metadata: authors: 0: author: Ali,Rabia
1: author: La Forgia,Gerard Martin
2: author: Maheshwari, Sunil Kumar
3: author: Raha,Shomikho
4: author: Shaik, Shabbeer
count: India
docna: 0: docna: Parallel systems and human resource
            management in India's public health services : a view
            from the front lines
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Labor Markets,Customs and Trade,Public Health Promotion,Health Service Management and Delivery
teratopic: Public Sector Development,Health, Nutrition and Population
abstracts: cdata!: 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,
            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.
geo_reg_key: 517198,517212,517191
repnme: repnme: Parallel systems and human resource
            management in India's public health services : a view
            from the front lines
display_title: Parallel systems and human resource
            management in India's public health services : a view
            from the front lines
listing_relative_url: /research/2014/06/19737148/parallel-systems-human-resource-management-indias-public-health-services-view-front-lines
topicv3: Health Services Delivery m1327294 1305,Public Health m1327519 635,Jobs m1503931 2670,Human Resource Management m1504248 2598,Health m1504661 3480
publishtoextweb_dt: 2014-06-01T00:00:00Z
historic_topic: Public Sector Development,Health, Nutrition and Population
no_of_pages: 36
author_keys: 0: author_key: 1057791
1: author_key: 434060
2: author_key: 943624
model_extractions: WPS6953 Policy Research Working Paper 6953 Parallel Systems and Human Resource Management in India’s Public Health Services A View from the Front Lines _Gerard La Forgia Shomikho Raha Shabbeer Shaik Sunil Kumar Maheshwari Rabia Ali_ The World Bank South Asia Region Health, Nutrition and Population Unit June 2014
Policy Research Working Paper 6953

# **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, 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.

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.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
By

# **Parallel Systems and Human Resource Management in India’s Public Health Services A View from the Front Lines**

Gerard La Forgia<sup>a</sup> , Shomikho Raha<sup>b</sup> , Shabbeer Shaik<sup>c</sup> , Sunil Kumar Maheshwari<sup>d</sup> and Rabia Ali<sup>e</sup> aHealth, Nutrition & Population Unit, East Asia and Pacific Region, World Bank, Washington DC, USA bSocial Development Department, World Bank, Washington DC, USA cCenter for Good Governance, Hyderabad, India dIndian Institute of Management, Gujarat, India eEducation Sector Unit, East Asia and Pacific Region, World Bank, Washington DC, USA JEL Classification: I1, H7, H83

**Key words:** India, health systems, governance, human resource management, public management.

# **Acknowledgements** :

The authors are grateful for comments on earlier versions received from Rajeev Ahuja, Sofi Bergkvist, Peter Berman, Jishnu Das, Ariel Fizbein, Nick Manning, Somil Nagpal and Vikram Rajan. This research was supported by a generous grant from DFID/India. The paper draws on field research, data, and transcripts prepared by the Center of Good Governance (CGG), Hyderabad, India and Wone Management Systems, Ltd. The CGG team consisted of Mr. Varada Raju, Radhakrishnam Raju, Manas Ranjan Kar, and Pavan Kumar B. The Wone team consisted of Vinita Satija and Puneet Gaur.
# **Parallel Systems and Human Resource Management in India’s Public Health Services A View from the Front Lines**

## 1. INTRODUCTION

There is growing evidence from some states in India that the delivery of public and private health services suffers both from an actual shortfall in qualified human resources, especially physicians, but also from unsatisfactory performance of existing service providers. A number of studies using large-scale quantitative data show that there is widespread absenteeism among medical providers in the public sector (Chaudhury et al., 2005, Banerjee, Duflo and Glennerster, 2008, Banerjee, Deaton and Duflo, 2004) and that even though public sector providers are at least as knowledgeable as trained providers in the private sector, and certainly more knowledgeable than informal sector providers, the low effort that these providers exert in clinical interactions reduces their efficacy relative to other alternatives (Das and Hammer, 2007; Das et. al. 2012). Although improving health outcomes is linked to a number of factors, supply side delivery deficiencies evidenced by absenteeism, work shirking, and low productivity limit the ability of government to improve service delivery and, ultimately, contribute to lagging health outcomes (Chaudhury et al., 2005; Misra et al., 2003; Lewis and Pettersson, 2009a,b; MOHFW, 2005a; Das and Hammer, 2007; Banerjee, Duflo and Glennerster, 2008; Banerjee, Deaton and Duflo, 2004).

Analytical work on human resources in health in India tends to center on the shortfall in actual numbers of personnel that public delivery systems require in order to meet the needs of the growing population as specified in population-based norms and policies (IPHS, GOI. 2007; MOHFW, 2008, 2005b). In contrast, understanding the high incidence of absenteeism, low productivity and low quality of service delivered by providers _already in the system_ draws less attention.<sup>1</sup> Moreover, there are relatively few studies that have examined the institutional workings of states and factors that may contribute to provider behaviors and performance.

This study focuses on understanding the institutional environment, in particular the policies, rules and processes that govern human resource management (HRM) in the public health system.<sup>2</sup> We analyze four HRM subsystems: postings, transfers, promotions and disciplinary practices from the perspective of front line workers – physicians working in primary care facilities and hospitals operated by state governments in rural areas.<sup>3</sup> These functions are considered major determinants of human resource performance (Sims, 2
2002; Burke and Cooper, 2004; Meyers and Allen, 1991).<sup>4</sup> The ways in which these four HRM functions are conducted in practice provide evidence of underlying accountabilities and incentives that can affect service delivery performance. To our knowledge, this is the first study that systematically examines HRM in a developing country’s health sector with a focus on the de facto practices as described by those whose livelihood and careers depend on them.

