A failure of imagination

June 25, 2016 [A FAILURE OF IMAGINATION]

A f a i l u r o f i m a g i n a t i o n - A n i l K u m a r . K o r r a p a t i

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A failure of imagination

Over estimations- Under accomplishments

The cluster health system in Andhra Pradesh

Atlast, the Government had drawn the curtains down.

The cluster system which was established in 2011, with a

vision of being a mentoring unit, providing supportive

supervision , facilitatory guidance to the primary health

care units is abolished, citing reasons which are very

humiliating is sad.

A tale of a one-way bridge



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Imagine a proposition where two cliffs are connected by a

foot bridge. A river flows in between. People on one side

of the cliff assert their supremacy as they have the

decision-making power, whereas people on the other cliff

follow these orders. On this ‗other cliff‘ are the people

who jump in and out of the flowing river, to take care of

the fishes and to maintain the balance of life in the river.

However, the rule-making side decides how often and for

how long the people on the ‗other side‘ may jump into

and remain in the river, how they are supposed to swim,

what fishing methods and styles they may use, and so on.

This rule-making, order-ensuring side never jumps into

the river itself, neither does it seek the opinion of those on

the other cliff who have to do so. The bridge between the

two cliffs has only one-way passage; the order-making

side uses it to pass on orders to the other side. Rarely does

a representative of the ‗other side‘ cross the bridge, and

when she does so it is usually to carry out more orders or

to explain a few instances of non-compliance.

Over the years this unquestioning obedience and trudging

the linear path of rules has spoiled the health system



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Many such incidents are being witnessed now a days in

the health system.(Unable to remain silent, I keep

scribbling thus)

This may sound absurd or, more disturbingly, rather

routine. This analogy is especially true for health system.

The great divide between the planners and implementers

is perhaps the most vital point to be looked into. Such is

the power of this divide that it punctures the intentions of

a well-meaning plan and turns it into a ragdoll.

Such orders and rules often lead to distress among health

care providers and program monitoring officers alike.

Health providers often get a repeated message of non-

performance, hence they lose interest in service And in

some adverse cases they are even pushed out of the

system.

Meanwhile, the monitoring officers overburdened with

mechanical tasks, are reduced to fulfilling orders,

updating registers and diaries. Most well-intentioned ones

among the group find it difficult to make the bridge two-

way. The river will deteriorate if both the ordering side

and the other side don‘t work together.



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And now let us read this ...

I am gnawed by the growing insensitivity that refuses to

see the schizoid in action of abolishing the Cluster system

headed by Deputy District Medcial and Health Officers,in

primary health care system in Andhra Pradesh .

The reigning idea of majoritarian jingoism that is hell-

bent on destroying the spirit of Supportive Supervision

and Facilitatory guidance has unleashed an initiative of

abolishing the clsuter system that harms the salient

features of the democratic fabric

I am not trying to be a high decibel or shrill trolling

individual advocating against this initiative, but it will

become dereliction of duty and unfair if we fail to take

cognizance of any fair complaints against the Ddmhos.

But, it will be unbecoming of a system if we were to

either endorse or even act on innuendoes and half truths.

It will appear as if we are ridiculing and beleaguering

them _the Deputy DMHOs



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Old problems mar the new solutions

The Cluster system headed by the Deputy District

Medical and Health Officers (Hitherto referred as Senior

Public Health Officers) was created as a new solution,

with a lot of hope as a part of ―Revitalization of the

Primary Health Care System‖ in 2011.

Deputy DMHOs were positioned as a part of

reorganization and revitalization of the primary health

care system expecting them to

• be catalysts of change,

• rejuvenate the existing primary health care system

and

• Build Public Health leadership, with a team oriented

approach, supposedly to function as a mentoring unit

providing Supportive Supervision and Facilitatory

guidance to the health institutions in their jurisdiction

in achieving our NRHM objectives and Goals

Initially a charming posting, now turns to be tragic.

This cluster system now appears flawed.

Old problems mar the new solution.



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To what extent are the Deputy DMHOs responsible for

this flawed functioning and to what extent is the health

system responsible for these flaws in the functioning of

the clusters??

Is the Government taking decisions on the cluster

system based on a flawed reasoning???

Karnudi chaavuku vanda kaaranalu annatto,(కర్ణు డి చావుకు

వంద కారణాలు అన్నట్టు )

There are myriad reasons for the flawed functioning of

the cluster system-Both Systematically induced system

failures and individual failures.

Contradictory styles of supervision

At one end the Government wants the Deputy District

Medical and Health Officers to function through

provision of Supportive Supervision and Facilitatory

guidance, but from the other end the system wants to

make them function with authoritative or traditional or

control style of supervision.



