Practitioner Perspective Section

Managing Human South Asian Journal of Human

Resources Management
Resources in Public Health 3(1) 7583
2016 SAGE Publications India
Care System in South Asia: Private Limited
SAGE Publications
Case Study of Pakistan sagepub.in/home.nav
DOI: 10.1177/2322093716640024
http://hrm.sagepub.com

Aneeqa Suhail1
Aisha Azhar2

Abstract
Health care is considered as one of the fundamental rights of every individual.
At the same time, efficient and effective delivery of health care service requires
pro-active management of health care professionals. The purpose of this article
is to highlight human resource issues and challenges faced by health care profes-
sionals in South Asia and identify suitable strategies for better management of
health care professionals. By using data from a pilot study in Pakistans public
health sector in the province of Punjab, the article explores ways of implementing
productive reforms to upgrade human resource management system in the public
health care sector in South Asian countries.

Keywords
Public health care, health care workforce, South Asia, human resource management

Introduction
Internationally, there has been a growing focus on health care workforce for
improved health outcomes (Drafke, 2002). The quality of health workforce plays
a vital role in the performance of health care systems but very little attention has
been given to its composition, training and performance in both developed and
developing countries (Beaglehole & Dal Poz, 2003). Hence, serious efforts from
national and international agencies are required to rebuild the public health work-
force. Human capital is the backbone of every organization and public health

1
Lecturer, UCP Business school, University of Central Punjab, Lahore, Pakistan.
2
UCP Business school, University of Central Punjab, Lahore, Pakistan.

Corresponding author:
Aneeqa Suhail, Lecturer, UCP Business school, University of Central Punjab, 1 Khayaban e Jinnah,
Johar Town Lahore, Pakistan.
E-mail: aniqa.suhail@ucp.edu.pk
76 South Asian Journal of Human Resources Management 3(1)

system is no exception. The functioning and growth of health care sector is highly
dependent on availability and quality of health workforce as well as its well-being
and satisfaction for timely and efficient execution of tasks (WHO, 2006).
However, research shows that human resource for health (HRH) has been a highly
neglected element of health care delivery system in South Asian countries
(Jamison et al., 2006).
In most countries, public health care system is one of the main sources that
provide subsidized health care services. The government expenditure on health
sector plays a pivotal role in the efficient delivery of public health care services
which ultimately leads to positive impact on human capital and economic growth
(Akram & Khan, 2007). However, South Asian countries including India,
Bangladesh, Pakistan and Sri Lanka have not paid sufficient attention to health
care facilities and health care providers. Health care financing in these countries
is considered suboptimal as compared to minimum standards, that is, 1.3 per cent
of gross domestic product (GDP), as prescribed by the World Bank (Akram &
Khan, 2007). The public health care expenditures reported are: India 1.2 per cent,
Bangladesh 1.1 per cent and Pakistan 1.0 per cent (The World Bank, 2012).
Majority of the South Asian countries lack the human resources needed to
deliver essential health interventions for a number of reasons, including low health
care budget, shortage of health care professionals, poor training and development
facilities, inadequate compensation and benefits for health care professionals and
migration of health workers from public to private and overseas health care
organizations due to dissatisfaction with facilities and condition of work in the
public health care sector (Gupta & Dal Poz, 2009).
The purpose of this article is to explore some of the issues faced by health care
professionals in South Asian Countries from the human resource management
(HRM) perspective. First, the human resource issues and challenges in Sri Lanka,
Bangladesh, India and Pakistan are outlined as representative cases of the
general situation prevalent in South Asia. Second, data collected from a pilot
study of public health sector of Pakistan is presented. The article then discusses
some of the limitations of the pilot study and provides directions for future
conduct of research in the subject area.

HRM Issues and Challenges in Public Health

Care System in South Asia
Sri Lanka
A major constraint in health care delivery in Sri Lanka has been the non-availability
of funds and the allocations made to provincial councils. Moreover, it is aggravated
by lack of planning and technical competencies and deficiencies in human resources
in the provincial health system (Ministry of Healthcare and Nutrition, 2011).
Human resources for health (HRH) in the country faces several challenges
including absence of administrative cadre, unorganized recruitment and selection,
lack of decentralization, geographic inequity, less number of teaching and training
Suhail and Azhar 77