Conceptually, we work from the premise that HRM practices and performance are determined by the institutional environment in which they are embedded (Manning, Mukherjee and Gokcekus, 2000; Bana and McCourt, 2006). The framework is illustrated in the Annex. This environment, which is influenced by worker preferences and external pressures, contributes to organizational performance (e.g., accountability, results focus, organizational discipline and employee morale) which in turn impacts service delivery performance. Our approach emphasizes de facto institutional and governance arrangements that give rise to behaviors which can perversely affect service delivery processes and outcomes (Wild et al., 2012; Devarajan, 2008; Fukuyama, 2013; Burke and Cooper, 2004; Lewis and Pettersson, 2009, a,b). Although not directly measured in this study, service performance consists of HR behaviors (e.g., absenteeism and low effort) which mediate actual service provision. We hypothesize the effects of the institutional environment on provider behaviors, and ultimately, downstream service performance.

Four findings contribute to understanding the institutional environment in India and its potential impact on provider behaviors. First, HRM practices are undermined by a parallel modus operandi in which key functions are often determined by political connections and side payments. These systems appear to be controlled by senior administrators and politicians. Second, we confirm what is well-known anecdotally: these parallel systems are widespread and predictable. Third, the occurrence of parallel systems in a ‘prereform’ state that has yet to formalize many HRM processes are no different from a ‘post-reform’ state that instituted HRM reforms in the public health service. Parallel systems are so embedded in the institutional fabric that reforms appear to have had little impact on what happens on the ground. Finally, parallel systems are open to manipulation by all participants – administrators, politicians and physicians – for their benefit, whether monetary or non-monetary. Given this scenario one can question the organizational identity (e.g., shared vision, values, and goals) and commitment of physicians if they feel victimized by parallel HRM practices or have the capacity to respond to the incentives and make the system work in their own interests.

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Our findings suggest an institutional environment in which formal rules of accountability are trumped by informal systems that respond to a different set of accountabilities and incentives. Parallel systems break any link between better performance and rewards (whether through promotions, “better” postings or even higher salaries) and instead create alternate margins for doctors to focus their attention on. For example, if a better posting is tied to the ability to pay, doctors may realign their effort _away_ from their public sector jobs, where pay-scales are fixed, towards private practice or other revenue generating activities where they can earn additional income to pay for a more desirable posting or transfer. How and in what manner the evidence on a parallel system that we document here _precisely_ leads to a decline in performance is a key topic for further enquiry.

This study adds to existing evidence on parallel systems, a well-known attribute of HRM practices among public officials and politicians in South Asian countries, including Pakistan (Hasnain, 2006), Nepal (Harris, et. al., 2013) and India (MPPGP, 2010; Saxena; 2005; Davis, 2003; Wade, 1985; 1982). Political interventions and side payments for certain HRM functions such as postings and transfers appear to be commonplace in Indian state-level public agencies. In 2004, the Indian Prime Minister raised the issue of a “transfer and posting industry” that was “debilitating the performance and morale” of the government’s administrative apparatus.

A few caveats are worth noting. The study measures the perceptions of physicians regarding HRM practices and parallel systems. Given the sensitivity of the topic and the need for a much larger sample than resources permitted, we did not directly measure respondents’ participation in parallel system. We do not suggest that all administrators, politicians and physicians actively partake in parallel systems to pursue their own interests. Clearly there are many physicians dedicated to providing the best possible care under difficult conditions, and they receive considerable support from politicians and senior administrators. However, the evidence reported here appears overwhelming that parallel systems may explain how certain HR functions operate on the ground. The extent to which similar systems are active in other states is a subject for future research.

Section 2 presents the methodology and sample. Section 3 outlines the institutional context of the two study states henceforth referred to as States A and B in this paper. Section 4 describes the findings and section 5 discusses implications for the institutional environment and delivery system performance.

4
Section 6 presents insights into why parallel systems exist and section 7 discusses addressing parallel systems. Section 8 recommends approaches to address the problem and a final section concludes.

# 2. METHODS AND SAMPLE

The study used qualitative and quantitative research methods and was conducted in two states, A and B.<sup>5</sup> Both methodologies adopted multiple data collection mechanisms to ensure reliability of the data and information collected. The qualitative findings were used to inform the design of the quantitative surveys and later validate or complement the quantitative findings. Field research was conducted in late 2011 and early 2012.

Multiple qualitative methods were applied to triangulate information from various sources. Focus group discussions were conducted with policy makers and administrators at the state and district levels, and facility physicians (Medical Officers - MOs) in three sampled districts in each state. In-depth interviews were conducted with 39 and 37 medical officers and health officials in States A and B respectively, including officials in the state secretariat. Secondary data and documents such as service records and government orders pertaining to the HR practices that are central to the study were collected from the study districts and respective State Department of Health (DH).

Quantitative methods consisted of a perception survey (PS) and Unmatched Count Technique survey (UCT). The findings from the focus groups and interviews were used to develop the questionnaires for the PS and UCT surveys. While we aimed to avoid ambiguous words and phrases; questions asking two or more opinions; or manipulative statements (Recantini, Wallsten, and Xu: 2000), based on information collected in the qualitative research, the PS and UCT surveys contained some sensitive questions used to gather and quantify respondents’ _views_ on the occurrence and workings of parallel systems.<sup>6</sup> While selfreporting perception surveys are commonly used for eliciting views of public servants on administrative processes and organizational performance, they have limitations for research on sensitive topics (Tourangeau, Roger, and Ting Yan. 2007; Barnett, 1998; Lee, 1993). The UCT methodology addresses this limitation by mixing non-sensitive with sensitive statements, isolating the latter.<sup>7</sup> Unlike most UCT instruments, however, we did not ask respondents about _their_ behaviors or participation in parallel systems. This would have required a much larger sample of respondents requiring considerably more 5
funding than was available. Rather, we asked about their general agreement with statements on deviant behaviors in their institutional environment. Finally, given the differences in some HRM processes across the two states, the wording of some questions was dissimilar in the PS questionnaires applied in each state.<sup>8</sup> The same groups of physicians in each state completed both the PS and UCT surveys. The surveys were applied to physicians working in Primary Health Centers (PHCs), Community Health Centers (CHCs), and to a lesser extent, block (subdistrict) medical officers in three districts in each state.<sup>9</sup> The surveys were field tested in one district in each state. 273 and 266 physicians responded in States A and B respectively, with a response rate of 65 percent.<sup>10</sup> All instruments were applied individually and confidentiality was ensured.<sup>11</sup> The districts were selected as representative of the universe of districts in each state, and include areas which are considered desirable (e.g., near urban areas) and undesirable (distant rural and tribal areas) to physicians. Sampling remote rural and near-urban districts also allowed for a more representative sample of physicians in terms of years of tenure. Typical of most districts in each state, the sampled districts had a large number of PHCs without assigned physicians due to a generalized situation of physician shortages in India. However, these vacant PHCs tend to be located in rural areas lacking social infrastructure and distant from urban centers. State A performs better than State B in female literacy, is more urbanized, and has higher per capita income. State A also has significantly lower mortality rates, and unlike State B, has undergone rapid improvements in many health outcomes in the last couple of decades. Progress in state B has been muted in comparison.

