ADALYA JOURNAL ISSN NO: 1301-2746

HUMAN RESOURCES MANAGEMENT PRACTICES IN HEALTH CARE SYSTEMS IN INDIA

DR.W.RAJA SOLOMON
ASSISTANT PROFESSOR OF CO-OPERATION
T.M.B.L. COLLEGE
PORAYAR-609307
NAGAI DISTRICT
TAMIL NADU

ABSTRACT

The purpose of this paper is to show how human resource management practices are linked
to professional and organizational commitment and its implications on health care sectors
and its reforms. They focus on making the health systems responsive through
strengthening financial systems, ensuring local participation and public private
partnerships, and autonomy of health facilities. The reform process, among other things,
intrinsically makes some fundamental assumptions some of which are as follows: high
organisational commitment of health care providers, high professional commitment of
health care providers, and adequate skills of healthcare providers. This paper examines
human resource management practices in Health care systems in India. Since development
oriented HR practices (HRD) are powerful tools to commit people working in health sector
to enhance the quality of care, we believe that health sector reforms will have to
concentrate on human resource issues and practices more than ever before in near future.

Keywords: HRM, Health Care Reform, Public-Private partnerships, financial systems.

INTRODUCTION

Human resources are often thought to be just another tool on par with financial or physical
resources. However, we believe that the development of the health workforce is a crucial part of
the health policy development process. The quality of health service delivery depends to a large
extent on the ability of Human Resource Managers to establish, develop and sustain an adequate
supply of skilled health workers who are motivated to provide high-quality health services.
Moreover, health workers should be present in sufficient numbers and appropriately allocated

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across different occupations and geographical regions. This requires the flexible use managerial
and problem-solving skills tailored for the health sector, as well as the implementation of Human
Resources Development policies. The goal of the HR management is to prepare human resource
professionals who work in the Health Sector to deal with the complexities and challenges of
managing today's workforce.

Problems in the area of managing Human Resource in the context of providing Health Services:

 These will include misdistribution of staff.

 Lack of resources to recruit.

 Train and support health workers among others.

Human Resources Management

Human Resource Management (HRM) is a planned approach to managing people effectively for
performance. It aims to establish a more open, flexible and caring management style so that staff
will be motivated, developed and managed in a way that they can give of their best to support
departments missions. Good HRM practices are instrumental in helping achieve departmental
objectives and enhance productivity. For the purpose of sharing experience and providing
reference in launching HRM initiatives, we have gathered in this booklet some good examples
introduced by departments.

HRM Good Practice Indicators/Initiative

Articulation of Vision, Mission and Values (VMV):

 Sense of purpose reflected in the department's VMV

 Elements of service culture captured in the department's VMV

 Involving staff in discussions and meetings to generate ownership

 Management commitment shown in resource allocation in achieving department's VMV

 Clear and effective communication programme in place to promote VMV

 Offering training to develop skills and behaviour in living the VMV

 Customer-focused culture reflected in departmental policies, procedures and practices

 Measurement system in place to track performance improvement

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 Demonstration of understanding of VMV and observable behaviour

Drawing up HRM Plan:

 The HRM Plan developed under the leadership of the senior management

 Department's strategic direction clearly articulated by the top team

 Debate and endorsement of strategic and ongoing HR issues by the top team

 HR actions to address HR issues debated, approved and prioritized by the top team

 Department's VMV revisited as part of the strategic review process

 An environment scan conducted to identify strategic HR issues

 Staff's input on ongoing HR issues sought through, for example, staff opinion survey,
focus group meetings, interviews, etc

 Specific objectives and sets of actions clearly spelt out in the HRM Plan and clearly
explained as to how each will help address certain HR issues in achieving departmental
Vision and Mission,

 Responsibilities to implement the HRM Plan clearly assigned

 Realistic implementation plan with adequate resource support,

 Review system in place

 Development of a human resource information system

Manpower Planning:

 A systematic information system in place

 A clear plan with action programmes in place to bridge supply and demand gaps,
succession gaps, and competency gaps

 Posting policy published and career paths made known to staff

 Competency profiles of key job grades developed and made known to staff

 Information derived from succession plan fed into training and development plans for
individual officers

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 Career interviews arranged for staff to gauge staff aspiration and offer career guidance
offered

 Regular review and update of the plan and competency profiles.

