were constructed from the interviews to understand transfer processes like frequencies of transfers and to assess if transfer rules were adhered. The analysis is based on a synthesis of document review, 19 in-depth interviews with MOs working with state health department and five in-depth interviews with Key Informants (KIs). Framework analysis approach was used to analyze data using NVIVO. RESULTS: The state has a generic transfer guideline applicable to all government officers but there is no specific transfer policy or guideline for government health personnel. The generic transfer guidelines are weakly implemented indicating a significant gap between policy and actual implementation. The formal transfer guidelines are undermined by a parallel system in which desirable posts are attained, retained or sometimes given up by the use of political connections and money. MOs' experiences of transfers were marked by perceptions of unfairness and irregularities reflected through interviews as well as the job histories. DISCUSSION: The generic transfer rules and ambiguity in how transfers are treated may explain the discrepancy between policy and implementation leading to systems abuse. This discrepancy could have negative influence on MOs' morale which could in turn affect distribution of MOs. Where possible, ambiguity in the rules should be avoided and a greater transparency on implementation of the transfer rules is needed. However, it may not be possible to make any significant improvements to P&T policies and how they are implemented until the external pressure that creates parallel systems is greatly reduced in translating HR policy into HR practice. CONCLUSIONS: Effective P&T policies and implementation may have important implications for organizational performance and may help to improve Human Resource (HR) policy and HR expertise. Also there is a greater need for transparency on implementation of the rules. However, it may not be possible to make any significant improvements to P&T policies and how they are implemented until the external pressure that creates parallel systems is greatly reduced.

Issues and challenges in recruitment for government doctors in Gujarat, India.

BACKGROUND: India faces a critical shortage of government doctors in rural and underserved areas. Several measures have been introduced to address the shortage, but significant problems still remain. The main aim of the current research was to understand the existing recruitment-related policies and systems in place for government doctors in Gujarat and to identify issues that prevent effective recruitment of doctors that could have implications for doctors' shortage in the state. The research also aims to fill the knowledge gap in the existing literature on why recruitment in civil services is an important HR function to address the shortage of doctors. METHODS: The study aimed at identifying the existing recruitment policies and practices for government Medical Officers (MOs) from Gujarat state in India. The analysis is based on document review to understand the existing policies, 19 in-depth interviews with MOs to understand the systems in place for recruitment of MOs, construction of job histories from interviews to understand various nuances in the recruitment system and five interviews with Key Informants to understand recruitment policies and their actual implementation. Thematic framework approach was used to analyse qualitative data using NVivo. RESULTS: While the state has general recruitment guidelines called the Recruitment Rules (RRs), these rules are very wide-ranging and fragmented. The MOs were neither briefed about them nor received copies of the rules at any time during the service suggesting that RRs were not transparent. The recruitment system was considered to be slow and very sporadic having possible implications for attraction and retention of MOs. The study results indicate several other system inefficiencies such as a long time taken by the health department to provide salary benefits and service regularization that has a negative effect over MOs' motivation. The study also found unequal opportunities presented to different categories of MOs in relation to job security, salary benefits and in recognizing their previous work experience leaving MOs unclear about their future thereby influencing the attraction and retention of MOs to government jobs negatively. CONCLUSIONS: If long-term solutions are to be sought, the health department needs to have an effective recruitment system in place with the aim to (1) address the slow and sporadic nature of the recruitment system (that is likely to attract more doctors and prevent loss of any doctors during recruitment) and (2) address the job insecurity issue that MOs have which also influences their other employment benefits such as salary, pension and recognition for the years of service they have given to the health department. Addressing these issues can improve motivation among doctors and prevent loss of doctors through voluntary turnover leading to better retention.

Initial posting-a critical stage in the employment cycle: lessons from the experience of government doctors in Gujarat, India.

BACKGROUND: With the critical shortage of government doctors serving in rural health centers in India, understanding the initial posting policies, processes, and practices become important from a retention point of view. The initial posting is a very critical stage of an employment cycle and could play an important role in influencing the key human resource for health outcomes such as turnover and performance. The current study aimed at exploring a rather unknown phenomenon of the initial posting-related processes, practices, and perceptions of Medical Officers working with the Public Health Department in Gujarat, India. METHODS: This was an exploratory study carried out in the state of Gujarat, India, that used qualitative methods first to document the extant initial posting policy with the help of document review and five Key Informant interviews; next, 19 in-depth interviews were carried out with Medical Officers to assess implementation of policies as well as processes and systems related to the initial posting of Medical Officers. A thematic framework approach was used to analyze qualitative data using NVIVO. RESULTS: The results indicate that there is no formal published or written initial posting policy in the state, and in the absence of a written and formal policy, the overall posting systems were perceived to be arbitrary by the study respondents. In the absence of any policy, the state has some unwritten informal practices such as posting the Medical Officers at their native places. Although this practice reflects a concern towards the Medical Officer's needs, such practices are not consistently applied indicating some inequity and possible implications over Medical Officers' retention and motivation. CONCLUSIONS: Initial posting is a critical aspect of an employment cycle, and the perceptions and experiences of MOs regarding the processes and practices involved in their initial posting can be crucial in influencing their performance and turnover rates. If long-term solutions are to be sought in addressing the availability and distribution of Medical Officers in the state, then there is a need to have clearly laid down initial posting-related policies that reflect the equity and consideration towards Medical Officers in placement-related matters.

Is the Annual Confidential Report system effective? A study of the government appraisal system in Gujarat, India.