# 3. INSTITUTIONAL SETTINGS

In order to interpret the perceptions of medical officers on de facto HRM practices, we briefly review the institutional context of each of these states as it relates to HRM. Although nomenclature varies somewhat, the Department of Health, Medical and Family Welfare (DH) is responsible for health services in both states. It is headed by a minister, an elected politician. Most high level administrative officials are career civil servants and belong to the centrally managed Indian Administrative Service (IAS). The remainder belongs to state civil service cadres. Many procedures and rules are similar for both states for the HRM functions under study here in part because they follow civil service rules that vary little across states. This 6
is especially the case for disciplinary and promotion practices, which follow Civil Service Conduct Rules (CSC).

Nevertheless, there are two notable differences between the HRM practices in the two states. State A put in place a reform that aimed to formalize and make the posting process more transparent, whether related to initial recruitment, transfers or post-promotion postings. Known as “counseling,” the process involves the application of defined criteria for approving the postings and one-on-one interaction between the physician applicant and HR administrative personnel in which vacancies and physician preferences are discussed. In theory, posting decisions resulting from “counseling” are made based on some combination of physician preference (e.g., spouses’ place of work), vacancies, and administrative requirements (e.g., years of service, tenure in a specific facility), with “seniority” defined by the years of service being the key consideration. Most criteria are usually subject to negotiation. State A also instituted a dedicated disciplinary cell to deal with punitive cases involving unauthorized absence and other major disciplinary breaches. In contrast, State B employs a “pre-reform” HR management system and does not undertake a formal counseling process or possess disciplinary committees. The implementation of posting processes and disciplinary actions is less institutionalized and more open to ad hoc arrangements.

Second, in State A, private practice by government doctors is illegal. In State B, government doctors are allowed to practice privately outside of their public work hours. In practice, however, a market of scarcity of physicians allows most government doctors to easily engage in private practice regardless of the rules. During recent field research on one Indian state, only 20 percent self-reported having a private practice while about 80 percent were actually found to be privately practicing medicine.<sup>12</sup>

# 4. RESULTS

# (a) Descriptive statistics

Table 1 presents the descriptive statistics on the respondents. A few characteristics stand out. The distribution of positions of respondents is roughly similar for both state samples with over half assigned to PHCs and about one-third to CHCs. The remainder is Block (subdistrict) MOs who occupy administrative positions. State B possesses a larger proportion than State A of recent recruits with less than two years of service. Also, compared to State A where over 40 percent of respondents have yet to be 7
transferred, only 27 percent of State B respondents face a similar situation. Interestingly, in State B 39 percent of respondents report a minimum tenure of one year and over two-thirds have remained at post for less than two years. In contrast, less than 40 percent of State A respondents report minimal post tenure of two years. The majority in either state have yet to be promoted. About 30 percent of the respondents report having a private practice.

|**Table 1: Sample HR an**<br>**State**|**d Administ**<br>**A (N=273)**<br>**(inp**<br>|**rative Cha**<br>**and State**<br>**ercent)**<br>|**racteristics**<br>**B (N=266) **<br>|**of Responde**|**nts**|
|---|---|---|---|---|---|
|**Position**|**PHC**<br>**MO**|**CHC**<br>**MO**|**Block**<br>**MO**|**--**|**--**|
|% State A|56.1|30.2|13.7|--|--|
|% State B|53.7|38.1|8.2|--|--|
|**Total Service (yrs.)**|**<2**|**2-6**|**6-12**|**12-18**|**>18**|
|% State A|15.6|36.4|20.8|14.5|12.6|
|% State B|26.7|35.8|17.2|12.5|7.8|
|**No. of Transfers**|**Not Yet**|**1-2**|**3-4**|**5-6**|**>7**|
|% State A|42.5|29.9|21.8|4.6|1.1|
|% State B|27.0|33.5|27.8|8.3|3.5|
|**Maximum post tenure (yrs)**|**<2**|**2 to 5**|**5 to 8**|**8 to 12**|**>12**|
|% State A|17.1|44.1|25.1|3.8|9.9|
|% State B|22.8|26.5|39.1|8.8|2.8|
|**Minimum post tenure (yrs.)**|**<1**|**1 to 2**|**2-3**|**3 to 5**|**>5**|
|% State A|15.0|22.7|19.4|23.9|19.0|
|% State B|41.2|36.1|13.9|5.1|3.7|
|**No. of promotions**|**Not Yet**|**Once**|**Twice**|**Three Time**|**s**<br>--|
|% State A|80.7|15.0|2.2|2.2|--|
|% State B|88.6|11.0|0.4|0.0||
|**Private practice**|**Yes**|**No**|**Can't say**|--|--|
|% State A|27.9|66.0|6.0|--|--|
|% State B|28.4|69.8|1.7|||

PHC: primary health center CHC: community health center (small rural hospital) block: smallest administration unit 8
(b) Postings and Physician Preferences Table 2 presents the UCT survey results on the perceived the prevalence of parallel systems. A high percentage of respondents in both states agreed with statements about managing initial and post transfer postings through “unofficial financial dealings.” In general, a higher percentage of (post- reform) State A respondents considered parallel systems to influence post-transfer than (pre-reform) State B respondents. However, a higher percentage of State B respondents considered these systems to affect initial postings than their State A counterparts.

|**Table 2. Postings in States A**<br>**Unmatched Count Technique(UCT) Sur**<br>|**and B**<br>**vey Results, 2011**<br>**UCT Score**<br>|**(%)**<sup>**a**</sup>**; (CI)**<sup>**b**</sup><br>|
|---|---|---|
|**Summary Statement**|**State A**|**State B**|
|Desired place of initial postings can be obtained through|65.3|81.4|
|unofficial financial dealings|(45.6-85.0)|(67.0-94.9)|
|Desired place of post-transfer postings can be obtained|89.1|67.8|
|through unofficial financial dealings|(65.5-112.8)|(48.9-86.6)|

aThe UCT scores represent the proportion of respondents (medical officers) who agreed with the specific statements in comparison to a control group not provided the same statement. The statements did not ask whether the respondents participated in such behaviors. b95% confidence interval.

