Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India Technica Brief October 2012 Context India faces critica human resources (HR) chaenges in the heath sector, incuding shortages in key cadres and in rura and under-served areas. Working Groups under the Nationa Rura Heath Mission (NRHM) as we as the Panning Commission s High Leve Expert Group have emphasised the importance and urgency of strengthening human resources for heath (HRH), noting that achieving universa access to quaity heath care is highy dependent on the quantity and quaity of the heath workforce. With an increased recognition of the importance of HRH, NRHM has been investing in deveoping more heath workers, especiay at the primary care eve. However, a major obstace has been that information on the heath workforce is imited, fragmented, and generay not in a format that can be easiy reviewed and shared. The minima amount of HR information that does exist is usuay kept in disparate paper fies, which are often not up-to-date. The heath information system in most states focuses on service deivery and does not incude sufficient HR information. This greaty reduces the abiity of decision-makers to access and use accurate and timey data to improve the effectiveness and efficiency of the workforce, which is critica in order to meet nationa heath objectives. An improved HR information system (HRIS) is an essentia too needed to improve HRH poicies as we as workforce panning, deveopment, and support. What is an HRIS? An HRIS provides managers and decision-makers with information needed to effectivey pan, deveop, and support their heath workforce, incuding information to identify and address probems. Generay, it incudes information on the heath workforce such as the number of workers by cadre, posting ocation, training quaifications, icensing status, as we as information on staffing and vacancies by faciity. Many modern HRIS are muti-database systems with significant capacity to anayse workforce probems and possibe soutions, as we as the capacity to ink HR and service deivery data. The strength and effectiveness of an HRIS does not soey depend on technoogy, but rather on the system being practica, userfriendy, fexibe, and abe to generate accurate and timey information. A good HRIS provides the foundation for strong workforce panning, deveopment, and management incuding recruitment, depoyment, retention, quaity assurance and productivity. Recommended Approach to Strengthen HRH and HRIS IntraHeath Internationa Inc. (IntraHeath) is a US-based nonprofit agency and a goba HRH eader, which advocates for strengthening HRIS as an essentia first step in most countries facing HRH chaenges. Based on experience of working in over 40 countries, incuding India, IntraHeath recommends the foowing steps to improve an HRIS: Ensure oca eadership: A Stakehoder Leadership Group (SLG) shoud be estabished for the HRIS and broader HRH efforts, to ensure oca ownership, appropriate customisation of the system, and sustainabiity. The SLG members shoud represent a broad group of governmenta and non-governmenta HRH eaders and stakehoders, and their roe incudes identifying the key HRH poicy and management issues and questions, and guiding the effort to strengthen the HRIS. Link with and improve existing information systems: The SLG or a working group inked with the SLG shoud assess existing heath information systems, information and communication technoogy infrastructure (e.g., existing networks, internet connectivity, software etc.) and reevant data currenty coected by different departments and groups in both the pubic and private sector. It shoud USAID FROM THE AMERICAN PEOPLE
identify the opportunities to ink with and compement existing systems as we as priority gaps that need to be addressed through an improved HRIS. Identify and customise software soutions: After the SLG agrees on key HRH issues, and the needed HRIS improvements, based on the assessment, it wi need to seek customised HRIS software soutions. The seected software soutions shoud compement existing systems and toos, to the extent possibe, in order to ower costs and acceerate impementation. Promote use of data: Once the improved HRIS generates data, it is critica to promote its use, which requires capacity-buiding and support to managers and decisionmakers. The SLG shoud aso mode use of the HRIS data, as it works on broader HRH issues. Ensure sustainabiity: Continuous engagement of the HRH eaders (incuding SLG members) is critica for optima use of the HRIS as we as for ensuring maintenance and improvements to the system in future. IntraHeath has deveoped the ihris Suite using open source software, to offer heath-care providers in deveoping countries ow-cost and easiy customised information systems for tracking and anaysing heath worker data. The ihris Suite consists of four toos for managing human resources information: Ÿ ihris Manage, a human resources management system Ÿ ihris Quaify, a training, certification and icensure tracking database Ÿ ihris Pan, workforce panning and modeing software Ÿ ihris Retain, workforce retention intervention costing too HRIS District Piot Experiences In India, the Nationa Heath Systems Resource Centre (NHSRC), the technica support agency for NRHM, works to strengthen state-eve heath information systems and HRIS. NHSRC invited IntraHeath to contribute its experience and expertise to the HRIS efforts, through the USAID-supported Vistaar Project. The Society for the Heath Information Systems Programme in India (HISP India), a technica partner of NHSRC, aso contributed to this coaboration, and the three