Srinivas Nallala

A study of organizational versus individual needs related to recruitment, deployment and promotion of doctors working in the government health system in Odisha state, India

BackgroundAn effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented.MethodsWe undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies.ResultsDespite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies.ConclusionsAdequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

Assessment of factors influencing retention of health workforce in rural and remote areas of Odisha, India

Background: The scarcity of qualified health workers in rural areas is directly affecting delivery of health services and their quality. Diverse interventions have been instituted by central and state governments to attract health workers to rural areas and to enhance the retention of qualified workers. However the reasons for not willing to remain in rural and remote areas are still poorly understood. This study explores factors influencing health workers retention in rural and remote Odisha. Methods: We carried out the study in six districts of Odisha selected randomly from three geographic and administrative regions of the state. We used a mixed methods approach to study this question using both quantitative and qualitative data. A total of 226 semi-structured interviews were conducted with doctors, nurses, pharmacists, multipurpose health workers (MPHW) and laboratory technicians. A multi stage stratified random sampling was used for selecting study participants working at sub centers, primary health centers and community health centers. Results: We found that excepting few districts, the ratio of MPHW (F) to population is around 5000 in the state which is at par with the prescribed norms. The ratio of government allopathic doctor, laboratory technician and staff nurses to population are: 13000, 40000 and 15000, respectively. Majority of health staffs perceive “strong personal will to serve people”, “physical infrastructure”, “training opportunities”, “support by seniors”, “good schooling for their children” and “promotion avenues after certain years of rural service” is very important for continuing to work in rural and remote areas. Most of the participants were found to be satisfied with the support they received from their seniors and the local community, and respect and trust of their patients.The major dissatisfiers for working in rural areas included existing promotional avenues after rural service, physical infrastructure, and schooling facility for their children. Five primary reasons ranked in order of priority cited by the study participants for continuing at the same place were, namely, permanent government service, pension facility, social service, source of regular income and job satisfaction Discussion/Recommendations: Professional growth in the form of promotion and skill development, suitable physical infrastructure at workplace and schooling for their children along with additional monetary incentives were the key and inter-relating factors influencing the retention of health workforce in rural and remote areas. Hence a combination of interventions like monetary incentives with enhanced career opportunities for professional growth (training, higher studies and promotion), scholarships and preference of seats in reputed (residential) schools to the children of staff working in rural and remote areas and suitable physical infrastructure at workplace would be more effective than financial incentives alone. There is a need for clearly defined human resource policy for health personnel across all cadres with defined parameters for performance appraisal, transfer and promotion.

Blended Training for Frontline Health Functionaries: Is this the Way Ahead?

Background: To test the change in the knowledge of the study participants following a Blended Training and Learning Approach (BTLA). Secondly, the paper also tries to discuss the use of this method over the classical classroom based trainings. Frontline health functionaries are the backbone of almost all health goals. It is therefore essential to ensure proper training of this cadre of workers for optimum service delivery. The present paper tries to discuss the use of an effective new training pedagogy over the classical classroom based trainings. Methods: A cross-sectional study was conducted from August 2013 to April 2014 in all districts in the state of Odisha. The study participants comprised of two groups. Group 1: Integrated Child Development Services supervisors, Child Development Project Officers received training on reduction of stunting. Group 2: Nutrition Counselors and Auxiliary Nurses and Midwifes received training on management of severe acute malnutrition (SAM). Selection of participants was done following complete enumeration technique. The training effectiveness was measured using paired t-test. Out of approximately 2400 participants identified across the state of Odisha, 2350 participants provided consent to participate in the study. Results: The change in knowledge was determined by using paired t-test. The results of the paired t-test for the training on reduction of stunting were significant, P < 0.001, indicates that there was a significant increase in the score from (mean = 11.4; standard deviation [SD] = 2.34) to the post-test (mean = 13.8; SD = 2.34). The mean increase was 2.4 with 95% confidence interval [CI] for the difference between means of 11.4 and 13.8. Similar test was conducted to evaluate the training on SAM. The results of the paired t-test were significant, P < 0.001, indicates that there was a significant increase in the score from (mean = 14.7; SD = 2.8) to the post-test (mean = 15.8; SD = 2.3). The mean increase was 1.12 with 95% CI for the difference between means of mean = 14.7 to mean = 15.8. There are different approaches that can be adapted during any training ranging from the traditional form of classroom teaching to the new technologically advanced forms of training such as e-learning. Understanding the merits and demerits, there was the felt need to try a newer approach of training. Thus, the method of BTLA was tried in the study and was proved to be effective. Conclusions: The newly tried and tested pedagogy of training would provide the necessary evidence for future policy decisions.

