A Jokhio, G Pappas, R Lancashire
deployment, healthcare system, human resources, pakistan
A Jokhio, G Pappas, R Lancashire. Health System Managerial Staffing Patterns: Public Sector Experience From Pakistan. The Internet Journal of World Health and Societal Politics. 2007 Volume 5 Number 1.
Poor human resource management and frequent changes in senior management has been associated with low levels of performance in the social sector in less developed countries.
A study of administrative data on transfer and posting was conducted on the 54 top provincial offices in the government of Sindh Department of Health over the period of 24 years (1981-2004). There were 689 transfers/postings made in the 54 key offices studied over the 24 year time period. Almost half (48.9%) of these postings lasted no longer than 1 year. The offices affected highest were tertiary/district care hospitals (54 times) and district health offices (37 times) respectively. High rate of frequent transfers/postings documented in the study among high level public health care delivery system managers in Sindh, Pakistan. Human resource policy in government bureaucracies should be developed to stabilize professional positions and improve the performance of the health care delivery system.
Human resources are the heart of the health system and health care managers have a critical role in determination of performance of the system (1,2,3). The quality of health services, their efficacy, efficiency, accessibility and viability depend primarily on the performance of those who deliver them (4, 5). However, research in this area has been neglected in developing countries (6).
In Pakistan the health system remains functionally weak and the quality of health services is poor, despite longstanding constitutional support for health care as a right and a large Ministry of Health at federal and provincial levels (7, 8). In Pakistan health sector performance has not been evaluated in terms of organization functioning i.e. in terms of inputs, processes or activities and outputs for different types of resources including human resources. Very little is known about compositions of health managers, their skills, and training, and specifically the policy for deployment.
Human resources for health have recently been emphasized as a central component in providing a stronger health system to achieve the Millennium Development Goals (9,10,11,12). The effect of human-resource policies on the success or failure of health systems has been the focus of recent studies (13,14,15,16,17). Absence or non-implementation of appropriate human resource policies that address appropriate numbers of staff, their qualifications, deployment, working conditions, and gender distribution are associated with many problems in the health work force (2, 18, 19).
Frequency of turnover of key managerial staff has also been associated with poor system performance (1). This paper documents levels and patterns of turn over of top managerial positions due to postings and transfers in the Department of Health in the province of Sindh, Pakistan. This description of the extent of the problem and patterns of position tenures for public health managerial staff is presented to help improve understanding and awareness of these issues towards appropriate human resource policy which may improve the management of the health sector in the country.
Sindh is the second largest of Pakistan's four provinces with 30 million inhabitants. The management of health care facilities and programmes is a provincial matter in the country, given full autonomy in implementation to provincial Departments of Health. The provincial Secretary for Health is the overall head of the health department. The Director General Health Services (DGHS) is responsible for the operations of primary and secondary health services and also plays a role of coordination of activities at the various levels. At the district level the District Health Officer/Executive District Officer Health (DHO/EDOH) is responsible for implementation of all the health services. Many preventive programmes, tertiary/secondary level hospitals or specialized institutions and medical colleges/universities are headed by the Programme Managers, Directors and Principals or Vice-Chancellors respectively, who provide and deliver a variety of curative or preventive and medical or health related services.
The Department of Health Sindh is comprised of sixty- two positions above grade 19 that have administrative or financial responsibilities. Fifty-five of those positions have both administrative and financial responsibilities over the twenty-four years in the study period. Records were incomplete for one of these positions leaving 54 for this study. The data for this study was obtained by written request to the Sindh Department of Health. The data can be found on publicly displayed placards listing the name and dates of service for each successive office holder of key positions. Because these placards are typically displayed in waiting rooms or other public spaces in the Ministry the data is verifiable and of high quality. The data does not provide information on where the postings was from inside or from outside of the Department. Gender was determined based on name recorded. Names in the culture of Pakistan are gender specific allowing this coding. Information was collected for the time periods between January 1981 and July 2004.
The information was copied on to code sheets in June 2005 entered into an SPSS data base. The tabulations presented in this paper were calculated using SPSS. The quality of the complete records is considered to be of high quality as they are public and they reflect financial matters. One of the authors (HJ) was a long time employee in the Sindh Department of Health provided extensive historical background information.
Analysis of these data focuses the patterns of the 689 transfers/posting over the time period. The total number of individuals who filled these positions was 314. Regarding patterns of transfers the main outcome measures are the numbers and duration of postings by different government's, by type of office, and by gender. The analysis also presents the numbers of individuals how were posted one or more time and patterns of individuals posted only once.
A total of 689 transfers/postings of managers were made over the 24-year period in the 54 key offices studied here, an average of 29 per year. Table one lists the 16 successive governments and indicates which type of governments were in power, military, political, caretakers (typically appointed by the military or reinstated governments. Figure one presents the number of transfer/posting per year over the time period demonstrating the high numbers, the erratic pattern and the general increasing number of transfers over the study period. One government lasted only 87 yet made 16 postings. The maximum number of transfers in a year was 53 in 1997 and the minimum was 9 in 1986.