hospitals, disparity in job performance and training facilities and lack of efficient
health care providers (Ministry of Health of Sri Lanka, 20011).
A study conducted by Sheriff (2005) reveals that Sri Lanka has been strug-
gling to develop human resource for health care industry since 1950s. To cater to
the needs of expanding health care system, the government has increased the
number of health care workers but in an unorganized manner. The health care
providers, employed in the public health sector, are highly dissatisfied resulting
in the shortage of nurses and other medical staffs (Sheriff, 2005). Research also
shows that training is offered on an ad hoc basis, and it is not based upon a formal
process of assessing staff needs nor is it linked to the organizations key priorities
and changes in the health sector and health practices (Ministry of Healthcare and
Nutrition, 2011). Although training is a formal component of the organization
and linked to staff and organizational needs, it is not available for all staff, nor is
it evaluated for results.
However, after the implementation of HRM reforms by Sri Lankas government, the
country is now ranked 94th in Human Development Index (Malik, 2013). They
have introduced better recruitment and selection practices and frequent training
opportunities and increased salaries for health professionals. Consequently, satisfac-
tion of health care workforce and quality of health care services have increased.

Bangladesh
The health care system of Bangladesh faces acute shortage of required number of
human resources in the form of physicians, medical technologists, nurses and other
paramedical staff (Ahmed et al., 2011). According to Mahmood (2012) other related
HRM problems such as absenteeism, poor service delivery, inefficiency and corrup-
tion are also deep rooted in the public health care sector of the country. Owing to
these problems, a large portion of the population depends on private and informal
health care systems for their health issues (Khan, Grbner & Krmer, 2012).

India
The main challenges faced by the public hospitals in India are deficient infra-
structure, deficient manpower, unmanageable patient load, equivocal quality of
services and high out-of-pocket expenditure (Bajpai, 2014). There is unwill-
ingness of doctors and other health personnel to serve in rural areas, while in
urban areas there is disproportional supply of health care professionals between
private and public sectors. Lured by better wages and working conditions,
health care professionals prefer to work in the private sector leaving the public
sector health organizations with insufficient and underqualified health care
workers (Labont et al., 2015).
Raut and Mukhopadhyay (2007) examined human resource for health
practices in two states of India (i.e., Madhya Pradesh and Gujarat). Findings
show that there was no formal mechanism in place for recruitment and selection.
78 South Asian Journal of Human Resources Management 3(1)

In spite of having large workforce, the directorates of both states did not have a
specialized HR department. The study further showed that there was immense
dissatisfaction among health care professionals regarding compensation, benefits
and promotion procedure. Junior doctors suffered from lack of training facilities.
There was hardly any system of induction training for medical officers of the
primary health centres when they joined the government health system.
Further, studies suggest that the human aspect of care is missing in most
training programmes. Medical colleges increasingly focus on high-technology
and private medicine rather than on community oriented primary care (Rao
et al., 2011). Nursing and paramedical education have deteriorated due to lack of
resources, leadership and rapid expansion without attention to quality.

Pakistan
There are 74 medical colleges and 32 dental colleges in Pakistan which produce
9,000 doctors and 2,000 dentists annually (Sheikh & Sabatinelle, 2011). There are
8 physicians for every 10,000 people in Pakistan as compared to 24 in the USA
and 25 in UK (OECD, 2009). In the urban areas, this ratio is 14.5, whereas it
is 3.6 in the rural areas (World Health Organization, 2012). This health workforce
is likely to remain stagnant or may get depleted as these medical professionals
consider migrating out of Pakistan for better opportunities and job security in
other countries (Safdar et al., 2010).
Hafeez et al. (2010) conducted a cross-sectional survey on Pakistans Human
Resource for Health Assessment with the help of World Health Organization
(WHO). The results for a sample size of 3,549 health care professionals show
that the satisfaction of private health care sector workforce is better than that of
public health care workforce. The employees in public health sector are dis-
satisfied because of inadequate salaries, lack of career growth and poor work
environment. The major problem in recruitment and selection is that majority
of the posts are vacant due to lack of trained staff or because of procedural
delays in appointing staff. Therefore, the public health care system only pro-
vides out-patient services, and even that is not up to the desirable standards of
health care. According to Mavalanka (2003), the major reasons for these pro-
blems are due to government and bureaucratic influence in hiring, delayed
appointments of health care staff and a general lack of accountability in the
public system.
As the pilot study reported in this article relates to Punjab province in Pakistan,
we give below a brief overview of the health care sector in this region.
With the average population of 396 persons per square kilometres, Punjab is
the most populous province of Pakistan. There are three ways in which doctors
are appointed in the public health sector in the province of Punjab. First, Punjab
Public Service Commission hires doctors in grade 17 after conducting written
exams and interviews. Second, the hospitals also hire doctors to fill urgent
vacancies. Third, the Punjab government also appoints doctors on contract or on
ad hoc basis.
Suhail and Azhar 79