Why medical students do not like to join rural health service? An exploratory study in India.

Introduction: Inadequate, inequitable distribution of the medical workforce remains a challenge across the globe, and India is no exception. Odisha, a state in India faces a major shortage of doctors particularly in rural and remote areas. In order to address this challenge, it is essential to understand medical students′ career plans, specialization preferences, choices of job location and sector, and views on working in rural and remote areas. This study explored the immediate and long-term career plans of final year medical students, their intended practice locations and underlying reasons for the choices. Methodology: A cross-sectional survey was conducted in all the medical colleges (three government and three private) in the state of Odisha. Through the systematic sampling method, data were gathered from 390 final year students. A semi-structured questionnaire was administered to the students and data were analyzed using SPSS version 20. Results: Of the 390 students, 290 (74.35%) were from a government college. The most preferred immediate career goal was postgraduation studies (45.9% of students in government medical schools and 54% in private). About 17% of government students and 9% of private students showed willingness to work in rural areas, in the long run. Nearly 44.5% mentioned opportunities for career growth, followed by the possibilities for higher education (26.8%) as major the factors for preferring an urban posting. Similarly, higher pay scales, better working conditions were major factors for preferring the private sector. Most of the students maintained that good housing, better salaries, and adequate facilities at the workplace would attract more students toward rural service. Conclusion: Since public funded medical students are not motivated to serve in rural settings, increasing the number of places or establishing new medical institutions may not be an effective solution to the issue. Approaches such as extended clinical apprenticeship in rural health facilities, long-term community engagement during medical studentship could be considered.

Mapping private-public-partnership in health organizations: India experience.

The dream of universal health care demands a much larger and wider approach, engaging not just the public but also the private sector. This paper has attempted mapping the present public-private partnership scenario in India using the WHO health system functions framework, giving an insight into the nature and extent of challenge of the present dominant model. A systematic review methodology was adopted to identify published literature on private-public partnership in India. From an initial pool of 785 articles were identified. Finally a total of 29 published articles meeting the inclusion criteria were included. The descriptive framework of Health system functions by WHO (2000), were used to analyze the data. All papers which were considered for the study were segregated based on the 4 prime health system functions: Financing; Management of non-financial inputs; Health service delivery and Oversight. The literature review reveals that more than half of the papers (51.72%) selected for the study were focused on health service delivery functions and quite thin literature were available for other 3 functions, which includes financing, management of non-financial inputs and oversight functions as per WHO. This finding raise an important question if the genesis of most of the public-private partnerships is out of the inability of the public sector in reaching out to a particular target group by virtue of its geographical position or difficulty in working with high risk groups. Considering the limitations of the present model of engagement of private and public sectors, it demands for an alternative model of engagement where the mutual strength that exists with each one of the partners, could be harnessed and complemented. An alternate model is to engage in tri-partite partnership (TPP) between the government, non-government and the corporates.

How supportive supervision influences immunization session site practices: a quasi-experimental study in Odisha, India

