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 both from an actual shortfall in trained health professionals and from unsatisfactory results of existing service providers working in the public and private sectors. This study focuses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism that can adversely affect service delivery processes and outcomes. We analyze four human resource management (HRM) subsystems: postings, transfers, promotions and disciplinary practices from the perspective of front-line workers-physicians working in rural healthcare facilities operated by two state governments. We sampled physicians in one "post-reform" state that has instituted HRM reforms and one "pre-reform" state that has not. The findings are based on both quantitative and qualitative measurements. 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.