A report prepared by Cyan and Young (2009) on Punjab Governments Efficiency

Improvement Program shows that a large share of the contract employees was
recruited at entry-level positions. Among the survey participants, 95.12 per cent of
the individuals were employed on fixed term and had not been promoted to senior
positions. In addition, it was also found that contract employees were less motivated
as compared with regular employees as the former had not been given benefits as
provided to the latter. There are no provisions for leave, pension and other benefits
for contract employees contributing to their dissatisfaction.
At the turn of new millennium, Punjab faced enormous challenges about its
human resources for health. There are 36 districts in Punjab and the doctors are
unevenly distributed in each district (Hafeez et al., 2010). Some of the health faci-
lities (especially in rural areas) have been closed in certain districts because there is
no one to run them. Doctors in Punjab are highly dissatisfied with their contractual
appointments, inconsistent promotion mechanism and low pay scale (Khan, 2007).
Current human resources for health policies are not responsive to the needs of the
population as there is no standard human resource development plan (Human
Resource for health in Public sector in Pakistan, 2006).

Pilot Study on HRM in Public Health Sector of Pakistan

The author conducted a pilot study to provide some empirical data about human
resource practices in the health care sector in Pakistan. Data was collected from
a sample of 20 respondents comprising doctors, hospital administrators and
government officials working in public health care institutions in Lahore, one of
the largest metropolitan cities located in the Punjab province of Pakistan.
Purposive sampling technique was used for the selection of respondents based
on minimum employment period of 3 years for junior doctors, 10 years for
senior doctors, 5 years for hospital administration staff and 2 years for Health
Secretariat staff. Semi-structured interviews were conducted with the respon-
dents. The interview questions covered a wide range of issues pertaining to
human resources for health, including recruitment, training, compensation,
career prospects, working conditions, health care reforms and overall HRM
policies and procedures.
Thematic analysis approach was employed for understanding and inter-
preting qualitative data (Braun & Clarke, 2006). Statements from the transcrip-
tions are presented as evidence to illustrate the actual reality of the phenomenon
using logical inferences from the data collected. Data was collected from many
sources providing different perspectives. First, doctors were interviewed from
different public hospitals in Lahore. Later, Hospital Administration and senior
management staff were interviewed to obtain in-depth information about human
resource management issues in the health sector.
The major findings from the thematic analysis of the data collected for this
study are provided below:
While recruitment through public service commission is favourably viewed
by majority of the respondents, there is considerable dissatisfaction with contract
80 South Asian Journal of Human Resources Management 3(1)

or ad hoc appointments. Contract employees are less motivated due to lack of

long-term career incentives. The major flaw identified from the analysis was
Sifarish Culture. Sifarish culture is generally described as hiring or promoting
a person based on personal references and contacts rather than on merit. In other
words, placements and other favours granted to employees based on nepotism are
generally referred as sifarish culture. The existence of sifarish culture is
evident in every institution of Pakistan but public sector is especially notorious
for it. Literature suggests that there is strictly hierarchical, centralized and corrupt
system along with high level of gender discrimination in administrative roles in
public sector organizations in Pakistan (Islam, 2004).
Respondents in our study repeatedly referred to the existence and detrimental
effects of sifarish culture. For example, according to a Professor in a medical
hospital, There are 100 seats for 3,000 applicants and these seats are allocated
only to the people who have some reference or Sifarish. To address this problem,
a Registrar suggested that the recruitment criterion should be made more
transparent and standardized.
Our analysis showed that a major flaw in the workforce management is non-
availability of seats that hindered further career progression. Most of the doctors
work honorary during their House job and Postgraduate training which makes it
difficult for them to support themselves and their families. As pointed out by a
post-graduate trainee, due to lack of seats, the government appoints doctors
on contract and on ad hoc (basis). This was supported by a Deputy Medical
Superintendent:

I have been working on contract for 17 years and have not been promoted due to lack
of available seats. Many doctors are working on the same pay scale in which they were
inducted 20 or more years ago there is no time bound promotion.