organizations formed a technica assistance team. This team offered to hep the State Heath Society of Bihar (SHSB) and the Jharkhand Rura Heath Mission Society (JRHMS) to strengthen their HRIS. In addition, the DFID-funded Bihar Technica Assistance Support Team (BTAST) aso contributed to this effort in Bihar. This work started with a piot in one district per state and the SHSB and JRHMS eaders chose the Siwan and Ranchi districts of Bihar and Jharkhand, respectivey. IntraHeath ed the technica assistance and capacity-buiding efforts for these two piots from mid-2010 through eary 2012. Over time, the state Departments of Heath and Famiy Wefare (DHFW) in Jharkhand and the Department of Heath (DOH) in Bihar became invoved, since the HRIS is important not ony for the NRHM, but for onger term eadership and management of the state heath sector. The piots were successfu, and in Jharkhand, the Ranchi district's HRIS is operationa and incudes over 1,900 empoyee records. In Bihar, the Siwan district's the HRIS is aso operationa and incudes amost 1,100 empoyee records. Key Resuts from the HRIS Piot Efforts: In March and September 2011, IntraHeath ed a review of the district piots in Bihar and Jharkhand respectivey, to assess the resuts and essons from the piot efforts in each state, gathering information from existing data, key informants, and reguar review meetings. The key findings from these reviews are summarised beow. Heath sector eaders in both states are committed to HRIS strengthening and scae-up: Bihar and Jharkhand heath officias have increased understanding and interest in improving their HRIS, and have provided needed eadership in areas such as ensuring timey data coection. The heath sector eaders (both NRHM and DHFW/DOH) are committed to statewide scae-up, incuding ongoing staff capacity-buiding. A functioning mode HRIS exists in both states and serves as a patform for expansion: The piots invoved the deveopment of a customised HRIS, using the open source ihris Manage software. The piot HRIS incuded basic HR data on a pubic heath sector empoyees in the seected district, and aowed users to generate simpe and user-friendy reports, organised by characteristics such as faciity name and type, job tite, date of recruitment, current posting, empoyment tenure, retirement and contract date. The piot HRIS is producing usefu information: HRIS reports are being generated in the piot districts with vauabe information about depoyment of heath workers, by job tite and faciity as we as by retirement status for reguar empoyees. The piots aso reveaed that many contractua
workers were unsure of their job status and were not receiving reguar contract extensions, given the ack of an effective mechanism to track contract renewa deadines. The initia reports aso exposed the critica need to standardise heath faciity names and categories and heath worker position tites. The piots have heped refine the systems requirements, in coaboration with key stakehoders and potentia users. Staff capacity is strengthened to impement and maintain the HRIS: State heath sector eaders designated appropriate staff to manage the HRIS piot work, incuding data coection, data entry and data quaity review at the state and district eve. Additiona state-eve capacitybuiding is needed, especiay in areas such as data quaity and data anaysis, and additiona staff training wi be needed in each district for statewide scae-up. Recommendations for Statewide Scae-up: The recommendations resuting from the piot experiences and review were as foows: Continue and expand strong eadership: These two states benefited from strong eadership for the HRIS effort. This wi need to continue for statewide scae-up and for future expansion of the scope of the HRIS. Formay constituting an SLG woud be hepfu in forging stronger inter-agency partnerships, probem-soving, and ensuring high eve use of the data. Buid capacity of HR unit: A strong HR unit within the state pubic heath sector is needed to ead core HRH efforts, incuding managing the HRIS. The states need a reguar system and staff to ensure data updates, anaysis and use. An HR unit is aso needed to ead efforts to expand the HRIS, such as to incude in-service training and performance management modues. An expanded and quaified HR unit is aso needed to improve HR management systems, such as recruiting, depoyment and workforce support efforts. Start with the basics: In order to buid support and create momentum for an improved statewide HRIS, the initia modues, scae-up and use of the system shoud focus on basic, priority HR areas such as vacancies, depoyment, retirement and workforce panning, rather than more sensitive areas such as measuring performance or tracking absenteeism. Once the HRIS is accepted and institutionaised, heath sector eaders can expand the HRIS to address more sensitive issues. A potentia area for future expansion in these two states woud be working with professiona associations to improve icensing and continuing education efforts. Estabish data standards and data fow processes: The piots reveaed the need for a standardised ist of heath faciities and heath worker position tites, as often mutipe names and category types are being used to refer to the same faciity, resuting in miseading data anaysis and reports. In addition, many personne are unsure of their position tites or continue to use outdated tites, because they have not received forma communication of tite changes. The piot efforts focused on customising and testing the software, data coection, and data quaity. An important next step is to deveop appropriate procedures to assign