Table 3 displays the results of the perception survey on posting preferences, processes and parallel systems. Using political connections appears to be the most effective route to secure a desired posting in both states (about 85 percent of respondents in both states) or avoid an undesirable one. The counseling policy is welcomed by physicians in post-reform State A. Over 70 percent of respondents agree that it has increased the transparency of posting practices. However, results suggest systematic deviations from formal processes and the DH does not divulge full information during counseling. It is common knowledge among State A respondents that the DH suppresses highly desirable locations near urban areas during counseling (86 percent). DH officials maintain that desirable vacancies are not revealed in order to first fill less desirable rural and tribal ones. But only about half of respondents consider this the reason. The findings suggest that the reform measures are not regularly applied, or can be readily bypassed through parallel systems. Most respondents (81 percent) consider that highly coveted postings are suppressed to enable an alternate posting process based on political influence and financial transactions.

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The percent of respondents perceiving this to be case vary little with their counterparts (84 percent) in State B which does not possess a counseling policy.

Parallel systems are driven in part by physician preferences for posts near urban areas (88 and 82 percent of respondents in States A and B respectively) and in locations with good potential for private practice (54 and 63 percent of respondents in States A and B respectively). Some locations are apparently so undesirable that the majority of respondents agreed that MOs prefer to secure medical leave to avoid such a posting (79 and 69 percent of State A and B respondents respectively).<sup>13</sup>

**Table 3. Posting Preferences and Processes in States A and B Perception Survey Results, 2011** **<u>(in percentages)</u>**<sup>**a**</sup>

||**% Ag**<br>|**ree**<sup>**b**</sup><br>|
|---|---|---|
|**Summary Statement**|**State A**|**State B**|
||N=273|N=266|
|**Preferences**|||
|Many candidates opt for (initial) postings in rural / tribal PHCs to secure<br>quicker eligibility for residency requirements|84.6|86.3|
|MOs generally choose locations which have good potential for private<br>practice|59.9|59.1|
|MOs generally choose locations that are nearer to urban areas|87.8|82.4|
|Some MOs go on medical leave to avoid undesired postings|78.9|69.2|
|**Processes**|||
|The vacancies that are suppressed during counseling are generally in and<br>around urban areas|85.8|N/A<sup>c</sup>|
|The reason for suppressing [desirable] vacancies is to fill the periphery first|53.6<sup>d</sup>|62.6|
|The counseling process has improved transparency of the posting process|70.8|N/A<sup>c</sup>|
|**Parallel systems**|||
|The reason for suppressing [desirable] vacancies is to facilitate some<br>prefixed unofficial arrangements motivated by political influence and|80.7<sup>d</sup>|82.8|
|financial dealings<br>Political connections are used toget desiredplaces ofposting.|86.3|84.1<sup>e</sup>|

aPercentage based on valid responses (exclude missing data). bCombines responses for “agree” and “completely agree.” cCounseling process not used in State B. dState A statements refer to the counseling process. e Survey statements for State B refer to approaching local politicians to secure a desired place of posting.

10
Interviews and focus groups confirmed that physicians prefer posts which are close to urban areas or located in semi-urban areas for both personal and economic reasons: urban areas offer better schools and basic services such as electricity and piped water while both urban and semi-urban areas offer better potential for lucrative private practices. According to one State B physician: “The incentive to continue to occupy [one’s] current post is to not disturb family and sometimes to protect thriving private practice.” Interviewees also affirmed the need for political influence and side payments to obtain preferred postings. Political influence to bypass the counseling process was captured in the following statement from two physicians in State A: _“On confronting the counseling committee on not including a vacant PHC of his preference, the administrative staff supporting the committee snidely remarked it is reserved for a candidate with political connection...”_ _“With right connections and some political (as well as local community) influence, it is possible to manipulate the system.”_

# (c) Transfers

Transfers<sup>14</sup> can be used by physicians to secure a desired posting (or avoiding an extended stay in an undesirable post) usually by making use of parallel systems. Transfers are also used by administrators to fill undesirable posts and “punish” staff for disciplinary breaches while politicians use transfers to secure postings for “preferred” candidates or remove the less preferred.

As in the case of postings, there is no structured transfer policy in state B, and there is no minimum or maximum tenure requirement (88 percent of State B PS respondents). Perception survey results suggest that DH officials have little role in the process (77 percent agreement), transfers occur at the behest of politicians (94 percent agreement), and physicians must make use of political connections (90 percent agreement) and side payments (78 percent agreement) to secure or block a transfer. The perception of one 11
state B interviewee, that side payments are apparently the norm to enable processing of transfers, is telling: _“When one wanted a transfer to be posted close to the place of spouses’ work place . . . one had to go through the same institutionalized informal system. Using spouse criterion_<sup>_15_</sup> _was only a means to gain the attention of higher ups. Once the application is accepted by the department on ‘spousal’ grounds, doctors would still spend some money to get it approved.”_ State A follows a formal transfer policy that defines the eligibility criteria, minimum and maximum tenure, and also involves “counseling” in assigning posts (after transfer approval). A minority of respondents (37 percent) considered the “transfer policy” clear-cut. Parallel systems appear to prevail as much as in state B where formal tenure rules are nearly absent According to the perception survey, twothirds of State A respondents agree that financial arrangements can be used to secure a desired place of posting through temporary transfers known as deputations. Reflecting on application of transfer policies in state A, one physician opined: _“Lack of strict adherence to the policy has resulted in people finding loopholes in the policy and tweaking it to suit their convenience.”_ If tenure rules and other criteria, where they exist, are not key criteria for determining one’s duration in a specific post, what does? The qualitative research suggests three factors: political and community connections, willingness and ability to pay, and demand for specific posts.

