Right place of human resource management in the reform of health sector.

BACKGROUND: In this paper the real role and place of human resource (HR) in health system reform will be discussed and determined within the whole system through the comprehensive Human Resource Management (HRM) model.
METHOD: Delphi survey and a questionnaire were used to 1) collect HR manager ideas and comments and 2) identify the main challenges of HRM. Then the results were discussed in an expert panel after being analyzed by content analysis method. Also, a deep focus study of recorded documents related to Health Human Resource Management was done. Then based on all achieved results, a rich picture was drawn to illustrate the right place of HRM in health sector. Finally, the authors revitalize the missed function of HRM within the health sector by drawing a holistic conceptual model. RESULT: The most percentage of frequency about HR belongs to "Lack of reliable HR information system" (91%) and the least percentage of frequency belongs to "Low responsibility of HR" (28%). The most percentage of frequency about HR manager belongs to "Inattention to HR managers as key managers and consider them in background" (80%) and the least percentage of frequency belongs to "Lack of coordination between universities' policies" (30%). According to the conceptual framework, human resources employed in health system are viewed from two comprehensive approaches: instrumental approach and institutional.
CONCLUSION: Unlike the common belief that looks HRM through the supportive approach, it is discussed that HRM not only has an instrumental role, but also do have a driver role.

Introduction

Often in the past, human resource management (HRM) has been isolated in a far corner of organizations, institutions and companies, preoccupied with hiring, training personnel and paying salaries and benefits and disconnected from the strategic goals and directions of the institution (1). That is because of Many people have traditionally equated HRM with “personnel administration” (i.e., hiring and job placement, employee salaries and benefits, compliance with labor laws, etc.). But now days many management experts and organizational leaders believe that HRM can be expected to play a much more important role in organizations and companies in the next years (2).

If we look more carefully and systematically at the functional impact of HRM in the current health system, in comparison with the past, then we would understand that the HRM not only is a single-functional job, but also is a multi-functional process involved the functional cooperation of all subsystems working within the health system. Therefore meeting the goals of any kinds of reform in the mentioned sector required to determine the functional and institutional place of HRM in relation to the other components of the whole system (3).

The efficient and effective management of human resources is an essential component of a high performing health system and can influence the success or failure of health sector reform and different organizations or institutions, In a way that employees counts as key to the delivery of health services and any health program. Improved management makes a positive difference in effectiveness, efficiency and sustainability of health services and a positive difference in health sector reform. But the most important problems the health care system has been facing are due to neglecting the place and the leveraged position of the HRM in recent years. In fact, the current so-called HRM function in health sector fall into the category of personnel administration, including recruitment and hiring processes, employee contracts, personnel files, performance appraisal, staff training and maintenance and assuring compliance with labor laws. They are also involved in the payroll and staffing contingency plans. In spite of the mentioned function, the health sector is still suffering from some basic challenges due to the malfunction of current human resource administration (HRA). Hence, for revitalizing the right place of human resources and the strategic role of human resource management within the whole system we need to redesign the former so-called HRM system and establish a new one through mapping a comprehensive model of HRM system with regard to changes happening in Work force competence and performance due to rapid, continuous change in the external environment (4).

In the newly redesigned HRM system, Multiple HRM roles are mentioned and introduced along with the personnel administrative functions of current system (recruitment and hiring processes, employee contracts, personnel files, performance appraisal, staff training and maintenance, assuring compliance with labor laws and payroll and staffing contingency plans). These roles include: 1) management of strategic human resources 2) management of firm infrastructure 3) management of transformation and change and 4) management of employee contribution (2).

As it was mentioned the importance of management of human resources and the way with which HR are managed, are to vital factors determining success or failure of health sector reform (5). Looking at existing documents of planned reforms in different countries, even reforms that have tried to improve working environments and incentives, have not always had the anticipated impact on health system effectiveness (6). One of the most reasons relates to the surprising lack of attention to the human (worker) elements of reforms, In a way that only recently meetings and papers begun to address human resource development issues in the context of health sector reform (5).

So with regards to 1) the vital role of HRM in success or failure of health sector reforms, 2) necessity of revitalizing the current traditional system of HRM to determine the right place of HRM in health reforms through redesigning the former so-called HRM system and 3) the necessity of changing the approaches to HRM from an instrumental to the institutional one, it is essential to introduce a comprehensive HRM model which meet the above mentioned necessities.

Hence, in this paper the real role and place of human resource in health system reform will discussed and determined within the whole system through the comprehensive HRM model.

Materials & Methods

In order to analyze the current status of HRM and determine the role of HRM in the function of mentioned sector, different actions were taken:

– We conduct surveillance through codifying a questionnaire. The questionnaire itself included some categorized open questions that were utilizing by the help of Delphi technique. The questions were graded into two following divisions:

○ The challenges which are faced by HR in health sector.