Performance Management System:

 Senior management's support and commitment in allocating the required resources and
according priority to this function

 Objective setting starting from the top and systematically cascaded and linked to the
departmental objectives

 All appraisers have been properly trained on PMS good practices and the required skills

 Mechanisms to ensure openness, fairness and objectivity of the appraisal process

 The system being competency-based to help identify training and development needs for
staff and their potential for taking up higher responsibilities

 Information gathered from the performance cycle linked to other human resource
functions

 Staff recognizing that performance management is a joint responsibility of the appraisee

and the supervisor

 Staff performance management being an ongoing process, not an annual event

 Review of the performance management system

Training and Development:

 Individual and departmental Training and Development plans in place and strategically
linked to departmental strategic objectives

 A diverse set of training and development activities (e.g. overseas attachment, overseas
training, secretariat attachment)

 Training and Development integrated with PMS and Succession Plan / Manpower Plan

 Timely induction training provided to all new staff with management training to be
provided systematically afterwards

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 Regular review of the Training and Development policies

 Evidence of improvement in work quality and efficiency,

 Managers' positive feedback on learners' performance

 Training courses rated highly in quality and relevance

Service Quality Enhancement:

 Customer focused culture as reflected in programmes, policies, procedures and practices

 Productivity and efficiency enhanced

 Staff taking more initiative to serve

 Measurement in place to track performance improvement

 Mode of operation being service oriented

 Public image enhanced

Health Care Systems in India

Health care systems are designed to meet the health care needs of target populations. There are a
wide variety of health care systems around the world. In some countries, health care system
planning is distributed among market participants, whereas in others planning is made more
centrally among governments, trade unions, charities, religious, or other coordinated bodies to
deliver planned health care services targeted to the populations they serve. However, health care
planning has often been evolutionary rather than revolutionary.

Healthcare is one of India’s largest sectors, in terms of revenue and employment, and the sector
is expanding rapidly. During the 1990s, Indian healthcare grew at a compound annual rate of
16%. Today the total value of the sector is more than $34 billion. This translates to $34 per
capita, or roughly 6% of GDP. By 2012, India’s healthcare sector is projected to grow to nearly
$40 billion. The private sector accounts for more than 80% of total healthcare spending in India.
Unless there is a decline in the combined federal and state government deficit, which currently
stands at roughly 9%, the opportunity for significantly higher public health spending will be
limited.

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One driver of growth in the healthcare sector is India’s booming population, currently 1.1 billion
and increasing at a 2% annual rate. By 2030, India is expected to surpass China as the world’s
most populous nation. By 2050, the population is projected to reach 1.6 billion. This population
increase is due in part to a decline in infant mortality, the result of better healthcare facilities and
the government’s emphasis on eradicating diseases such as hepatitis and polio among infants. In
addition, life expectancy is rapidly approaching the levels of the western world. By 2025, an
estimated 189 million Indians will be at least 60 years of age—triple the number in 2004, thanks
to greater affluence and better hygiene. The growing elderly population will place an enormous
burden on India’s healthcare infrastructure.

The Indian economy, estimated at roughly $1 trillion, and is growing in tandem with the
population. Goldman Sachs predicts that the Indian economy will expand by at least 5% annually
for the next 45 years (see chart), and that it will be the only emerging economy to maintain such
a robust pace of growth. Expanding middle class India traditionally has been a rural, agrarian
economy. Nearly three quarters of the population still lives in rural areas, and as of 2004, an
estimated 27.5% of Indians were living below the national poverty line. Some 300 million people
in India live on less than a dollar a day, and more than 50% of all children are malnourished.
Middle Class % of entire Population

1998-99 44.92

2001-02 50.53

2009-10(estimate) 62.95

Source: CRIS Infac, 2005

Another factor driving the growth of India’s healthcare sector is a rise in both infectious and
chronic degenerative diseases. While ailments such as poliomyelitis, leprosy, and neonatal
tetanus will soon be eliminated, some communicable diseases once thought to be under control,
such as dengue fever, viral hepatitis, tuberculosis, malaria, and pneumonia, have returned in
force or have developed a stubborn resistance to drugs. This troubling trend can be attributed in
part to substandard housing, inadequate water, sewage and waste management systems, a
crumbling public health infrastructure, and increased air travel.