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The decision of the Government on abolishng the cluster

system in primary health care is likely to have far

reaching consequences not only among the Ddmhos but

also among the public health cadre.

Unfortunately, it conflicts several principles of

Monitoring and supervision and symbolizes the confusion

in the health system over the utilization of the Deputy

DMHOs _Who have an average service of 15-20 years in

the Andhra Pradesh Medical and Health Services

It also reflects the organizational culture of lack of

trust/trust deficit, lack of support to imbibe change and

failure to accept the lacunae in the health system.

While the NHM apart from accountability and

transparency, inherently values in Systems approach in

dealing with the lacunae in the health system and imbibe a

healthy OC (Organizational Culture) in the health system,

we seem to have followed a rather contradictory approach

in dealing with the Cluster system.

Organizational culture is a system of shared

assumptions, values, and beliefs, which governs how

people behave in organizations. These shared values have

a strong influence on the people in the organization and

dictate how they dress, act, and perform their jobs.



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Just as water is invisible to the fish swimming in it, yet

affects their actions_ Culture consists of unseen elements

such as assumptions and values that affect organizational

life.

We are failing to recognize the dimensions of the

Organizational culture

Flawed reasoning….

Public health outcomes and impact are very intangible

and are difficult to predict and measure and take a long

time for results to be visible. It is like working on

unpredictable‘s based on predictions

The cluster system is just Five years old, weakened by

• lack of adequate capacity building,

• lack of administrative powers,

• lack of managerial support,

• lack of sufficient financial support,

• lack of functional support system,

• lack of adequate infrastructure.



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They are made to work as proverbial donkeys.

Systematic system failure

We had contextualized the clusters and positioned

Deputy‘s but failed to provide a framework and a milieu

to the officers to function effectively

It is well-known that the Public Health System is facing a

grave shortage when it comes to Medical Officers and

staff nurses. Many Primary Health care and Secondary

care units are facing an acute shortage of staffs. Young

officers, barely out of their teens, are handling bigger

responsibilities than ever before and stepping up to

discharge additional duties. These young officers are

untrained and lack managerial capacities, lack

responsibility and commitment, dedication, sincerity

Dealing with these young officers without any authority is

like playing a game without a referee and a third empire

These young officers fail to understand the spirit of

Supportive Supervision and Facilitatory Guidance.



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It is time we started thinking about our frontline health

workers and junior Medical Officers who are getting

disillusioned with their roles.

CHNOs(Community Health and Nutrition Officers)

headed by the Ddmhos, are placed in dingy rooms,

dependant on water and electricity on CHCs or

APVVP_other system in the Health care system which

always offers a cold shoulder to the Public Health

personnel.

CHNOs –not provided with an OS (Office Subordinate,)

Sweeper- not provided with any OOE, with team

members who are either adamant or arrogant or

disobedient or problem creators. Working in such

unproductive workplaces, surmounting unseen problems

needs motivation and appropriate capacity building

The system is failing to address either of the Herzbergs

factors for the effective functioning of the clusters_ the

Job dissatisfiers (Hygiene factors) or the Job

satisfiers(Motivational factors){Herzberg‘s theory of

motivation}

Adding salt to the injury, the Ddmhos lack public health

competencies and the system had failed in traversing this

gap, this is furthered by the lack of support for them by



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the District Officers, who always instruct them to deliver

goods without addressing the well known root causes. The

District Medical and Health Officers turn a blind eye and

a deaf ear to their concerns and issues, acting as if they

are unaware of the issues and concerns, just blaming and

blaspheming the Ddmhos

This is what a lady Deputy DMHOs says

In her own words…

Patience is the key to success but how to maintain the

calm with the irresponsible people and get the work

extracted is the big question. It's becoming impossible to

remain motivated when you have decided to quit and the

process gets delayed . Don't know how long the dilemma

continues. All the planning going for a toss.

Even though disappointment is not uncommon but this

one is quite painful. Working atmosphere won't change

yet to perform to perfection. A productive workplace

appears to be a Herculean task ???

Individual failures

Is it ineptitude or inaptitude??



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Is it ignorance or arrogance??