responsibiity and access rights for maintaining and managing the HRIS, protecting the data from damage or tampering, and ensuring privacy. Promote data-based decision-making: It is important to deveop routine mechanisms for HRIS data sharing, such as by incorporating use of the data into reguar review meetings hed at faciity, bock, district, and state eve. This wi require capacity to anayse and review basic HR data at a eves. Data sharing and use generay resut in increased interest in the data, and in turn, improved quaity of the data. HRIS data and routine reports shoud be critica toos for HR management, incuding ensuring staffing and service standards are met at each faciity. Statewide Scae-up Experience Both state governments appreciated the data resuting from the piots, and began statewide scae-up efforts soon after the review of the district piots. The state eaders activey ed the scae-up process, and requested continued Project technica assistance during the scae-up effort. The Project focused on capacity-buiding inputs, especiay to ensure strong data maintenance and quaity systems. The state officias and Project team worked to ensure that data inputs were standardised, such
as the various categories of job tites, faciity names, and other critica fieds that were previousy uncear. These standardised input categories are critica for accurate HRIS reports. The Project team aso assisted with training sessions for state and district government staff, deveoped job aids to support improved data coection, and heped to standardise the data input fieds to reduce data entry errors. Bihar Scae-up: The DOH decided to continue data coection for a districts and a heath worker cadres in the state, and to conduct data verification by cadres, in a phased manner. The first phase focused on doctors, foowed by nurses, auxiiary nurse midwives (ANMs) and then other heath empoyees. During each phase, the DOH team set timeines for the competion of data coection and verification, and appropriate government officias were responsibe to oversee the activities and monitor progress. The DOH sponsored training sessions on the HRIS and data entry for the district teams. This initia scae-up effort did not incude personne from state medica coeges and their affiiated hospitas or nursing and ANM schoos. However, in June 2012, the DOH eaders decided to incude these institutions and began efforts to incude these personne, in order to deveop a more compete HRIS. The DOH named a Joint Monitoring Committee to oversee the HRIS effort and ensure use of the data, which is an important deveopment for sustainabiity and use of the HRIS. The Joint Monitoring Committee met four times from Juy to September 2012 to review and address technoogica and heath system reated issues to strengthen the HRIS scae-up efforts, further demonstrating the state eadership s commitment to scae-up success. They have aso put data coection and maintenance protocos into pace. In addition, the state eaders, who now have an increased to appreciation for the vaue of compete, accurate, and timey data, have decided to estabish an HR ce at the state eve, to ead HRH efforts in the state, incuding management of the HRIS. As of September 2012, the Government of Bihar has more than 38,500 individua empoyee records avaiabe in the state HRIS. Of these records, cose to 8,000 are doctors, 2,500 nurses, 12,000 ANMs and 16,000 other empoyees. The data revea current heath worker depoyment, education eves, retirement dates and vacancies by faciity, which can inform important HRH decisions in the state. The initia data coection is compete for doctors and nurses and data coection for ANMs and other heath workers is schedued for competion by the end of 2012. 1 Iustrative HRIS Data: Number of Doctors by Service Category in Bihar Service Category Reguar Contractua Tota State Heath Services 2,662 0 2,662 District Heath Services 0 2,342 2,342 Medica Education (Aopathic) 1,022 111 1,133 AYUSH Services 237 1,046 1,283 Medica Education (AYUSH) 88 0 88 Other 213 242 455 Tota 4,222 3,741 7,963 1 Doctors incude those with the MBBS and recognised AYUSH degrees The HRIS provided the DOH in Bihar with a comprehensive picture of how many doctors they have empoyed across the various service categories. It aso aows them to access more detais on each service category, down to the faciity ocation and specific characteristics of each doctor (such as speciaisation). This data heped the DOH eaders to reaise that there are many doctors working outside of DOH faciities (incuded in the Other category), such as with the District Jai Hospitas, District Poice Hospitas, and State Empoyee Insurance Hospitas. Jharkhand Scae-up: In Jharkhand, the DHFW decided to scae up the HRIS by focusing first on doctors in the state, and then using these essons to inform data coection for other cadres. Simiar to Bihar, the DHFW eaders put protocos in pace for data coection, with timeines and appropriate government officias overseeing the process. As of September 2012, the DHFW team has entered the data and estabished the HRIS personne records for more than 1,550 Medica Officers empoyed by DHFW across the state. The data on Medica Officers revea current posting, empoyment history, areas of speciaisation, retirement dates and training status, which can inform important HRH decisions in the state. The DHFW team has aso coected most of the data for other cadres and they are beginning the data entry process for these cadres. In addition, the state is initiating a data centre within the DHFW, which wi ead in HRIS maintenance, data anaysis and generating reports.