In the greater India, the hospitals are run by government, charitable trusts and by private
organizations. The government hospitals in rural areas are called the (PHC)s primary health
centre. Major hospitals are located in district head quarters or major cities. Apart from the

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modern system of medicine, traditional and indigenous medicinal systems like Ayurvedic and
Unani systems are in practice throughout the country. The Modern System of Medicine is
regulated by the Medical Council of India, whereas the Alternative systems recognised by
Government of India are regulated by the Department of AYUSH (an acronym for Ayurveda,
Yunani, Siddha & Homeopathy) under the Ministry of Health, Government of India. PHCs are
non-existent in most places, due to poor pay and scarcity of resources. Patients generally prefer
private health clinics. These days some of the major corporate hospitals are attracting patients
from neighboring countries such as Pakistan, countries in the Middle East and some European
countries by providing quality treatment at low cost. In 2005, India spent 5% of GDP on health
care, or US$36 per capita. Of that, approximately 19% was government expenditure but now the
situation is changing.

HUMAN RESOURCES MANAGEMENT PRACTICES IN HEALTH CARE SYSTEMS

Human resources are often thought to be just another tool on par with financial or physical
resources. However, we believe that the development of the health workforce is a crucial part of
the health policy development process. The quality of health service delivery depends to a large
extent on the ability of Human Resource Managers to establish, develop and sustain an adequate
supply of skilled health workers who are motivated to provide high-quality health services.
Moreover, health workers should be present in sufficient numbers and appropriately allocated
across different occupations and geographical regions. This requires the flexible use managerial
and problem-solving skills tailored for the health sector, as well as the implementation of Human
Resources Development policies. The goal of the HR management training seminar is to prepare
human resource professionals who work in the Health Sector to deal with the complexities and
challenges of managing today's workforce.

Human resources, when pertaining to health care, can be defined as the different kinds of clinical
and non-clinical staff responsible for public and individual health intervention. As arguably the
most important of the health system inputs, the performance and the benefits the system can
deliver depend largely upon the knowledge, skills and motivation of those individuals
responsible for delivering health services. As well as the balance between the human and
physical resources, it is also essential to maintain an appropriate mix between the different types
of health promoters and caregivers to ensure the system's success. Due to their obvious and

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important differences, it is imperative that human capital is handled and managed very
differently from physical capital.

Human resource professionals understand the importance of developing a culture that can enable
an organization to meet its challenges. They understand how communities of practice can form
around common goals and interests, and the importance of aligning these to the goals and
interests of the organization. Given the significant changes that globalization of health care can
introduce, it is important that human resources professionals be involved at the highest level of
strategic planning, and not merely be positioned at the more functional, managerial levels. By
being actively involved at the strategic levels, they can ensure that the HR issues are raised,
considered and properly addressed. Therefore, human resources professionals will also need to
have an understanding not only of the HR area, but of all areas of an organization, including
strategy, finance, operations, etc. This need will have an impact on the educational preparation as
well as the possible need to have work experience in these other functional areas.

When examining global health care systems, it is both useful and important to explore the impact
of human resources on health sector reform. While the specific health care reform process varies
by country, some trends can be identified. Three of the main trends include efficiency, equity and
quality objectives. Various human resources initiatives have been employed in an attempt to
increase efficiency. Outsourcing of services has been used to convert fixed labor expenditures
into variable costs as a means of improving efficiency. Contracting- out, performance contracts
and internal contracting are also examples of measures employed .Many human resources
initiatives for health sector reform also include attempts to increase equity or fairness. Strategies
aimed at promoting equity in relation to needs require more systematic planning of health
services. Some of these strategies include the introduction of financial protection mechanisms,
the targeting of specific needs and groups, and re-deployment services. One of the goals of
human resource professionals must be to use these and other measures to increase equity in their
countries.

Examination of the relationship between health care and human resources management reveals
three major problems: rapidly escalating health care costs, a growing number of Indians without
health care coverage and an epidemic regarding the standard of care. These problems each have
significant consequences for the well-being of individual Indians and will have devastating
affects on the physical and psychological health and well-being of the nation as a whole.