It is like from Pathos to Bathos for majority of the

Ddmhos …

Ddmhos working in the cadre of the Deputy Civil

Surgeons were basically competent to provide preventive,

clinical and curative/teaching services were absorbed in to

the public health system, without providing capacity

building on the requisite basic public health competencies

_ Managerial, Leadership, Epidemiological, Analytical,

Statistical, Collaborative , Team building, Report writing,

Conduction of meeting, Communication, Partner-

shipping skills

Working as Deputy Civil Surgeons either at CHC or PHC

they used to find some satisfaction at the end of the day

by providing curative, preventive, surgical (FP Services)

services before being posted as Ddmhos. Now they lack

that satisfaction and they are getting demotivated. This is

like from Pathos to Bathos for them (పెనం నండి పొయ్యిలోకి

పడట్టు )



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Of course majority are unable to deliver the goods

because of the ineptitude, and almost all because of

inaptitude.

What is sacrosanct about the Deputy District Medical

and Health Officers??

They have an immense experience and knowledge with

them. It is only that they are failing to put it in a

structured manner and failing to unlearn certain

knowledge which is obsolete.

They should have been coached, empowered, engaged,

and embraced for better service delivery and taught to put

their knowledge and experience in a structured manner

with a tinge of enhanced skills.

An intensive SIX months training should have been

imparted for improvement of this system, with regular

periodical reorientation, to imbibe professionalism in

them, focusing on their ineptitude and inaptitude.

While, every bureaucrat takes a compulsory refreshing

capacity building once in every 3 years, how come this

profession with far reaching deliverables denied this???



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Missing the bigger picture with our Deputy District

Medical and Health Officers?

The system has to justify the perceived perfidy of the

District and State Health officers who seem to have

forgotten their work and the promises made to them.

The ‗treacherous‘ politicians; the ‗Machiavellian‘

bureaucrats; the ‗arrogant‘ officers; the ‗indifferent‘ bean

counters or the ‗unreasonable‘ ex(retired) Health Officers

— they are all on one side, failing to understand the

intricacies of the failing health system. And it has

unravelled.

The system is failing to provide an open platform for

discussion and any opinions and demands expressed are

considered as amounting to heresy, which constitutes a

grave development in organizational culture and provide a

fertile ground for elements inimical to health system.

It is a critical set back as we are not looking at the big

picture.

The fact that the Ddmhos issues and concerns had been

relegated to files for far too long is obvious from the

sensitive issues of the problem and the indignation of the

aggrieved. The fact that no opportunity had been given to



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an interlocutor underscores the divide and truculence of

both sides.

But it behoves the leaders of our Government,

bureaucracy and most importantly the Health system, both

serving and advising, to realize that this standoff cannot

be resolved in such an unconducive manner/approach.

This is because; on one side you have the professional

doctors, who have saved many lives, and the other side

those who should be thankful for that. This attempt of

looking down upon the Ddmhos will demoralize one of

the finest systems.

Eventhough all these issues of the Ddmhos are not met,

and their concerns not addressed they may have forced

the government to achieve them through bellicose means,

but if it was so,what kind of health work force would we

leave as a legacy? One that fights its own government to

get its due? Where does the story end? What prevents this

pyrrhic victory from becoming a new ‗doctrine of

belligerence‘ that the health work force use to press their

demands in future? And what example would they set for

their junior officers, struggling to keep themselves

motivated?



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The resolution to Ddmhos issues and concerns doesn’t

have to consist of a single silver bullet.

Solutions could have been a combination of re-skilling,

training with the basic public health competencies and

funding them for entrepreneurship; and a slew of other

measures to ensure the dignity and decorum of our

medical professionals.

We can achieve this outcome provided we comprehend

that this is not just a dispute between Ddmhos and the

government. It is a professional issue, with far reaching

social consequences and every policy maker needs to

pitch in.

Because, provision of health services is a too serious a

process to be left to the politicians and bureaucrats

And of course, our Dmhos should have also learned to

work/gain knowledge and unlearn certain knowledge, and

come out with tangible results with better planning,

partnerships, convergence, innovations, and utilizing

available evidence based initiatives, working in a system

with scarce resources which have to be optimally utilized,

as they seem to be not making any effort.



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The Ddmhos have learnt knee jerk jingoism. They should

have detested from this working style and have a plan for

their work. They should have realized that if they fail to

plan, they are planning to fail. Instead of always bickering

and blabbering, they should learn to think constructively

and positively

The state and district administrations should have also

supported them with a streamlined reporting system and

time bound activities, informed with sufficient time

period for deliverables, so as to enable them to have a

breathing space and strengthen them by taking then into

confidence and heed their complaints against belligerent

and disobedient staffs

And their INGORANCE cannot be bliss and they may be

judged to be ARROGANT.

But the game is over,

The Ddmhos should start a new leash of life ...

I empathize with them.



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THE LAST LAUGH . . .

Healthcare

A failure of imagination