Prolonged tenure facilitates the cultivation of deeper political and community relations. By virtue of a long stay and developing a support network among local leaders and politicians, MOs can enjoy long tenures in desirable posts. Local community leaders and politicians may try to retain doctors in their areas which they view as high performers. However, MOs may be transferred at any time if they fall out of favor with local politicians and administrators.

12
While not every doctor may need to cultivate political connections, interviews suggest it certainly helps. The current system benefits doctors who are able to foster and sustain ties with politicians. In the words of a state B interviewee without access to these privileges: _“MOs with political and administrative connections are the winners in this system. Lack of formal transfer policy allows them to pick and choose the place of work. The option to get a transfer from a better place to a best place for these doctors is easy.”_ Willingness and ability to pay is another factor determining the likelihood of securing a transfer. According to two State B physicians who have had differing success in obtaining transfers: _“In my long 14 years of stay in one PHC, I tried to get transferred to other places closer to urban areas. Every attempt yielded no result since I was unwilling to pay for the transfers. The only method that will yield a transfer request is by payment. The local [politician] is the conduit and he quotes the amount as a “fee” to get the transfer or to endorse the transfer application...”_ _“This may not be the ideal system, but I at least have the guarantee that if I approach right persons and with appropriate price, I can get a transfer to a place of my liking.”_ Protection of private practice can also be a motivating factor. In the words of one state A physician: _“It is not uncommon to get protection from being transferred out for the sake of building up private practice, even if it means bending the rules of the department and/or buying the protection.”_ Demand for a specific post also contributes to length of tenure. A desirable post may be coveted by an MO with sufficient political connections and ability to pay, resulting in the issuing of transfer orders to the incumbent. But the latter can respond by garnering political support (e.g., reaching out to higher level politicians and administrators) or making payments to fend off the transfer. Conversely, if the post is not wanted by others due to its undesirability or if the incumbent physician refuses to pay for a transfer, she may remain there for many years.

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# (d) Promotions

The research found only indirect evidence of parallel systems in promotion processes. However, the findings show promotion processes are irregular and that performance, however defined, is not a criterion for promotions. Promotion processes follow broader Civil Service Conduct Rules in both states. Eligibility for promotion in both states requires at least 12 years of service, completed annual confidential reports (ACRs) and absence of disciplinary actions. As is the case across the Indian public service, seniority is the principal if not only factor determining promotion to a higher cadre.<sup>16</sup> Table 4 displays the findings of the perception surveys for promotions in each state. The main difference relates to the seniority criterion. Physicians in State A consider that promotions are based on seniority (63 percent) while only a minority of their State B counterparts (29 percent) shares this perception. Only 17 percent of State B respondents consider that promotion criteria are followed.

**Table 4:  Promotion in States A and B Perception Survey Results 2011,** **<u>(in percentages)</u>**<sup>**a**</sup>

||**% Agr**<br>|**eeb **<br>|
|---|---|---|
|**Summary Statements**|**State A**<br>**N=273**|**State B**<br>**N=266**|
|The Departmental Promotion Committee (DPC) is constituted regularly|26.7|6.4|
|Time-bound promotions are being given|23.4|N/A<sup>C</sup>|
|Promotions are done based on the departmental seniority lists|62.7|29.1|
|The promotion process follows the promotion criteria of the department.|N/A<sup>d</sup>|17.2|
|The Confidential Reports (CRs) are being filled in annually|32.3|57.7|
|Ultimately, it is the MOs, who have to ensure that their updated CRs are sent to the|||
|DH, at the time of promotions|68.4<br>|57.5|
|MOs have to oblige in unofficial payment to department staff to get their personal|N/A<sup>d</sup>|77.2|
|filesprocessed faster.|||

aPercentage based on valid responses (exclude missing data) bCombines responses for “agree” and “completely agree” cTime bound promotions not specified in State B rules d Statement not included in State A survey.

In both states, the promotion process suffers several shortcomings. Securing documents for promotions is challenging. Only 32 percent of respondents in State A, and 58 percent in B, agreed that ACRs are completed regularly, and the majority agree that physicians themselves must ensure completion and submission of the reports. Further, only 27 and 6 percent of State A and B physicians respectively agreed that the Department Promotion Committee (DPC) is constituted regularly.

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However, parallel systems are used to facilitate paperwork. DHs are notorious for sluggishness in maintaining up-to-date personnel files. Since files such as ACRs must be in order to administer promotions respondents report that they often must pay to expedite the process (77 percent in State B).

Even if ACRs were completed in a timely fashion and DPCs met regularly, several other factors contribute to the reported scarcity of promotions (see Table 2) and suggest that career advancement is not a major motivation for physicians. First, differences in salaries among grades are marginal and offer little incentive for physicians to seek promotions.<sup>17</sup> Second, the mandatory transfer (upon promotion) may not be desirable. For example, 64 percent of respondents considered that the primary reason that many MOs do not seek a transfer or forego promotion is to protect their private practice. Further, except for rural facilities, posts don’t become vacant for long periods, and as seen earlier, rural posts are generally undesirable. Thus promotions may be undesirable unless they lead to a leadership position such as district medical officers or departmental health within DH (both of which would usually require significant political support). Third, interviews suggest a widespread acknowledgement that promotions are unrelated to performance. As mentioned, seniority considerations dominate promotion decisions. ACRs are only a qualifying requirement and not used to decide priority for promotion. As a performance evaluation mechanism, they are often considered subjective and discretionary; ACRs need only be completed and on file.

# (e) Disciplinary Practices

Disciplinary actions were lax in both states and certain aspects were found malleable to parallel systems. Similar to promotions, both states follow Civil Service Conduct Rules for disciplinary actions against medical officers, applying more or less similar processes. However, one key difference is that State A has created a disciplinary cell which is headed by a DH Deputy Director. Consonant with more informal management of HR processes, State B does not possess such an organizational structure, allowing for greater subjectivity in disciplinary practices.