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The physical health of many Indians is compromised because these factors make it difficult for
individuals to receive proper consultation and treatment from physicians. This can have
detrimental effects on the mental state of the patient and can lead to large amounts of undue
stress, which may further aggravate the physical situation.

Examining various case studies through secondary data approaches makes it evident that human
resources management can and does play an essential role in the health care system. The
practices, policies and philosophies of human resources professionals are imperative in
developing and improving Indian health care systems.

Developing countries also face the problem of investing in the training of health care
professionals, thus using precious national resources, but losing many of their trained
professionals to other areas of the world that are able to provide them with more opportunities
and benefits. Human resources professionals face the task of attempting to find and/or retain
workers in areas that are most severely affected by the loss of valuable workers.

Human resources management plays a significant role in the distribution of health care workers.
With those in more developed countries offering amenities otherwise unavailable, chances are
that professionals will be more enticed to relocate, thus increasing shortages in all areas of health
care. Due to an increase in globalization, resources are now being shared more than ever, though
not always distributed equally.

HRM initiatives in Health Care Sector:

In taking HRM forward, we need a strategic and integrated approach in managing people
effectively for performance. In taking a strategic and integrated approach, HRM is linked to the
department's strategic direction in a systematic way. Such an approach is often reflected in the
following practices - clarifying a department's strategic direction by way of articulating its
Vision, Mission and Values statement; establishing the strategic linkage and integrating HR
programmes through a HRM Plan; and projecting its short to long term human resource needs
through a Manpower Plan. At the same time, all managers must adopt a more open, flexible and
caring style in managing their staff. Such an approach is reflected in a number of ways. The three
most common practices are - managing people effectively for performance through an open
Performance Management System (PMS) that will call for individual objectives tied to
departmental objectives, regular coaching, and developing staff on the job; enhancing staff's

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competencies to perform better through effectively training people to achieve departmental

objectives and results; and delivering quality service through training and engaging staff in
developing a service culture in addition to business process re-engineering and work
streamlining.

Building HR capacity for health reform

• It is important to recognise the distinctive features and historical legacy of HR management in

the health sector if reform is to be effective.

• HR issues need to be considered at an early stage in health care reform and not be an ‘add on’.

• Health care reformers have frequently been over-optimistic about what can be achieved without
the necessary resources, human or financial, to make it happen. The commitment of senior policy
makers to the HR agenda is vital otherwise it won’t be taken seriously.

•The process of health sector reform – who is involved, the sequencing of developments, and the
institutional mechanisms to support reform require as much consideration as the content of
reform.

• Human resources for health work is frequently focused narrowly on workforce planning and
training, effective HR is characterised by a much wider agenda.

• Developing an effective HR strategy requires ensuring that ownership, external fit and internal
fit issues are addressed.

• The focus on reforming pay systems, which has yielded limited results, has diverted attention
from the important issue of non-pay rewards, work re-organisation and questions of performance
management.

The HR function

• Developing HR capability requires investing in the training and development of both HR

specialists and line managers/professionals with staff management responsibilities.

• It is vital that any investment in specialist HR capacity evaluates the different ways to deliver
the HR function. Even if outsourcing is rejected the in-house HR function should be properly
audited and monitored.

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• To be effective the HR function must develop both an operational and a strategic HR capacity.
The HR function should not try to run before it can walk – robust HR policies and practices
should be developed before attempts at devolution or more radical changes in employment
practices should be pursued.

ISSUES PERTAINING TO HUMAN RESOURCES IN HEALTH CARE:

When examining health care systems in a global context, many general human resources issues
and questions arise. Some of the issues of greatest relevance that will be discussed in further
detail include the size, composition and distribution of the health care workforce, workforce
training issues, the migration of health workers, the level of economic development in a
particular country and socio-demographic, geographical and cultural factors. The variation of
size, distribution and composition within a county's health care workforce is of great concern.
For example, the number of health workers available in a country is a key indicator of that
country's capacity to provide delivery and interventions. Factors to consider when determining
the demand for health services in a particular country include cultural characteristics, socio-
demographic characteristics and economic factors.

Workforce training is another important issue. It is essential that human resources personnel
consider the composition of the health workforce in terms of both skill categories and training
levels .New options for the education and in-service training of health care workers are required
to ensure that the workforce is aware of and prepared to meet a particular country's present and
future needs. A properly trained and competent workforce is essential to any successful health
care system.

