AM Zakir Hussain

HEALTH is a labour-intensive sector. Globally, about 45 per cent of the total expenditure in the sector goes to managing human resources. Human resources in the health sector work in a dynamic atmosphere. Like any other service sector, the health sector also has two facets – demand and supply side. On both these fronts it is the human resources that wield the mantle.

As in an automobile, where the driver is the most important factor, not withstanding the importance of its passenger and/or the owner, the health sector also hinges on the health workers, including the professionals and the para-professionals. If we agree to this proposition then we know where to put the bucks. Yes, it is the health personnel who should get priority in terms of expenditures and attention. To an uninformed stakeholder it might sound awkward but the fact is if you cannot ensure commitment and dedication of the health personnel then all other resources become meaningless in their hands, as those would either remain unutilised or be used inefficiently due to either lack of enthusiasm or transparency or lack of expertise. Those who do not agree will, I am afraid, fix a cart before the horse, with all its consequences.

It should, therefore, be in the fitness of things that the first and the foremost consideration is given to develop human resources in the sector in such a manner that fulfils the expectations, which it is paid up for. And, what are the expectations? Well, there are in fact plenty. For one thing, they are expected to serve the ailing humanity and serve those well who seek out and need health, i.e. this service would be an intervention that would be effective in terms of reducing the suffering of those who seek help.

Suffering comes in many shades and hues, e.g. length of suffering, cost of suffering, and consequences and end result of suffering. Cost of suffering in economic terms would mean price of medical service, wage foregone and other marginal or opportunity costs that are borne by the sufferer and not to talk about the individual, familial and social costs or costs that is incurred from the lack of well-being. This means the human resources in the health sector, unlike most other sectors that do not in fact deal directly with human being, need to be responsive to the health needs of the people, which in effect mean that they need to be sensitive to the multifaceted ramifications of these needs.

This partly comes from the family background, i.e. how s/he has been raised in the family setting – what are the family values which a future physician will grow up with and also partly on how and which environment s/he will be taught in. This implies that every health personnel need to be tested very meticulously before s/he is recruited or even selected for the sector, to assess his or her attitude to life – his or her own and of others, that s/he will be expected to serve. This also means that the very best ones are required to be chosen, because it is a matter of life and death of human beings, which will be bestowed in their hands. We also need to appreciate at the same time, however, that the very best does not come cheap, i.e. s/he needs to be remunerated as a very best buy.

What are the present methods and techniques of developing the human resources and then recruiting and managing them in the health sector? There are several arenas we need to explore in order to answer this question, e.g. needs of human resources in the health sector in terms of number by categories or types and by geographical location. By categories or types we mean type of service providers by sex and by technical background, e.g. physician by specialisation, nurse, paramedic, etc. Before gauging the needed number we need to decide certain parameters of standards, i.e. what should be the ratio of different categories of service providers and the service recipients, e.g. specialist: population ratio, nurse: physician ratio, etc. Not to miss the point, these will be affected by the topography or the transportability of a place as well.

Specialisation will again depend on the disease pattern or health risk of a place. Its skill mix will also depend on the socio-cultural or religious sentiment of a place. Some of the places may be more conservative than others and will, therefore, necessitate more female health staff, etc for female service seekers for example. This will also be determined by other quality factors, e.g. what should be the optimum time for a consultation and patient examination, which will, of course, vary according to the gravity and nature of a given health problem. Another determinant will be how skilful a health-care provider is, not only in terms of technical skill but also as a conversationalist. As these will affect the number of diagnostic tests, for example, that a service provider might require; which might thereby delay the contact time between a service provider and service recipient and also escalate service costs. Transparency in the administration and good fiduciary arrangement are issues again which will also have some bearing.

The numbers are crucial because a system has to operate, exhibit and ensure efficiency through especially personnel management. This necessitates knowledge about the exact requirement for a given category of staff or skill mix. The present trend in Bangladesh, however, is to establish more hospitals and, therefore, more medical colleges and paramedic and nursing institutes to stow into these hospitals. In the competition between ‘prevention is better than cure’ and establishment of ‘disease palaces’, it is always the former that takes drubbing politically. A recent prospectus of a ‘now in the offing’ medical college even expects to export physicians to foreign countries for earning foreign currencies, citing examples that in the US almost 40 per cent of the physicians are from India. Isn’t there a need to assess how much these expatriate physicians in actuality are sending remittances or how many of them would in fact ever serve the people of their own nation and how much would be the net return of the investment that a country has to make to produce these physicians for other countries!

We need to ponder more deeply on the way the health sector personnel are developed, recruited and managed. There is no consensus, as we have seen earlier, on what the total number of various categories of physicians, nurses or various categories of diagnostic technicians, etc in the country should be. Any need assessments that are claimed to have been conducted so far do not really make any sense, because unless you have a standard what would be the yardstick for the measurement of need, for example?

A fundamental question would be what the health sector service providers should be required for. Answer to this question is necessary to decide as to what should be the medical, paramedical or allied education or training and curricula like for these service providers. This should not need any emphasis that the training or educational curricula should be trimmed around the needs of the people of the soil. It would not be only physical or medical need but social and psychological need of the people as well. Making required services available will not suffice. The basic education or in service or pre-service/pre-placement training also has to consider the fact that the service providers, in addition, have to learn the art of making the service recipients interested enough to avail those services. This part is totally ignored in our medical and allied educational system.

Recruitment process even for the professionals in the health sector is questionable. What does the Public Service Commission look for in a candidate for example, before one is recommended for recruitment? Will it be wrong to say that it has failed the expectation of the people of the country? If not agreed to, then we will be tempted to ask why then those who are recommended for recruitment by the Commission for public jobs in the health sector fail so miserably in delivering the expected goods to the teeming millions? Something is wrong somewhere, isn’t it? Where is it going wrong then and who is responsible for this?

Lastly, if one believes that man behind the machine is more important than the machine itself then very obviously the personnel management system in the health sector should get the number one priority. Amazingly this is one area that the decision-makers in the health sector seem least bothered about. Neither do the medical curricula have topics on personnel management nor are the managers trained on management during their in-service period, with any degree of seriousness. The result is obvious and staring at our face. If we could only recognise it for the sake of the wretched people of this country.

M Zakir Hussain is health-sector management and public-private partnership specialist

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