Table 5 presents the PS findings. The results are generally similar in both states. Over 60 percent of respondents agree that disciplinary actions are not implemented effectively. Grievance mechanisms appear more dysfunctional in State B (81 percent of respondents) than State A (64 percent respondents).

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In both states, however, the majority of respondents agree that upon facing a disciplinary action, physicians seek informal resolution by approaching their immediate superiors for minor infractions or higher level officials for major infractions. Contrarily, it is also in the interest of health officials to informally resolve such matters to avoid litigation, unwanted press inquiries and perhaps more importantly, interference from physicians’ political allies.

**Table 5:  Disciplinary Processes and  in States A and B Perception Survey Results 2011,** **<u>(in percentages)</u>**<sup>**a**</sup>

|**Summary Statements**|**% Agr**<br>**State A**<br>**N=273**|**eeb **<br>**State B**<br>**N=266**|
|---|---|---|
|Disciplinary actions are not implemented effectively in the department|63.6|63.4|
|There is no proper grievance redress mechanism in the department|63.5|80.8|
|In case of small issues, MOs approach their immediate superiors|82.8|92.7|
|In case of grave issues, MOs approach higher level authorities|93.3|95.3|
|Some MOs who had committed “grave deviations” and face disciplinary action had<br>‘managed’ to come out of them without apunishment|61.2|58.6|

aPercentage based on valid responses (exclude missing data) bCombines responses for “agree” and “completely agree” About 60 percent of PS respondents in both states perceive that MOs are able to avoid sanctions when facing charges resulting from “grave deviations”. The UCT survey results (not displayed in Table 5) confirm that MOs can circumvent disciplinary actions through unofficial dealings and side payments. A much higher proportion of State A respondents (91 percent) considered this to be the case than their State B counterparts (58 percent agreement). These findings suggest that the formal processes established in State A are readily bypassed by physicians facing disciplinary actions. For example, during in-depth discussions physicians confirmed that political connections are used in overcoming charges. One MO in State A commented: _“In one instance, the District Health Officer had to accommodate the request by a Minister’s representative in not initiating disciplinary action. The MO had been found not attending PHC work for more than 4 months without formally applying for leave.”_ Another example of parallel systems involves avoiding undesired “repostings” following disciplinary actions. PS respondents consider “managing” reentry after unauthorized leaves (e.g., absenteeism) 16
prevalent in both states (76 and 62 percent of States A and B respondents respectively). Despite the existence of formal rules and the special disciplinary cell to handle such cases, the findings suggest that this practice is more common in State A. To facilitate reentry and secure a preferred location in a subsequent reposting, physicians can make financial payments or use political connections, as confirmed by over 75 percent of State A PS respondents and nearly 70 percent of State B respondents in the PS. This is also reflected in the following statement by an MO in state A: _“MOs . . . that are absconding from services spend money to get the reposting. There have been instances of serving MOs absconding from service and working overseas. When they return, by spending money, they get their reposting...”_

# (f) The Market and Its Movers

The findings from interviews and focus groups suggest the existence of a market for physician postings and transfers.<sup>18</sup> For example, several interviewees in both states voluntarily stated the price for various posts, claiming that the price is well-known and “post specific.” The value depends on several criteria, including proximity to urban centers and the existence and location of a physician’s private practice. Payments are allegedly channeled to politicians, senior administrators, or both; but many physicians claim that the largesse is shared with administrative staff (see below).

Paying for a posting or transfer is not a one off transaction. For example, to be successful in private practice, prolonged tenure is paramount. To avoid getting ‘bumped out’ by another MO, it is not uncommon to “buy protection” by making regular “installment payments” to retain a favored post (e.g., one which allows or maintains easy access to private practice). According to a State B physician: _“[for] MOs with a thriving private practice, the desirability is to continue to remain undisturbed. Local politicians keep tab on the MOs with private practices and a price has to be paid in regular intervals. Failing to keep the local politician in good humor usually results in figuring the MOs in the transfer list, and price of getting it reversed or stopped costs higher than the regular ‘fee’ to be paid in intervals.”_ 17
Most transactions are arranged through known intermediaries. A theme that dominated the research is the role of ‘political agents’ - usually relatives or personal secretaries of the elected representatives and departmental administrative staff, referred to more widely as clerks. These agents facilitate access to political leaders and higher level officials for favorable treatment in the four HR functions under study here. For example, these intermediaries contact MOs regarding undisclosed post vacancies in desirable locations or are contacted by physicians regarding the same. They also serve as conduits for channeling payments received by MOs. In the words of respondents from State A and B respectively: “ _To expedite the transfer request, one is expected to give money to the clerks at various levels.”_ _“The agents approach the MOs or even other government officials offering service to get transfers done. It is also not uncommon in some cases where the MO is desperate to get the transfers, usually know whom to contact and how to approach the local public representative holding [a key] position.”_ A high percentage of perception survey respondents (74 and 75 percent in States A and B respectively) consider that these agents “play the role of conduits for MOs to get a desired place of postings.” Similar results emerged from the UCT survey where, for example, 89 percent of State A respondents considered that “department staff exercise undue authority over MOs and indulge in unofficial financial dealings.” Physicians seeking a transfer usually have to pay on both ends of the transaction: the intermediaries as well as the final designator or decision maker who arranges the requested action (e.g., posting, transfers, etc.).

# (g) Perceptions by Physician Characteristic

To check whether perceptions reported in the survey varied by specific traits of the respondents, we regressed probability of agreement with statements related to the four human resource functions on certain physician characteristics.<sup>19</sup> Annex Table 1 presents selected results by one characteristic: years of tenure.

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Agreement on posting preferences was found to be fairly stable, and preference for facilities close to native place of residence, urban areas, and areas promising adequate educational opportunities for children do not vary systematically with physician characteristics in either state. Longer-serving physicians were significantly likelier to agree with a general preference for facilities near urban areas, as well as those with better opportunities for private practice, than were less experienced ones.