The migration of health care workers is an issue that arises when examining global health care
systems. Research suggests that the movement of health care professionals closely follows the
migration pattern of all professionals in that the internal movement of the workforce to urban
areas is common to all countries. Workforce mobility can create additional imbalances that
require better workforce planning, attention to issues of pay and other rewards and improved
overall management of the workforce. In addition to salary incentives, developing countries use
other strategies such as housing, infrastructure and opportunities for job rotation to recruit and
retain health professionals, since many health workers in developing countries are underpaid,
poorly motivated and very dissatisfied. The migration of health workers is an important human
resources issue that must be carefully measured and monitored.

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Another issue that arises when examining global health care systems is a country's level of
economic development. There is evidence of a significant positive correlation between the level
of economic development in a country and its number of human resources for health. Countries
with higher gross domestic product (GDP) per capita spend more on health care than countries
with lower GDP and they tend to have larger health workforce. This is an important factor to
consider when examining and attempting implementing solutions to problems in health care
systems in developing countries.

Socio-demographic elements such as age distribution of the population also play a key role in a
country's health care system. An ageing population leads to an increase in demand for health
services and health personnel. An ageing population within the health care system itself also has
important implications: additional training of younger workers will be required to fill the
positions of the large number of health care workers that will be retiring.

There are also ethical considerations when examining the practice of recruiting health care
professionals, particularly if they are recruited from regions or countries where health care
shortages already exist. The rights of individuals to move as they see fit may need to be balanced
against the idea of the greater good of those left behind.

Due to the shortages, it has been found the level of health service in rural or poor areas has
decreased, leading to lower quality and productivity of health services, closure of hospital wards,
increased waiting times, reduced numbers of available beds for inpatients, diversion of
emergency department patients and underuse of remaining personnel or substitution with persons
lacking the required skills for performing critical interventions

It is also essential that cultural and geographical factors be considered when examining global
health care systems. Geographical factors such as climate or topography influence the ability to
deliver health services; the cultural and political values of a particular nation can also affect the
demand and supply of human resources for health. The above are just some of the many issues
that must be addressed when examining global health care and human resources that merit
further consideration and study.
Human resources in health sector reform also seek to improve the quality of services and
patients' satisfaction. Health care quality is generally defined in two ways: technical quality and
socio-cultural quality. Technical quality refers to the impact that the health services available can

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have on the health conditions of a population. Socio-cultural quality measures the degree of
acceptability of services and the ability to satisfy patients' expectations.

Human resource professionals face many obstacles in their attempt to deliver high-quality health
care to citizens. Some of these constraints include budgets, lack of congruence between different
stakeholders' values, absenteeism rates, high rates of turnover and low morale of health
personnel. Better use of the spectrum of health care providers and better coordination of patient
services through interdisciplinary teamwork have been recommended as part of health sector
reform .Since all health care is ultimately delivered by people, effective human resources
management will play a vital role in the success of health sector reform.

CONCLUSION & SUGGESTIONS

Human resources are often thought to be just another tool on par with financial or physical
resources. However, we believe that the development of the health workforce is a crucial part of
the health policy development process. The quality of health service delivery depends to a large
extent on the ability of Human Resource Managers to establish, develop and sustain an adequate
supply of skilled health workers who are motivated to provide high-quality health services. We
have found that the relationship between human resources management and health care is
extremely complex, particularly when examined from a global perspective.

In developing countries, the migration of health workers to more affluent regions and/or
countries is a major problem, resulting in citizens in rural areas of developing countries
experiencing difficulties receiving adequate medical care. Since all health care is ultimately
delivered by and to people, a strong understanding of the human resources management issues is
required to ensure the success of any health care program. Further human resources initiatives
are required in many health care systems, and more extensive research must be conducted to
bring about new human resources policies and practices that will benefit individuals around the
world.

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World Health Organization: World Health Report 2003: Shaping theFuture. Geneva 2003
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Website References:

http://www.cdc.gov/ncidod/dvbid/dengue/

http://www.human-resources-health.com/content/2/1/3

Emerging Market Report: Health in India 2007 www.pwc.com/globalhealthcare

en.wikipedia.org/wiki/Health_care_system

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