BACKGROUND: Effective performance appraisal systems can not only motivate employees to improve performance but also be important for the performance of organizations. However, the appraisal systems in civil services called the Annual Confidential Report (ACR) systems can be ineffective and do not contribute to employees' learning and development. With this background, the current study aimed at understanding the ACR system and assessing its effectiveness. The research aims to contribute in filling the knowledge gap in the existing literature on the need as to why the ACR system in civil services is an important human resource management (HRM) function. METHODS: The analysis is based on policy review to understand the extant appraisal-related rules and policies. Nineteen in-depth interviews with medical officers (MOs) working with the government health department of Gujarat, India, were conducted. The main objective of the research was to assess the effectiveness of the actual appraisal system called or referred to as the ACR as perceived by MOs. Thematic framework approach was used to analyze qualitative data using NVIVO 9. Themes were built around five features of an effective appraisal system, i.e., purpose, source, feedback quality, link of the ACR system with other human resource functions, and administrative effectiveness. RESULTS: The five features of the effective appraisal system studied in the current research (purpose, source, feedback quality, link of ACR system with other HRM functions, and administrative effectiveness) indicate that the overall appraisal system is ineffective. The overall appraisal system was perceived to be subjective and one directional in character by the study respondents. Furthermore, respondents perceived the appraisal system to be a ritual and where MOs hardly got to know about their performance, especially good performance. Hence, the feedback loop, an important feature for an effective appraisal system, was absent. The overall ACR system functions in isolation with no link to other HRM functions such as training and counselling, and a weak link with salary administration and promotion. CONCLUSIONS: Addressing the five features or domains of an effective appraisal system can lead to improved perceived fairness MOs have on the current appraisal system which may further influence the satisfaction and motivation positively. Improved motivation and satisfaction with the appraisal system can influence two important human resource for health-related outcomes, i.e., performance and retention.

Developing a tool to assess motivation among health service providers working with public health system in India.

BACKGROUND: Addressing the shortage of health service providers (doctors and nurses) in rural health centres remains a huge challenge. The lack of motivation of health service providers to serve in rural areas is one of the major reasons for such shortage. While many studies have aimed at analysing the reasons for low motivation, hardly any studies in India have focused on developing valid and reliable tools to measure motivation among health service providers. Hence, the objective of the study was to test and develop a valid and reliable instrument to assess the motivation of health service providers working with the public health system in India and the extent to which the motivation factors included in the study motivate health service providers to perform better at work. METHODS: The present study adapted an already developed tool on motivation. The reliability and validity of the tool were established using different methods. The first stage of the tool development involved content development and assessment where, after a detailed literature review, a predeveloped tool with 19 items was adapted. However, in light of the literature review and pilot test, the same tool was modified to suit the local context by adding 7 additional items so that the final modified tool comprised of 26 items. A correlation matrix was applied to check the pattern of relationships among the items. The total sample size for the study was 154 health service providers from one Western state in India. To understand the sampling adequacy, the Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett's test of sphericity were applied and finally factor analysis was carried out to calculate the eigenvalues and to understand the relative impact of factors affecting motivation. RESULTS: A correlation matrix value of 0.017 was obtained narrating multi-co-linearity among the observations. Based on initial factor analysis, 8 out of 26 study factors were excluded from the study components with a cutoff range of less than 0.6. Running the factor analysis again suggested the inclusion of 18 items which were subsequently labelled under the following heads: transparency, goals, security, convenience, benefits, encouragement, adequacy of earnings and further growth and power. CONCLUSIONS: There is a great need to develop instruments aimed at assessing the motivation of health service providers. The instrument used in the study has good psychometric properties and may serve as a useful tool to assess motivation among healthcare providers.

Beyond job security and money: driving factors of motivation for government doctors in India.

BACKGROUND: Despite many efforts from government to address the shortage of medical officers (MOs) in rural areas, rural health centres continue to suffer from severe shortage of MOs. Lack of motivation to join and continue service in rural areas is a major reason for such shortage. In the present study, we aimed to assess and rank the driving factors of motivation important for in-service MOs in their current job. METHODS: The study participants included ninety two in-service government MOs from three states in India. The study participants were required to rank 14 factors of motivation important for them in their current job. The factors for the study were selected using Herzberg's two-factor theory of motivation and the data were collected using an instrument that has an established reliability and validity. Test of Kendall's coefficient of concordance (W) was carried out to assess the agreement in ranks assigned by participants to various motivation factors. Next, we studied the distributions of ranks of different motivating factors using standard descriptive statistics and box plots, which gave us interesting insights into the strength of agreement of the MOs in assigning ranks to various factors. And finally to assess whether MOs are more intrinsically motivated or extrinsically motivated, we used Kolmogorov-Smirnov test. RESULTS: The (W) test indicated statistically significant (P < 0.01) agreement of the participants in assigning ranks. The Kolmogorov-Smirnov test indicated that from policy perspectives, MOs place significantly more motivational importance to intrinsic factors than to extrinsic factors. The study results indicate that job security was the most important factor related to motivation, closely followed by interesting work and respect and recognition. Among the top five preferred factors, three were intrinsic factors indicating a great importance given by MOs to factors beyond money and job security. CONCLUSION: To address the issue of motivation, the health departments need to pay close attention to devising management strategies that address not only extrinsic but also intrinsic factors of motivation. The study results may be useful to understand the complicated issue of work motivation and can give some useful insights to design comprehensive management strategies that are based on motivational needs of MOs.