The number of postings that were made and the length of time postings lasted differed for the various positions studied here. The offices listed in Table 2 are arranged by rank starting with the highest, Secretary of Health and provides the numbers of postings, the average number of postings made for each office during the study period, and the length of time posting lasted. While high levels of instability are observed greater instability occurred in higher offices. The office of the Secretary of Health saw 20 changes in personnel in 24 years; half of them served for less than a year. The number of Director of Generals of Health Services was 13 over the same period. For the eight preventative program posts half of the posts lasted less than a year, out of the total 689 transfers/postings, 337 (48.9%) lasted no longer than 1 year, whilst 158 (22.9%) lasted 1-2 years, 93 (13.5%) 2-3 years, 42 (6.1%) 3-4 years and only 59 (8.6%) were in post longer than 4 years. The median length of time for all posts was 371 days (Table -2).
The male/female ratio of the health managers was 299:15 (95.2%:4.8%). The median number of days in post for females was 1061 days compared with 368 days for male staff (Table-3). The number of staff with occupying two posts (dual charge) at the same point of time in their job history was 36 (11.5%).
Over the study period there were 314 different individuals who filled the 54 offices studied here. Half of those who served (150 individuals) worked on key managerial posts in the Department only once during the 24 years period (Table 4). The number of staff, who occupied managerial posts two times in different periods, was 74 (23.6%) and 3 or more times was 90 (28.7%).
Among the 150 people who were posted only once during the study period 33 (22.0%) were in post no longer than 3 months, 21 (14.0%) no longer than 6 months and only 37 (24.7%) staff were in post longer than 2 years. Again it was higher level offices that were most commonly filled by persons. Ten of the twenty Secretaries were posted lesser than 1 years. Among then medical superintendents of hospitals (54 times out of 150) and district health officers, heads of the district health offices (37 times out of 150) respectively were posted only once on these managerial posts (Table-5).
High frequency of postings and transfers were observed during the 24 years of data examined in this study. The overwhelming picture emerging from the data is instability in the bureaucracy associated with changing governments. Political instability has been used as an indicator of poor governance (20).
Limitations of this analysis include lack of knowledge about the number of persons who were retired from the posts studied and lack of data on age of persons posted. Of the 314 person who passed through the Department during the study period some must have left due to retirement as part of the normal progression of a career. While there are no definitive norms for the optimal number of posting for the 54 offices over a 24 year period, it is clear that retirement would not account for the high numbers observed here. The general pattern of instability for the bureaucracy is not diminished by lack of information on numbers of retirees.
Under-representation of women among those who manage was also observed in this study. This pattern is not due to paucity of qualified women in medicine in Pakistan who are equal in number to men (21). Under representation of women in the managerial and decision-making positions leads to less attention to and poorer understanding of problems specific to women and the particularities of their utilization patterns (22). For an efficient and effective development of a health care system that meets the needs of women equitable gender distribution in the workforce is necessary (23).
The causes of this pattern of instability are not the subject of this analysis but some suggestions for further study are offered here. It is clear that the instability of postings is related to political instability in the country. We can not say, however, that the dates of the transfers were related specifically to changes in government. Rather it appears that government instability has led to a continuous process of change in postings. Motivation to abuse power for personal financial gain is another force that leads to frequent transfers and postings (24, 25). Another motivation may be desires for less demanding, non-clinical or non-managerial posts. The causes and specific consequences of high levels of turn over of key managers warrant further study.
Frequent transfers of senior managerial staff in Sindh is a probably factor associated with poor performance of the system. Managers who serve in only one position suggest they lack of experience or credentials of office holders. Staff turnover is a well known proxy for poor bureaucratic functioning (1). A well-motivated, appropriately skilled, and well deployed workforce is crucial to the success of health delivery system (2, 26). Management of performance, staffing, training and working conditions are synergistically determine the performance of any health care system (2, 19, 27, 28).
These findings have implication for human resources policy in the Government of Pakistan. The evidence presented here has filled a critical gap in knowledge regarding the policy and planning issue of deploying health care managerial staff in a public health sector in Pakistan. These data and in-depth future research in the areas of health services management and health systems performance will guide policy makers to improve the health care delivery for achieving the millennium development goals (10). Selection criteria based on skills, trainings, qualifications and deployment of the managers when linked to data on health system performance can contribute to improve functioning of bureaucracy (11, 12, 14). Human resource criteria can be established through policy or established as law. These sorts of procedures would stabilize the bureaucracy in the face of political uncertainties. The extent to which stronger bureaucratic rules alone can improve the efficiency of government in the face of political instability remains a question.
Dr Abdul Hakeem Jokhio. M.B; B.S, PGD: H&HSA, M: HSM, PhD. Associate Professor Department of Community Health Sciences Aga Khan University, Stadium Road Karachi 74800, Pakistan Ph: +92 (21) 486 4813 Fax: +92 (21) 493 4294- 493 2095 Email: email@example.com