Perceptions that processes for postings, transfers, and promotions are generally open to manipulation through political and financial means was widespread and probability of the agreement did not vary systematically with physician characteristics. The only exception was in the case of agreement on use of unofficial payments to modify posting orders in state B: the more experienced were between 20-40 percentage points more likely to agree than those with less than two years of experience. In State A, however, physician tenure was negatively associated with perceptions of parallel systems, though the association was not significant. In general, the longer a physician is in the system, the more familiar he is with the shortcomings of the de jure processes that ought to be followed, and the more keenly he observes de facto deviations from them.

# 5. PARALLEL SYSTEMS,  THE INSTITUTIONAL CONTEXT AND ORGANIZATIONAL PERFORMANCE

Using diverse methods, this study measured the perceived incidence of deviations from formal rule sets and parallel systems in HRM practices in the health sector in two Indian states. In this section, we synthesize the findings of parallel systems related to institutional environment, organizational performance, and potential impacts on service delivery.

# (a) The Institutional Environment and Organizational Performance

What do our findings suggests about the functioning of the institutional environment and organizational behaviors governing Indian state health authorities in rural areas? We offer several propositions.

Parallel systems governing HRM practices are widespread in both states and engender an environment of low rule and policy credibility and lax organizational discipline. HRM rules, where they exist, are applied 19
in an ad hoc way. Senior physicians in rural facilities have come to expect that such can be easily bypassed. The incidence of de facto parallel HRM practices in a post-reform institutional environment (state A) where there is more specification of rules and processes (e.g., counseling) and special units to enforce disciplinary practices (e.g. disciplinary cell) displays only marginal differences from a pre-reform context (state B) in which informality is essentially institutionalized.

Parallel systems are predictable, and similar to the findings of Wade (1985) and Davis (2003) on the irrigation and water-sanitation sectors, probably operate like markets in which desirable positions are for sale. However, the findings also suggest that physicians with well cultivated political connections can secure and retain desirable posts without payment. Certain HR procedures (such as processing of ACRs) can be facilitated through side payments. Some administrative practices, such as withholding information on the availability of desirable posts, may be both a cause and effect of a parallel system determining the assignment of posts.

Physicians act rationally in their response to the incentives of parallel systems. Their behaviors are motivated by preferences - which depend on their career status, desire for PG (specialist) studies, family residence or whether they practice privately - with the system responding to such rational choices. However, not all physicians are able to take advantage of the system. In general, it favors those who have developed strong political ties, are willing to pay and able to pay.

HR policies apparently do not have political backing and there is no clear or effective delegation of authority to administrative officials regarding important HRM functions. Politicians appear engaged in well-organized parallel systems involving the micromanagement of HR decision making, at least in the case of physicians. Lower level political handlers and DH administrative staff serve as conduits for arranging financial and non-financial deals, particularly in the case of transfers and postings.

Finally, the morale and organizational commitment of physicians appear to be low. For example, in State B, over three-fourths of respondents stated that they would leave public service if the state lifted its moratorium on voluntary retirement – even if opting out of government services would result in the loss of all accrued retirement benefits.<sup>20</sup> Opportunities for career advancement appear limited. Parallel systems can result in anomalies such as those found in both states where physicians abscond from their posts (e.g. unauthorized leave) or use authorized medical leave to avoid undesirable postings.

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# (b) Impacts on Service Delivery

Although the study did not directly examine the link between parallel systems and health system performance, the findings suggest several hypotheses. The lack of organizational commitment may contribute to the low levels of effort observed in public sector physicians (Das and Hammer, 2007), contributing to inferior quality of care. Further, physicians absconding from their posts (whether as authorized leave or not) usually are in remote areas and of greatest need to patients there. Such practices may contribute to the high rate of physician absenteeism observed in rural PHCs in India (Chaudhury et al, 2005; Banerjee, Duflo and Glannerster, 2008; Cheriyan, Arya and Singh, 2010).

The study also finds that the most undesirable posts are allocated to new recruits (e.g., recent medical school) with limited experience and usually deficient training and supervision to provide good quality care. However, the new recruits seek these positions to facilitate admission to PG (specialist training) programs. This may contribute to the phenomenon observed by Das et al., 2012 in which higher quality doctors are generally located in well-off areas in and around urban areas while the lowest quality physicians are generally found in remote tribal areas.<sup>21</sup> The institutional environment and corresponding organizational behaviors appear only marginally related to results. Promotions are unrelated to performance (which is rarely assessed) and even severe disciplinary breaches such as unauthorized and long-term absenteeism are not sanctioned; instead absconders can make use of parallel systems to be reinstated with back pay and benefits. Under such a system oversight to enforce attendance and work rules would be daunting tasks.

# 6. EXPLAINING PARALLEL SYSTEMS

We review four possible interpretations explaining the endurance of parallel systems in India’s public health systems: political economy, divisions among physicians, citizen demand for private care and physician shortages.

One explanation is the dynamic between patronage politics, bureaucratic politicization and lack of citizen voice (Mehta, 2003; Saxena, 2005). Although in principle administrative structures in India are separate 21
from politics, in practice, these dimensions are closely tied. It is the nature of the bureaucratic – political bonds in India that drive the emergence and continuity of parallel systems.<sup>22</sup> Students of Indian public administration suggest that because local politicians in India must draw on their own financial resources to fund political activities they face strong incentives to raise financing through managing and intervening in HRM functions.<sup>23</sup> There remains much less public outrage than may have been expected given the low performance of the public health care system observed in public health service delivery. While it may be debated whether patients in poor areas have ‘exited’ from using the public system to private providers (Hirschman, 1970), the current reality remains that a large section of the poor – the intended beneficiaries of public services - seek health care from private providers, some of which are less than fully qualified. Household surveys show that over 80 percent of outpatient care is provided by private providers (MSPI 2004). This may partly explain why local politicians, with very few exceptions across Indian states, do not make health into an electoral issue or held accountable for the low system performance.

