Determinants of workforce availability and performance of specialists and general duty medical officers in Rajasthan, India

Statement of the Problem The availability of adequate number of people to man and manage the programmes alone may not necessarily lead to successful implementation of programmes. The health systems need to ensure their competencies and commitment to make health programmes a success. One of the biggest challenges has been extremely poor capacity building at every rung of health care. The situation is further worsened by a shortfall in the human resource at every level, especially for specialists. There also has been quite a mismatch in the number of medical-officers and specialist medical officers posted at a place and the actual requirement at the place. Methodology In order to study and understand the issues for optimal workforce management and human resource development for addressing the HR issues a study on determinants of workforce availability and performance of specialists and general duty medical officers was taken up  in association with the NHSRC. This included assessing the gaps between the services expected and those provided at a facility level, along with analyzing the recruitment, compensation, transfer and training policy of medical officers and specialists. On the basis of discussions with the NHSRC and the State Health Department, four districts were selected on the basis of the Human Development Index (HDI). The institutions surveyed were District Hospital, Sub-Divisional Hospital, Community Health Centres and Primary Health Centres. In addition to an institutional survey, 40 doctors (30 general duty medical officers and 10 specialists) were also interviewed on a pre-designed format. The findings were discussed with the state government and accordingly finalized. Findings Most of the facilities and the various essential equipments were available at all the district hospitals but at the CHCs, some exceptions were found. At the PHCs, the equipments were insufficiently available. It was found that one-fifth of the sample doctors had completed 25 years of service. It also came to the fore that out of all the doctors, approximately 18% were lady doctors. A large number of doctors employed in the public system have qualified from rural background and an inclination towards specialization was indicated. It was found that the medical personnel are not being treated equally in terms of transfers. A reasonably high degree of dissatisfaction was found among the doctors in terms of their remuneration. Only 11.25% doctors got promoted within 5 to 10 years of their joining state services. Regarding the perception on availability of work space, instruments and drugs, supporting staff, logistics and community support, the specialists were found to be satisfied but in case of generalists, only 64% are satisfied. The study concludes that posting, perception regarding specialization, hierarchical satisfaction, quality of facilities and services, support from supervisors, performance appraisal and HR policy are the determinants for the workforce availability. Discussions The Availability of Doctors at the peripheral facilities is an index of functioning of health department and failure to make the services of Doctors consistently available at peripheral facilities let down the image of health services delivery. What is generally prevalent in Rajasthan is not only a gap between the required number of posts and the sanctioned posts but also a shortfall between the sanctioned posts and of those which had been filled up. There is an urgent need to create a strong “Human Resource Cell” in the Directorate.  This cell should initiate the development of an HR Policy which may set transparency in deployment, transfers and promotions of Doctors in the field. It is felt that the state government should formulate a detailed set of guidelines for postings and transfers of Doctors in the Medical, Health and FW Department. Increased and improved facilities must be provided to the doctors so that they can be improved in their periphery and the quality of services must be improved. Sustainable retention demands availability of residential accommodation. This would also call for placing sufficient nursing staff, making laboratory technicians available, equipping with sufficient material like syringes, needles, cold chain equipments and surgical material.


Introduction
The availability of adequate number of health professionals to manage health programmes alone may not necessarily lead to their successful implementation. The competencies and commitment of these professionals also need to be ensured. One of the biggest challenges, in this regard, has been poor capacity building at every rung of health care. The situation is further worsened by a shortfall in the human resource, especially specialists. There has often been a mismatch between the number of required and sanctioned posts and also between sanctioned and actual number of medical-officers and specialists posted in a health facility.

Methods
In order to study and understand the issues of optimal workforce management and human resource development, a study on determinants of workforce availability and performance of specialists and general duty medical officers was conducted in Rajasthan. The study was done in association with the National Health Systems Resource Centre. The study aimed at assessing the gaps between the services expected and those provided at a facility level, along with analyzing the recruitment, compensation, transfer and training policy of medical officers and specialists.
On the basis of discussions with the National Health System Resource Centre and the State Health Department, four districts were selected on the basis of the Human Development Index (HDI). The institutions surveyed were District Hospital, Sub-Divisional Hospital, Community Health Centres and Primary Health Centres. In addition to an institutional survey, 40 doctors (30 general duty medical officers and 10 specialists) were also interviewed on a pre-designed format. The findings were validated through discussions with the state government.

Results
It was found that one-fifth of the sample doctors had completed 25 years of service. Of all the doctors in the sample, 18% were lady doctors. A large number of doctors employed in the public health system hailed from rural background and expressed an inclination towards receiving specialized training. It was found that the medical personnel were not being treated equally in terms of transfers. A reasonably high degree of dissatisfaction was found among the doctors in terms of their remuneration. Only 11.25% doctors got promoted within 5 to 10 years of their joining the state services.
Regarding the perception on availability of work space, instruments, drugs, supporting staff, logistics and community support, the specialists were found to be satisfied but in case of generalists, only 64% are satisfied.
The survey showed that most of the infrastructural facilities including essential equipments were available in all the district hospitals and community health centres, barring a few in the latter. However, in the primary health centres, such facilities were not sufficiently available.
The results indicate that posting, perception regarding specialization, hierarchical satisfaction, quality of facilities and services and human resource policy are the determinants for the workforce availability.

Discussions
The results of the study call for a need for better planning and management of human resource policy. Such planning should ensure transparency in deployment, transfers and promotions of doctors in the field. Increased and improved facilities should be made available to doctors in peripheral health institutions. Specifically, this would call for placing sufficient nursing staff, making laboratory technicians available, equipping with sufficient material like syringes, needles, cold chain equipments and surgical material.

Funding statement
The study was funded by the National Health Systems Resource Centre, New Delhi.