Gearing public/civil service reform to the health agenda rather than efficiency

As well as the human resource issues of increasing coverage of services to poor people, there is an emphasis on improving efficiency of human resource utilisation. Often civil service reform has focused on reducing staffing numbers but the sustained improvements have been elusive (Civil Service Reform: a review of World Bank assistance). Although efforts to improve efficiency cannot be ignored, the main focus has to be on improving effectiveness of service delivery.

Efficient but largely ineffective service delivery wastes most of the expenditure – inefficient but effective service delivery wastes only some of the money. The message for human resources must be to concentrate on effective use of human resources rather than efficient use of human resources.

Arriving at clear, universal principles to guide HR management in all health sectors can be difficult: health systems vary widely, and models of HR practice tend to focus on individual firms rather than complex national systems like health provision. However, three general principles can be arrived at to guide the development of effective HR strategy:

• Ownership: an effective HR strategy must be owned by key stakeholders, including ministry officials, trade unions and staff. The use of widely-agreed mission statements and corporate values, and clear messages about the goals of HR strategy can help foster ownership.
• External fit: HR strategy should be in line with the external health policy environment if it is to be effective. Crucially, HR strategy should be developed as part of the organisation’s overall policies and agendas, rather than as a separate means of quantifying the numbers of staff needed at different levels.
• Internal fit: personnel policies need to be internally consistent if they are to be effective. Competency frameworks can help ensure ‘internal fit‘, by linking HR needs to the attitudes and behaviour of staff.
  

The World Bank supported civil service reforms (CSRs) during the 1980s and 1990s as a means to remove what it saw as institutional impediments to market-led development in client countries. The Bank's own review of these reforms suggests that they were largely ineffective in achieving sustainable results in downsizing, capacity building, and institutional reform. Recommendations include re-
categorisation of CSR interventions, and increased monitoring and standardisation of CSR performance indicators.

Presenting an analysis of data obtained from a 1999 survey of public officials in Bolivia the authors of The experience of public officials in Bolivia: what works in a weak institutional environment? use detailed survey data to map the points of weakness, and to identify the characteristics of organisations within the public sector that seem to be working well. The report draws conclusions regarding targets for reform and lessons that can be learnt. The premise for the surveys is that the performance of public officials depends upon a series of factors. These factors include their institutional environment, the trust that they have in the future, the degree to which they believe that rules will be enforced, belief that resources will be provided, and belief that policies will make a difference.

Health sector workers respond to inadequate salaries and working conditions by developing various individual ‘‘coping strategies’ — some, but not all, of which are of a predatory nature. The paper When staff is underpaid: dealing with the individual coping strategies of health personnel reviews what is known about these practices and their potential consequences (competition for time, brain drain and conflicts of interest). By and large, governments have rarely been proactive in dealing with such problems, mainly because of their reluctance to address the issue openly. The effectiveness of many of these piecemeal reactions, particularly attempts to prohibit personnel from developing individual coping strategies, has been disappointing.