○ The challenges which are faced by HR manager in health sector.

– The questionnaires were distributed among HR managers of 46 universities of MoHME. Then the received data (HR manager ideas and comments) were analyzed through applying quantitative content analysis method by the help of which we extract the frequency of responses. Next, in order to identifying the main challenges an expert panel was formed within which the acquired and analyzed frequencies were discussed. Then according to the reached accord of the present experts, the most frequent phrases (chosen by approximately 75% of managers) were selected the main challenges (7).

– Along with running the expert panel, a series of deep focus studding of recorded documents regarding to HRM in the health field, was launched.

– Then based on all achieved results, a rich picture was drawn to illustrate the right place of HRM in health sector (8).

– For making sure that the picture is reliable and comprehensive enough to include all essential and impressive factors and their interdependent relations, the first draft of it was sent to some well-known HR professionals and health sector stakeholders.

Generally, by drawing such holistic conceptual figure, the authors wanted to revitalize the missed function of HRM by illustrating the identified characteristics and HRD capacity of human resource management system within the health sector (9).

Results

Health care sector as an immense system consists of some sub-systems carrying their task out and helping the whole system approach its goal. The point is that if only one of the sub-systems esp. those whose functions are vital and play a strategic role in the whole system, performs incompletely, then the whole system would not be able to function successfully, too. Therewith, any kind of coincidence in the function of the sub-systems would result in Inconsistency in the systems function (10).

Regarding the mentioned approach, findings are divided in two parts:

Extracted challenges

Since, a holistic approach to HRM system required to review the current status, a list of challenges (Table 1) was defined. Then, based on the determined indicator (frequencies upper than 75%), the main challenges was extracted which are introduced (within two main groups):

Table 1:

HRM challenges in point of view HR and HR managers

Group	Challenges	Frequency	%
HR	Inappropriate and unequal distribution of HR	40	87
	Lack of reliable HR information system	42	91
	low HR productivity	40	87
	low HR motivation	37	80
	High rate of expert drain from public health sector and from country	36	78
	Shortage of required HR	28	61
	Low payment to HR	20	43
	Inappropriate staff appraisal	21	46
	Inappropriate quality of HR	22	48
	Low responsibility of HR	13	28
	other	9	20
HR Manager	Inattention to HR managers as key managers and consider them in background	37	80
	Excess involvement in interpretation of HR laws and regulations	36	78
	Low authority	15	33
	Low mutual relations with headquarter managers	20	43
	Lack of coordination between universities’ policies	14	30
	others	10	22

○ HR challenges

○ Inappropriate and unequal distribution of HR

○ Lack of reliable HR information system

○ low HR productivity

○ low HR motivation

○ HR managers’ challenges

○ Inattention to HR managers as key managers and consider them in background

○ Excess involvement in interpretation of HR laws and regulations

According to the table 1 the most percentage of frequency about HR belongs to “Lack of reliable HR information system” (91%) and the least percentage of frequency belongs to “Low responsibility of HR” (28%). And the most percentage of frequency about HR manager belongs to “Inattention to HR managers as key managers and consider them in background” (80%) and the least percentage of frequency belongs to “Lack of coordination between universities’ policies” (30%)

Part B) real place of HRM

According to the conceptual framework, human resources employed in health system are viewed from two comprehensive approaches: the first one is instrumental approach and the other one is institutional. That would be described ahead:

– Instrumental approach: as shown in the rich picture, there are several levels of HR in the labor market. Some of these including experts, skilled, semi-skilled and blue color workers who provide services based on their knowledge (academic etc), experience and so forth. In fact, the HR in these levels, work according to specific job manual with limited authority in some jobs. Therefore, these HR are seen as instrument to achieve the system goals (11).

– Institutional approach: the two other main categories shown in the HR spectrum are super professionals and professionals. In these levels, HR shapes the system. In other words, the entire system and its performance are instituted by these people’s thought. Therefore, these resources not only account as supportive ones but also consider as the driver capital.

Based on the mentioned words, authors believed that human resource should not be considered as merely a supportive resource just like the other resource such as financial, physical etc. That’s because without the HR, either instrumental or institutional, the other resources doesn’t make any sense within the system.

Thus, the issue of managing these complex resources is more sophisticated than the resources itself. As discussed before, the so-called HRM, providing be properly defined, is Ideal Human Resource Administration but not HRM.

Properly defining HRM changes to a vital matter especially in health sector where there are direct relations between quality of policy and HR and population’s health. Hence, having holistic view, as shown in the framework, the HRM penetrated in all the dimensions of health sector.

Conceptual framework

As it is shown in the conceptual framework (Fig.1), we have tried to represent a systemic view of Human Resource Management, in the health care sector within which the ideal Human Resource Administration is distinguishable.

