Health worker posting and transfer at primary level in Tamil Nadu: Governance of a complex health system function

Abstract

Background:Posting and transfer (PT) of health personnel – placing the right health workers in the right place at the right time – is a core function of any large-scale health service. In the context of government health services, this may be seen as a simple process of bureaucratic governance and implementation of the rule of law. However the literature from India and comparable low and middle-income country health systems suggests that in reality PT is a contested domain, driven by varied expressions of private and public interest throughout the chain of implementation.Objective:To investigate policymaking for PT in the government health sector and implementation of policies as experienced by different health system actors and stakeholders at primary health care level.Methodology:We undertook an empirical case study of a PT reform policy at primary health care level in Tamil Nadu State, to understand how different groups of health systems actors experience PT. In-depth qualitative methods were undertaken to study processes of implementation of PT policies enacted through ‘counselling’ of health workers (individualized consultations to determine postings and transfers).Results:PT emerges as a complex phenomenon, shaped partially by the laws of the state and partially as a parallel system of norms and incentives requiring consideration and coordination of the interests of different groups. Micro-practices of governance represent homegrown coping mechanisms of health administrators that reconcile public and private interests and sustain basic health system functions. Beyond a functional perspective of PT, it also reflects justice and fairness as it plays out in the health system. It signifies how well a system treats its employees, and by inference, is an index of the overall health of the system.Conclusions:For a complex governance function such as PT, the roles of private actors and private interests are not easily separable from the public, but rather are intertwined within the complexities of delivery of a public service. This complexity blurs conventional boundaries of private and public ownership and behaviour, and raises critical questions for the interpretation of coordinated governance. Hence, the imperative of enforcing rules may need to be complemented with bottom-up policy approaches, including treating PT not merely as system dysfunction, but also as a potential instrument of governance innovations, procedural justice and the accountability of health services to communities they seek to serve.

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region

“…Local governance was a social accountability approach to enhance transparency and accountability at the local level. In three studies ( Cleary et al , 2013 ; Garimella and Sheikh, 2016 ; Panda et al , 2016 ), it was found to be effective by enabling space for decision-making at the local level. It improved health units’ performance by enhancing local authorities’ decision-making and enabling them to apply a bottom-up approach.…”

Health worker transfer processes within the public health sector in Ghana: a study of three districts in the Eastern Region

“…Due to power dynamics, the administrators are likely to prevail, leaving health workers with unmet needs [7]. The unmet needs facilitate dissatisfaction among health workers, which negatively affects health service delivery, for example by increasing absenteeism [2–4, 7, 25, 29].…”

“…In low- and middle-income countries (LMICs), posting and transfer (PT) practices, referring to how frontline health workers and administrators are geographically posted and transferred within public health facilities, have been recognized as a main barrier for having an effective workforce [1–3]. Previous studies found that health workers’ dissatisfaction with their postings and inadequate support for them to discharge their roles effectively are linked to absenteeism, low morale, and poor quality of health services [4–6].…”

“…In Ghana, as well as in other LMICs, policies and procedures to guide PT decisions exist, yet they have been described as being ambiguous, arbitrary, and non-transparent in practice [4, 6–8]. Due to a lack of clear guidelines and procedures, PT decisions are likely to be formally or informally negotiated outcomes based on diverging interests from the ones posting or transferring and the ones being posted or transferred [2, 6, 7].…”

“…There is a paucity of research on transfer practices [2, 4, 6]. By gathering perspectives from health administrators with decision-making authority in terms of PT and frontline health workers who have transferred within the public health service delivery agency in Ghana, namely GHS, this exploratory study aims (1) to identify rationales behind transfer decisions and (2) to examine how transfers are managed in practice versus current PT policies and procedures.…”