It is now proven that when it comes to the delivery of services that involve public goods or quasi-public goods, India ranks amongst the very worst. In a very large measure, this is because it is the government that has taken it upon itself not only to deliver these services, which is bad enough, but also to prevent the private sector from doing the job, which is worse.
When you get right down to it, the key difference turns out to be one in management. Be it education or health or any other thing, the private sector simply manages its systems better.
True, it also makes mistakes. But overall it works less at cross-purposes with itself and society than the government does. Where increasing supply is the objective, the private sector performs much better than the government does.
An important element in this difference is the way an organisation manages its manpower. In this paper*, Sunil Maheshwari, Ramesh Bhat and Amit Dhiman of IIM-A have taken up an issue that, in the context of the health sector, no one discusses in our country: how to get government employees in this sector to work.
The key problem they have identified is the commitment of the staff. Why is it so poor, they ask. They surveyed and discussed the problems of the health delivery system with 175 doctors working as district medical officers in four states, accounting 22 percent of the population.
Basically, at the root of it all lies a simple fact: hard work and merit don't matter in the government system. Promotions and career prospects are determined by other considerations and laggards are not punished. To quote, "the study finds a critical linkage between human resource (HR) practices and the commitment of doctors working in the government.
Specifically, following HR practices are found critical in influencing organisational commitment: transparency in selection/postings, supportive training and capacity strengthening climate, recognition of performance and regular performance feedback." There are other problems as well, relating to the way the system is run.
Thus, "this study highlights the criticality of administrative and structural issues for reforms of healthcare sector in India." It comes as no surprise that there is no speclialised HR function in the health departments of the central and state governments. Given how critical doctors are to health delivery -- just as politicians and bureaucrats are to corruption -- it is typically Indian that no attention is paid to HR.
So, say the authors, if the government is serious about improving health services, "the departments of health across states need to broaden and deepen the understanding of HR management and planning issues. For this purpose they may need to set up HR division having appropriate competency and skill-mix to address issues and work towards making the right changes."
The findings of the study are striking, not because all this was not known but because in spite having known them for so many years, the government seems unable to effect the necessary changes. For example, doctors are not consulted in staffing decisions while, naturally, they would "want to be consulted whenever an employee is posted in their department."
Most of the doctors surveyed also said that there is a lack of transparency. "As the decision-making in the sector is highly centralised, staffing decisions are influenced more by political and administrative concerns than by the field requirements...Doctors also perceive that most of the selection processes are inadequate to test peoples' skill. Consequently employees with inappropriate skills enter the health sector."
Opportunities for continued education are also low and "there is low concern for people development and a poor training climate (score 3.2). This results in lower commitment, and frustration among the doctors." But what change can you expect from a system where the health minister of the country fails to sign degrees for two years?
*Implications of human resource practices and other structural factors on commitment of public medical professionals in India, IIM-A, Working Paper No 2007-08-04, August 2007.