Fig. 1:

Comprehensive human resource management in health sector (Redesigned)

Moreover, we have tried to show the differences between the HRM and the ideal HRA, although it is important to mention that, the current HRA of health sector does not work properly as the ideal one illustrated in the conceptual framework.

According to the conceptual framework the education subsystem works and regulates its outputs in harmony with the merit HRA through need assessment procedures. In other words the education subsystem produces what is required by the HRA from one side and the population (as the representative of the society) from the other side. Therefore the required HR would be sent to the labor market within which different level of knowledgeable HR, are in access.

Progressively, if all subsystems work appropriately through filtering the right labor according to the required competencies and job vacancies, selecting and recruiting the elites, planning for lifelong developing and maintaining etc., then we can claim the right and required services would be delivered to the right population. Otherwise the health system faces lots of disharmonial challenges due to any kinds of deficiency in the function or mutual relations made between its subsystems.

In fact the main purpose of the authors of drowning such comprehensive framework is to illustrate a rich picture of the right place of HRM within the health sector through showing that:

– the HRM differ from the ideal HRA and the ideal HRA is a part of the HRM

– HRM is a systematic and systemic process involving all subsystems of the whole health care system

– HRM is an inseparable subsystem of the health system without which the whole system wouldn’t be able to deliver the right services.

– To have a workable HRM, we need to apply a systemic approach, for constantly surveying the relationship between the subsystems working within the health system.

– HRM not only is not a single-based function, but also is a processed-based one. In other words, we can’t delegate all responsibilities of HRM to a unit or department as the only trustee. That is because of the multi-functional nature of HRM that make it imperative for all subsystems and stakeholders within the whole system to take some part of HRM’s function in harmony and accompany with the other subsystem’s.

– In as much as the function of the whole system depends on the function of the HRM, for launching any kind of reforms or restructuring in the whole system, we must first reform the function of HRM.

– There is an interdependent relation between the function of health sector and the HRM. Thus, we can conclude that all problems the health system is facing with stem from the malfunction within the HRM.

– Putting attention to the place of HRM illustrated in the figure, we understand the basic role of the HRM. Unlike the idea of many experts, HRM not only consider as a single supportive subsystem, but also it is claimed to be an institutional multi- functional subsystem which include the function of all subsystems working within the whole system (12).

Discussion

Our findings confirm that not only the HRM is not merely the supportive unit, but also has a dominant place in a health system. It is important to note also that these results were consistent with the study of Gregory C. Kesler (13).

In fact, providing the role of HRM subsystem is properly defined, it can drive the whole system through the way determined in Health reform. The most outstanding concern of authors to study this subject is that since years ago, the health system has been suffering from fragmented HRA. Moreover, there is no holistic attitude within health sector to approach HRM (7). In fact, the present system of HRM is a traditional HRA that is facing lots of functional deficiency due to conducting the HRA in to piecemeal HRA! In other words a kind of turbulence is detectable among the function of HRA’s components, in a way that each subsystem who is involved in the process of HRA within the health care system, work not only in disharmony with the other part of the system, but also without paying attention to the quality and quantity of the output of the other subsystems. For example in our health care sector, although it is titled the ministry of health care and medical education, there is no evidence showing the interdependency between these three main functions of the health sector. From one side, the education subsystem that is responsible for training the right number and qualified human resources is doing its job without being aware of the need assessment and inquiry of other subsystems like HRA and the population or even the labor market. From other side, there is disorganization between the internal components of HRA consisting of the assessment center (staffing and recruitment), training and development, maintenance etc. Part of above mentioned issues refers to matters such as occasionally contradictory laws and regulations; difficulty of change due to organizational hugeness, hierarchical structures and rigid bureaucracy; internal and external disharmony; lack of knowledgeable HR managers etc. Therefore, to make the suggested conceptual framework applicable, the current so-called HRM should be regenerated (regarding all required components and their relationships). The regenerated system must be accountable to cover the illustrated scope in the framework. Moreover, regarding to the previous mentioned matters, a fundamental change in health system is required. For this, the high level advocacy and holistic restructuring are needed, too. These amendments should be done in several levels (i.e. parliament, government, MoHME, other organizations involved in health etc).

To make a better understanding of the HRM illustrated in the conceptual framework and the real place of it in the whole system, a series of complementary studies are required. These studies should be focused on below fields:

– Fundamental analysis of dominant laws, Regulations and documentations relates to HRM in health sector

– Pathological studies in HRM challenges in health sector

– Knowledge Assessment studies for evaluating the HR managers working in health sector

Therefore, Human resource management can be defined as the integrated set of roles, functions, components, decisions, systems and processes in the whole system that meet the needs and support the work performance of all stakeholders (policymakers, governmental officers, employees, clients, population etc) in order to accomplish the mission, goals and strategies of the health sector

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.