Introduction

Human resources for health can play a central role in providing stronger health systems in achieving the Millennium Development Goals [₁₂₃₄]. The World Health Report 2006 has given high priority to development of effective workforce policies and strategies for health management and planning for developing countries [₅]. Proper functioning of public health programmes has been linked with the public health workforce adequate trainings, skills and knowledge [₆₇]. Delivery of essential public health services the public health workforce requires up-to-date knowledge and skills. To meet the training and continuing education needs of an evolving workforce, a clearer understanding of the functions and composition of the public health workforce both now and for future is required [₈]. The human work force is an important input and has a strong impact on public health system performance [_910111213].

In Pakistan health system is inundated due to problems such as structural fragmentation, resource scarcity, corruption, and inefficiency [₁₄₁₅₁₆]. Policy recommendations have been made which emphasize building human resources capacity of health service providers, health managers and administrators to support a viable and sustainable health reform process [₁₇]. However no study has been done in the country which documents the current capacity of health managers, health administrators and health providers. Very little is known about the type and composition of health managers: their training and educational requirements, the skills required for the job and on the job.

The aim of this study was to assess the types of training, professional experience, experience, and skill level of public health managers in one province in Pakistan, the first such study in the country to document the current status of human resources development, supply and distribution. Policy implications of the findings of this study are offered that emphasize the need for capacity building.

Methods

Public health sector in Pakistan is organized in a federal system with management and planning functions devolved to the four provincial governments. 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. Provincial health secretariat heading by the Secretary for Health leads on most policy & planning decisions for health services and employ health personnel. 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.

Public health sector initially recruits medical doctors (basic medical degree M.B:B.S) for the provision and implementation of medical and health related services through public services commission exams. According to service rules/regulations there are three basic cadres with grades of initial recruitment/induction and future career paths or developments. These include: 1) General Cadre- medical officer in grade 17 with basic requirement is medical graduation (M.B:B.S in Pakistan), 2) Specialist Cadre in grade 18 with basic requirement being medical graduation and medium level post graduation diploma in a specific specialty and 3) Teaching Cadre starts as Assistant Professor in grade 18 with basic requirement of medical graduation and higher level post graduation in a subject area.

After entry in the service, the selection of managers is often made from general cadre. The general cadre medical officer starts as general duty medical practitioner and moves up the management ladder up to grade 20 after having working experience at various levels, in different capacities and on the basis of length of service. The specialist moves up to grade 20 in a similar manner but remains as the specific subject specialist without any involvement in teaching or management. The teaching cadre moves up to professor level at grade 20 or above and teach remaining in a medical college/hospital. All the heads of medical college or university must be from teaching cadre.

The Department of Health Sindh is comprised of sixty positions above grade 19 that have administrative or financial responsibilities. Fifty-three of those positions were selected for the study having administrative, financial and implementation responsibilities. The data for this study was obtained by written request to the Government of Sindh Department of Health.

A structured questionnaire was sent to all current heads of fifty-three positions in June 2005. Non-responders were sent a second copy of questionnaire three month later. The questionnaire included the respondent’s job title, basic pay scale/grade, educational qualifications, and field of specialization, special key skills and in-service training received and the type of working experience in public health sector. Data collection was completed in July 2006. The quality of the complete records was considered to be of high quality as the respondents are public officials providing information about their direct positions and they had been requested to provide information from the senior most official in the Department, the Secretariat.

Here working experience means the responsibilities or using expertise how and where at what level and capacity. Special skills mean skills required for performing the job adequately like organizing, planning, administration, computer skills, languages etc. The grade is considered as basic pay scale of salary according to the level, position and seniority. Cadre defines the level and capacity in completing the responsibilities includes career path and further development of an employee like teaching, clinician, professor. Categories of training include any professional training enhancing the capacity in completing the job responsibilities for a position.

The data of individual variables were summarized using frequency distribution in SPSS. The analysis examines the number of individuals of different cadres who filled managerial positions, number of individuals and type of qualifications/field of specialization, number of positions and type of any in-services professional training received and positions with type of working experience or special skills.

Results

Questionnaires were returned from 50 of 53 health managers with complete information, a 94 percent response rate. Table one lists the type of managerial positions by gender, cadre and the working grade in the public health sector. Altogether 76% managerial positions were occupied by the medical officers of general cadre, 14% by teaching cadre and 10% by specialist cadre. The male/female ratio of the health managers was 48/2 (96%:4%) (Table one). More than 50% of the positions were occupied by officer in grade 19 or below.