Given that some physicians perceive themselves as victims of parallel systems, it would be logical to assume that there could be instances of collective action to bring about HRM reforms. With the exception of one state (described below), this has not been the case. Part of the reason may stem from the fact that the physicians are themselves divided as a group, with many invested in maintaining the status quo (whether the older generation in senior administrative positions or those who are able to make the system work in their favor).

Another reason may relate to instances of positive deviations in which parallel systems are used to post qualified and motivated physicians where need is greatest. A small subset of interviewees corroborated such arguments and would signal more positive conclusions from the workings of the current system. For example, those in favor of the continuation of the current parallel practice argue that it allows physicians to rally community support behind ostensibly ‘good service’ to pressure a local political leader to use his influence on the health department to block transfers. Good doctors, or those perceived to be good doctors, laboring in PHCs enjoy immense popularity among the community and getting or retaining highly performing doctor posted in their constituency can contribute to the popularity of local politicians.

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The inability of state governments to fill sanctioned positions due to a broader physician shortage in India is also argued to facilitate parallel systems and weaken implementation of existing rules. Given high vacancy rates, doctors posted to less favorable or remote postings can bargain through informal means to secure preferable postings where vacancies remain. In a context of significant doctor vacancies in PHCs, the bargaining position of serving doctors is strengthened and they can therefore overturn a posting or transfer order by relocating to vacant posts of their choosing by making use of parallel systems, and thereby undermining rules and formal processes.<sup>24</sup>

# 7. ADDRESSING PARALLEL SYSTEMS

Changing the institutional arrangements to address the shortcomings highlighted in this study will be a formidable challenge in light of the fact that parallel systems are an embedded institutional modus operandi for HRM in Indian public administration. Most observers of the Indian administrative apparatus suggest that addressing parallel systems would require broad civil service and political reform.<sup>25</sup> Civil service reform would be required even for specific policies such as linking promotions to performance. The Administrative Reform Commission in India is among a handful of agencies in India that have championed large-scale government reform measures, with only partial success. While such reforms are possible in principle, they may take at least a generation to accomplish. Barring large scale civil service and political reform, there are some _within system_ approaches that, while not a panacea, can contribute to addressing the institutional problems detailed in this study.

First, bottom-up arrangements and structures for social accountability can be developed in which beneficiaries secure a greater voice in holding public officials accountable through civic engagement.<sup>26</sup> This approach draws on the mandate of the National Rural Health Mission (NRHM) to make health services more accountable to the people and aims to involve communities and local government institutions (Panchayati Raj - PRIs) in the monitoring of health services in part through supporting village health committees and facility-based health societies. For example, PRIs are expected to “own, control and manage” public health services; and the Village Health Committees of _Gram_ (village) _Panchayats_ (GP) are expected to develop Village Health Plans which would eventually be aggregated into District health Plans. PRIs also have to assume responsibility for monitoring health staff, for example, the attendance of community nurses at Sub-Health Centers (SHC) and their visits to their assigned villages.

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At the block and district levels PRIs have been inducted into the _RogiKalyanSamitis_ (RKS), health societies or committees that oversee and upgrade Block Primary Health Centers, Community Health Centers, District or other hospitals. RKSs receive lump sum “flexi funds” from NHRM to make facility improvements.

Second, accountability mechanisms – such as improving information availability and transparency on HRM practices (as is already underway in some states such as Tamil Nadu, Karnataka, Bihar, Odisha) – may be considered to build a more conducive environment to ensure accountability of HRM. Other additional measures would include, for instance, more systematized data collected on rule application regarding postings, transfers, grievances, etc. can generate more detailed audits of HRM practices by government auditors such as the Comptroller Auditor General (CAG). A proportion of central funding for NRHM can be made conditional on civil society reviews of HRM practices or state health departments can be incentivized to provide some tangible ‘achievables’ (e.g., publicizing all vacancies, approved transfers, initial postings etc.) that would raise rule enforcement and credibility.

Third, state authorities can enact new and more precise rules of the game governing HR functions. For instance, in 2005 the State of Tamil Nadu reformed rules and processes governing postings, transfers and promotions the purpose of which was to address parallel systems such as those analyzed in this report. Driven by a strong health department leadership and a powerful physician association, Tamil Nadu authorized career advancement schemes, defined a hierarchy of promotion and designation tracks, and set specific eligibility criteria, timelines and processes for postings and transfers. All vacancies are posted on the website of the state’s health department, suggesting greater transparency. The state’s physician association keeps a watchful eye on all processes and is quick to denounce any discrepancies.<sup>27</sup> Assessing the impact of these measures would be an important subject of further inquiry.

A fourth approach is empowering patients by providing them with choices in the health delivery system while forcing providers to be more responsive to demand, and therefore performance, since their financial well-being depends on it.<sup>28</sup> This is being achieved through a handful of central and state government sponsored health insurance schemes (GSHIS) launched recently by central and state governments. This approach is complementary to the aforementioned social accountability approach since it gives people additional freedom to select where they seek care and providers have an incentive to be responsive to them. While GSPISs are not a magic bullet,<sup>29</sup> they may provide a much-needed challenge to the current 24
subordination of the delivery system to top-down bureaucratic and political control, and the concomitant distortions analyzed in this report.

# 8. CONCLUSION

Based on the views of front line workers, our findings on HRM provide insight into reasons why public service delivery in India’s health sector demonstrates low performance while providing a deeper understanding of how the institutional environment really works. As India moves forward to achieve its laudable goal to significantly increase public spending for health and extend coverage to all its citizens, we recommend it support initiatives that challenge the institutional status quo. Creating more doctors will not address the root causes of current institutional arrangements that contribute to low worker commitment and effort. While large scale civil service reform will take many years and may not be politically feasible, there are alternative solutions already under implementation in India that need greater consideration today. The government can strengthen its investment in empowering social accountability mechanisms and incentivize HRM administrative reforms that nearly all states should adopt as a priority. Further, the government can empower the poor in enforcing choice in the health care they seek through a focus on increasing subscription to government-sponsored health insurance schemes. Scaling-up these approaches will require strong leadership, a combination of top-down and bottom-up engagement, and a willingness to experiment, promote on-the-ground solutions and apply learning-by-doing approaches (Andrews, Pritchett and Woolcock, 2012).

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