The study also revealed that government trainee doctors are underpaid and
overburdened with work. They typically have very long working hours, without
appropriate facilities, and inadequate security conditions. As pointed out by a
medial superintendent, A young doctor is treated like a donkey and he is expected
to do as much work as he can. However, there are fixed timings for the senior
cadres, such as professors.
The House Officers, Post Graduate Trainees and Medical Officers complained
about low pay. The families of these doctors are not entitled for health benefits.
The promotion structure for doctors is defined on paper but it is not implemented
properly. Unavailability of seats and vacancy-based promotions are the major
flaws of promotion process. As pointed out by one of the respondents, in Punjab,
the government has not set up any new hospital since 1996. This has made it
impossible to implement time-bound promotions. As a result, unlike employees in
other public sector agencies, health care employees do not get promotions and
higher salary despite long years of service. The following statements are represen-
tative of the bitterness among respondents on this aspect:

If we compare the doctors with civil servants, the doctors have higher education,
tough training, long working hours and much more sensitive job responsibilities.
Suhail and Azhar 81

However their salaries and benefits are less as compared to civil servants. (Professor
of Cardiology)

Salary of a young doctor has no comparison with other government servants. The basic
salary may be equal but the incentives and facilities which bureaucrats get have no
comparison with what is offered to the doctors. (Professor of Surgery)

Further, respondents reported that the major causes behind human resource
management problems in public health sector were low priority given to this
sector and a lack of will from the government to improve HRM in the health
care sector. Though doctors are administrative head of the hospitals, they are
powerless and subservient to the bureaucracy in all matters. Pointing to these
administrative flaws, a Professor of Surgery stated:

Bureaucracy runs the entire public health care system. Although there are written rules
and procedures, the administration is reluctant to implement them properly. Both the
government and bureaucracy are reluctant to bring human resource reforms in health
sector. In fact, health has never been a priority of any government.

This view was further supported by an Assistant Professor of Surgery: Pakistan

has a culture of feudalism. Bureaucrats have always been enjoying control over
the medical community and other public sectors. (As a result) doctors have to go
to the bureaucrats for every petty issue.

Discussion and Conclusions

Our pilot study on the health sector of Pakistan provides further support to
existing literature (e.g., Abid, 2012; Islam, 2004; Khan, 2007). The study reveals
that doctors in the Punjab province of Pakistan are highly dissatisfied with their
contractual appointments, inconsistent promotion mechanism and low pay
scale. Most of the doctors work honorary during their house job and
Postgraduate training due to lack of financial resources and unavailability of
seats. Salaries of junior doctors are woefully inadequate even to fulfil their
basic needs. Doctors have a defined eight working hours per day; however, they
work much more than eight hours without compensation. The promotion policy
is not implemented properly due to lack of sufficient seats and vacancy-based
promotion system.
The practical implication of this research is that the recruitment and selection
process must strictly follow the set rules and regulation of Punjab Public Service
Commission. Structured training must be provided in both public and private
hospitals. Salary of junior doctors should be equivalent to other public sector
organizations, so that they do not feel discriminated. Regular promotion avenues
need to be created for the doctors according to the written rules of Public Service
Commission.
This article adds to the growing literature on the human resources for
health, especially in South Asian countries by extending our understanding of
82 South Asian Journal of Human Resources Management 3(1)

the key issues and challenges across the region. It underscores the critical
importance of human resource for health as one of the essential pillars of the
health care system. For the successful implementation of health interventions,
adequate numbers, quality, well-being and satisfaction of health work force
are very important.
In order to further understand and address the complex issues of health care
delivery in the public sector of South Asian countries, longitudinal and multi-
methods studies with larger sample size and broader coverage of population
should be conducted to make an assessment of the changes and new opportunities
provided in the public health sector. This study was conducted in the public health
care organizations only. A study of both the public and the private health care
sectors will provide us with a holistic picture of health care services and institu-
tions in South Asia. This will not only help us compare differences in the two
sectors but also show how both the public and the private sectors could comple-
ment and supplement services provided to health care clients.

Acknowledgements
The authors would like to acknowledge the extensive revisions and improvements made
to the earlier versions of the paper by Professor Mohan Thite and Professor Sudhir Saha
and thank them for their editorial support. We would also like to acknowledge the help
of Suhail Ahmad, Past District Governor, Rotary International 3270, and Atiqa Maryam,
PhD scholar at Department of Management, Faculty of Business and Economics, Monash
University, Australia, for their contribution to this article.

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