Table two shows different managerial positions with level of education/qualification. All the health managers had a basic medical degree (M.B; B.S), in addition three had a minor diploma in a clinical subject, ten had a master level degree in a clinical subject, only four had master level degree in public health and two had training other than in public health or a clinical (Table-2).

Table three shows managerial positions with type of any in-service training during the service period. Eighty percent of the managers report having received no professional in-service training received during their service period. Only six percent had their professional training in administration, eight percent had training in clinical and six percent had other than clinical/administration/teaching including computer etc (Table-3).

Table four reports the managerial positions having previous working experience in the public health sector with any special skills relevant to management. Sixty percent reported for having experience or occupying managerial/administrative positions only, eighteen percent in both administration and clinical, six percent in administration and teaching while 16% had in all the three areas i.e. administration, teaching and clinical. Only eighteen percent health managers replied that they had special skills concerned to administration/management (Table-4).

Discussion

This study of the top fifty managers in the Department of Health, Sindh reveals that very few have training or qualifications beyond a medical degree (M.B; B.S). The study describes that beyond basic medical qualification most were without background in health management/administration. Neither have many clinicians/medical in grade 19 occupying managerial positions been provided with in-service training in management. These results suggest that current public health system has major deficiencies related to low managerial capacity of senior health managers. Generally if health managers are not according to formal and informal qualifications and with appropriate skills the system cannot function properly [₅].

Under-representation of women (4%) working as manager’s observed in this study seems to be part of a long term trend as documented by in a previous study of 24 years of human resources data for the Department of Health Sindh [₁₈]. This imbalance exists despite the large numbers of female medical graduates for many years.

This documentation of low levels of training related to management of the health system must be added the observation of high levels of staff turnover of personnel in the Department documented in a previous study [₁₈]. A picture emerges of an instable bureaucracy and managers without specific training in management of the health system. The related management problems (absenteeism, corruption, poor efficiency) that have been documented in the Pakistan’s public health system can perhaps be better understood against this back drop of poor human resources management [_1920212223]. The stagnation of improvement in health indicators is another likely result of these issues which should be further studied [₂₄].

Limitations of this study include the fact that information relies solely on reported information and self perception of senior health managers. In additional training alone may not translate into capacity. Furthermore this study was done at one point in time with one set of managers. Human resources are dynamic and might better be understood with a study of a number of points in time or a longitudinal study. While the study reports on current circumstances the authors suggest that this study reflects a long term trend based on the lack of rules and guidelines or requirements for training in the government health sector. This study can not answer questions productivity and performance of the sector, which may be related to the low levels of training reported.

Policy recommendations of this study must be considered within the context of an unstable, corrupt bureaucracy. Without an enabling environment training alone can not change the performance of a work force. Despite these limitations more and better trained health managers in Sindh seem a somewhat obvious recommendation that these findings support. Both degree programs and training of those in service are critical needs for scaling-up priority interventions [₂₅]. Also essential are the human resources development polices and planning improve effective delivery of health services and performance of public health system [₆₇₂₆]. Effective development of health managers requires a systematic, interactive, ongoing continuous process, in which training experiences are combined with practice of the new skills “on the job” [₂₇].

Recommendations for more training of health managers in Pakistan is quite realizable in the short term because health management training programs exist in the country, both short courses, master level degrees, and PhDs [₂₈]. Issues about the appropriateness of this training must be addressed. In addition there are many Pakistanis who received international education in health systems management. Service rules, selection criteria, and the general malaise in the public sector may be reasons why people with appropriate educational background have not found their way into public service and into the positions studied here.

Figure 1

Table 1: Administrative/managerial positions by number, gender, cadre, and grade: Sindh Department of Health, Pakistan 2006***

Figure 2

Table 2: Administrative/managerial positions by number, and level of education: Sindh Department of Health, Pakistan 2006*

Figure 3

Table 3: Administrative/managerial positions by number, and reported in-service training: Sindh Department of Health, Pakistan 2006*

Figure 4

Table 4: Administrative/managerial positions by number, and reported working experience and special skills: Sindh Department of Health, Pakistan 2006*

Correspondence to

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: hakeem.jokhio@aku.edu