In this first of a three-part blog series on the IRD-CHMI Health Market Innovations Hub in Pakistan, we provide an overview of the first meeting of the Hub Working Group Members and discuss key lessons-learnt around human resource for public health.
Operating in Pakistan presents an intricate milieu of social, economic and political considerations. Innovative programs in the country often face a similar set of challenges, yet few have regularly shared learning or documented best practices. Advocates for innovative approaches, such as social business models for private healthcare, find a very challenging environment. In addition, programs struggle to reach meaningful scale and to further expand services.
In response to this knowledge gap, Interactive Research & Development (IRD), as CHMI’s Regional Innovation Broker for Pakistan, has developed a Health Market Innovations Hub. This initiative brings together organizations from across the spectrum of healthcare delivery in Pakistan in order to enable the scale-up and replication of promising health market innovations in the country as well as to promote the establishment of linkages between organizations. This is the first of three posts relating discussion and results from this work.
Harnessing the large private health sector in Pakistan
Nearly three-quarters of Pakistanis now seek healthcare through the private sector. A large and unregulated private healthcare delivery system has mushroomed given poor standards of quality and care within the public healthcare infrastructure. Few national efforts have succeeded in protecting individuals from catastrophic healthcare related financial shocks.
In the last few years, government agencies and private-sector groups have sought to increase access to healthcare for low-income communities through innovative programs and market-based interventions. Unfortunately these initiatives remain grant dependent and often struggle to ensure sustainability once funding is exhausted.
Health innovations conclave in Dubai
In November 2013, the IRD-CHMI Health Markets Innovations Hub convened the inaugural meeting of its Innovation Working Group members at the Interactive Group offices in Dubai. The goal of this platform was to invite a group of organizations that could contribute to the body of evidence for the growth of the health market innovations space in Pakistan, keeping in mind the contextual realities of the country and to suggest solutions to overcome them.
Human resource strategies to fight brain drain
The Working Group explored topics including the scale-up of services, sustainability, impact evaluations, public-sector linkage, and the use of technology in health. Based on demand from participants, we also added a session focusing on acquiring appropriate human resources for public health and services delivery. We discussed recruitment, building appropriate incentives, and ensuring career progression within the public health and development sector in Pakistan.
The participants acknowledged challenges in two broad areas, making the distinction between staff involved in management, research or programmatic activities and staff required for field-work. For the former group, the primary challenge is in ensuring talented individuals stay in the country—although “brain-drain” is not unique to Pakistan, recent socio-political circumstances have accentuated the process.
Participants discussed various staff remuneration models and noted that HR policies in the development sector were quite distinct to those practiced in the corporate sector. For example, only larger organizations offer online recruitment portals, provision of car and fuel allowances, and bonuses linked to outputs on key performance indicators.
While payment was an important driver in attracting talented human resource, non-monetary incentives can also aid in low turnover, in particular for young individuals. Flexibility in supporting concurrent education or allowing study-leaves for completing higher qualifications is also important. One example is utilizing the Fulbright program in Pakistan, which supports tuition fees for graduate education and contributes towards our capacity development.
Some professional specializations come with unique challenges. For programs with information technology requirements, recruiting and retaining software industry professionals is difficult in a project-driven environment. Some participants suggested recruiting recent graduates from local computer science programs and providing them with on-job training, which can foster incremental capacity growth within an organization.
Building research capacity
Participants said that people retuning to Pakistan after having trained in research-oriented programs in the west sometimes struggled to continue pursuing their research goals, given the tendency of organizations to have larger budgets for programmatic rather than research purposes. Given operational challenges and commitments, publishing manuscripts and carrying out research activities often becomes challenging. Participants discussed using an academia-based model where salary support was distributed across grants for managers and researchers. Some suggested leveraging existing or actively developing new networks at foreign universities and collaborating for research projects where academics can use field-sites established by programs for research projects. This not only supports the development of research capacity in the organization, it also provides financial support.
Challenges in recruiting and sustaining quality field-level staff
The participants highlighted well-known challenges around poor literacy and education levels for field-staff. They pointed to high turnover, with employees switching jobs based on offers of very modestly higher remuneration elsewhere, often as little as an additional USD 3 per month. One implication is the high cost of training new staff members, of particular concern to programs operating in rural settings with additional costs for monitoring and supervision.
Many said incentives linked to staff performance could help scale up public health programs. This way, expenditures can be linked to program objectives, programs can allow for flexibility for part-time work and also reward entrepreneurial abilities. Social franchise models cited several successful instances of franchisee sustainability and recovery of loans and capital investments. However, high programmatic and monitoring costs for ensuring quality are barriers towards the operations themselves becoming self-sustaining. Providing health insurance plans to employees was cited as an important non-monetary incentive and an important source of minimizing employee turnover.
One solution could be to improve health information systems that monitor the performance of health workers and simultaneously improving patient outcomes.
Stay tuned for more insights from IRD, CHMI’s regional innovation broker in Pakistan.