Parallel Systems and Human Resource Management in India's Public Health Services: A View from the Front Lines

Abstract

There is building evidence in India that the delivery of health services suffers from an actual shortfall in trained health professionals, but also from unsatisfactory results of existing service providers working in the public and private sectors. This study focusses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism, which can adversely affect service delivery processes and outcomes. The paper considers four human resource management subsystems: postings, transfers, promotions, and disciplinary practices. The four subsystems are analyzed from the perspective of front line workers, that is, This paper is a product of the Health, Nutrition and Population Unit, South Asia Region. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The authors may be contacted at glaforgia@worldbank.org. physicians working in rural health care facilities operated by two state governments. Physicians were sampled in one post-reform state that has instituted human resource management reforms and one pre-reform state that has not. The findings are based on quantitative and qualitative measurement. The results show that formal rules are undermined by a parallel modus operandi in which desirable posts are often determined by political connections and side payments. The evidence suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. These systems appear so entrenched that reforms have borne no significant effect.

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Making Politics Work for Development: Harnessing Transparency and Citizen Engagement

“…La Forgia et al (2014) provide case studies from India of a thriving "parallel system" for human resources management in the public health sector that is based on political connections and bribes, rather than on formal rules. Through connections and bribes, doctors are able to obtain the public clinic posts they desire, regardless of their performance on the job.…”

“…Nonelected public offi cials perform in the shadow of fl awed elections that generate weak political incentives and perverse behavioral norms. For example, powerful leaders at both national and local levels might interfere with the recruitment and management of frontline public service providers by ensuring that their cronies are appointed or promoted to leadership positions in public facilities La Forgia et al 2014). Such use of government jobs as political patronage can dilute professional norms in the public sector.…”

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

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