Background Routine immunization (RI) is a key child survival intervention. Ensuring acceptable standards of RI service delivery is critical for optimal outcomes. Accumulated evidences suggest that ‘supportive supervision’ improves the quality of health care services in general. During 2009–2010, the Government of Odisha and UNICEF jointly piloted this strategy in four districts to improve RI program outcomes. The present study aims to assess the effect of this strategy on improvement of skills and practices at immunization session sites. Design A quasi-experimental ‘post-test only’ study design was adopted to compare the opinion and practices of frontline health workers and their supervisors in four intervention districts (IDs) with two control districts (CDs). Altogether, we interviewed 111 supervisor–supervisee (health worker) pairs using semi-structured interview schedules and case vignettes. We also directly observed health workers’ practices during immunization sessions at 111 sites. Data were analyzed with SPSS version 16.0. Results The mean knowledge score of supervisors in CDs was significantly higher than in intervention groups. Variegated responses were obtained on case vignettes. The control group performed better in solving certain hypothetically asked problems, whereas the intervention group scored better in others. Health workers in IDs gave a lower rating to their respective supervisors’ knowledge, skill, and frequency of supervision. Logistics and vaccine availability were better in CDs. Conclusion Notwithstanding other limitations, supportive supervision may not have independent effects on improving the quality of immunization services. Addressing systemic issues, such as the availability of essential logistics, supply chain management, timely indenting, and financial resources, could complement the supportive supervision strategy in improving immunization service delivery.

Effect of Supportive Supervision on Routine Immunization Service Delivery-A Randomized Post-Test Study in Odisha

Introduction: Routine immunization is a key child survival intervention. Issues related to quality of service delivery pose operational challenges in delivering effective immunization services. Accumulated evidences suggest that “supportive supervision” improves the quality of health care services. During 2009-10, Govt. of Odisha (GoO) and UNICEF jointly piloted this strategy in four districts to improve routine immunization. The present study aims to assess the effect of supportive supervision strategy on improvement of knowledge and practices on routine immunization among service providers. Materials and Methods: We adopted a ‘post-test only’ study design to compare the knowledge and practices of frontline health workers and their supervisors in four intervention districts with that of two control districts. Altogether we interviewed 170 supervisors and supervisees (health workers), each, using semi-structured interview schedules. We also directly observed 25 ice lined refrigerator (ILR) points in both groups of districts. The findings were compared with the baseline information, available only for the intervention districts. Results: The health workers in the intervention districts displayed a higher knowledge score in selected items than in the control group. No significant difference in knowledge was observed between control and intervention supervisors. The management practices at ILR points on key routine immunization components were found to have improved significantly in intervention districts. Conclusion and Recommendations: The observed improvements in the ILR management practices indicate positive influence of supportive supervision. Higher level of domain knowledge among intervention health workers on specific items related to routine immunization could be due to successful transfer of knowledge from supervisors. A ‘pre-post’ study design should be undertaken to gain insights into the effectiveness of supportive supervision in improving routine immunization services.

Care Seeking Behaviour of Older Adults with Hip Fracture in India: A Qualitative Study

Background: Hip fractures among older adults is a serious public health issue in India due to increase in ageing population. Availability and timely access to surgical care is essential for reduction of mortality and morbidity from hip fractures and thereby decreasing inequalities among older adults. The notion of access to care is multi-dimensional and the “three-delay” framework can be applied to understand the causes for delay between sustaining a hip fracture and receipt of appropriate care. The aim of this study is to determine the processes in decision-making, identify cause for delays in obtaining care, and the potential barriers and facilitators to seeking appropriate care in time. Methods: A qualitative study was conducted (30 in-depth interviews) in seven healthcare facilities (4 public; 2 private and 1 alternative care center) in two administrative district of Odisha, India. The study was undertaken by George Institute for Global Health, India, in collaboration with Indian Institute of Public Health-Bhubaneswar from July 2014 to January 2015.Participants were aged 50 years or older with hip fracture including males and females. Data was categorized using NVIVO software and analyzed by thematic analysis. Results: Majority of participants perceived hip fracture injury will heal on its own and does not require surgery. They were not aware of the consequences of such an injury, comorbid conditions and available healthcare facilities. Family/community members played a significant role in the choice of surgeon and in accessing health care facility. Participants who had an injury outside their home were taken immediately to the hospital whereas those who fell inside home get delayed in reaching hospital. The delay from time of injury till access of care varied from few hours to months. People with a hip fracture and their relatives had strong faith and belief in traditional health care system, i.e. Traditional bonesetters within their local community. Conclusion: Our study findings emphasize on the need for quick decision- making to access nearest health facility with the provision of surgical care. We recommended further research studies to be conducted in varied settings to widen our knowledge in care pathways for the management of hip fractures in India.