Iustrative HRIS Data: Presence of Speciaists in Community Heath Centres in Jharkhand Buiding capacity to use the HRIS data for programming, incuding inter-operabiity with the Heath Management Information System service deivery data According to the Indian Pubic Heath Standards, each Community Heath Centre shoud have one physician speciaist in paediatrics, obstetrics and gynaecoogy, and anaesthesioogy. However, the HRIS data reveaed a severe shortage in speciaist doctors, which the DHFW in Jharkhand is working to address. Chaenges and Next Steps Athough exceent progress has been made, there are chaenges in strengthening the state HRIS. One of these is a reuctance to share some requested data, especiay among Medica Officers. Strong heath sector eadership commitment and an abiity to expain the importance of the HRIS wi hep to encourage staff to share the needed information. There are aso shortages of quaified staff to operate and maintain the HRIS at the required statewide scae, and a need to designate a responsibe unit (with strong inks to other key units such as the HR unit), and buid their staff capacity. Finay, there is imited experience and capacity in using the data in heath sector decision-making, and that wi need to be expanded over time. The important next steps for optima effectiveness of the state HRIS, incude: Paediatrics Obstetrics and Gynaecoogy or EmOC Trained Anaesthesioogy or Life Saving Anaesthesia Skis (LSAS) Trained 28 166 65 129 37 157 0 50 100 150 200 CHC with Speciaist Number of community heath centres CHC without Speciaist Competing data entry and verification for a heath worker cadres Ensuring impementation and institutionaisation of data quaity, maintenance, and protection protocos The states have aready begun using the HRIS, with a number of heath sector eaders reviewing the initia reports, incuding reports on depoyment of doctors and other heath workers to identify gaps and consider actions to fi key vacancies. For exampe, in Bihar, the state HRIS team generates reports on the number and depoyment of doctors, and the review of these reports has recenty become a part of the state-eve Civi Surgeon s monthy review meetings. As a resut of the HRIS data, DOH eaders have been abe to identify posts where doctors are not reporting for duty over a ong period of time, and they are taking actions to ensure these positions are fied. In addition, DOH eaders are improving recruitment and posting of speciaist facuty for medica education, because they now have a more compete database of a doctors empoyed by DOH. In Jharkhand, DHFW eaders have reviewed the data in the system, identified gaps, and initiated the recruitment process for doctors in high need speciaties (such as obstetricians and anaesthesioogists) and for high need areas across the state (such as at community heath centres). Concusion The initia district piot efforts in Bihar and Jharkhand estabished a mode district HRIS using customised open source software, buit staff capacity in data coection, quaity assurance and use, and demonstrated the vaue of the information generated. Heath sector eaders in both states appreciated the district effort and are eading scae up efforts to deveop a statewide HRIS, to improve heath workforce panning, deveopment and support. The piot and statewide scae-up efforts have generated a number of essons and best practices. Significanty more data is now avaiabe, on the education, empoyment status, ocation, and other characteristics of individua heath workers, which wi faciitate more strategic decision-making and improved access to heath care for these states. This effort has demonstrated how a strong HRIS can pay an important roe in reaching India s goa of universa heath coverage. Buiding institutiona capacity to maintain and ensure use of the HRIS, such as through a strong HR unit in each state
Vision IntraHeath Internationa beieves in a word where a peope have the best possibe opportunity for heath and we-being. We aspire to achieve this vision by being a goba champion for heath workers. Mission IntraHeath empowers heath workers to better serve communities in need around the word. We foster oca soutions to heath care chaenges by improving heath worker performance, strengthening heath systems, harnessing technoogy, and everaging partnerships. For more information, visit www.intraheath.org The Purpose of the Vistaar Project To assist the Government of India and the State Governments of Uttar Pradesh and Jharkhand in taking knowedge to practice for improved materna, newborn, and chid heath and nutritiona status IntraHeath Internationa Inc. is a US based nonprofit agency working to improve the heath status of individuas, famiies, and communities. Because heath workers save ives, IntraHeath is committed to increasing the numbers of heath workers who are present, ready, connected, and safe. For over 30 years, in more than 90 countries, IntraHeath Internationa has empowered heath workers to better serve communities in need, fostering oca soutions to heath care chaenges, improving heath worker performance, strengthening heath systems, harnessing technoogy, and everaging partnerships. IntraHeath eads CapacityPus, the USAIDfunded goba eadership project which heps countries address their heath worker chaenges and contributes to goba impact through aiances. CapacityPus serves partner countries by offering state-of-theart expertise, modes, toos, training, and References High Leve Expert Group Report on Universa Heath Coverage for India, Panning Commission of India (2011). Human Resources for Heath, Chapter 4, pp: 141-178; Accessed on 27 December 2011 at http://www.phfi.org/images/what_we_do/hl EG_Report_Dec_2011.pdf India: Towards Universa Heath Coverage 5. Human resources for heath in India. Mohan Rao, Krishna D Rao, A K Shiva Kumar, Mira Chatterjee, Thiagarajan Sundararaman. www.theancet.com Pubished onine January 12, 2011 DOI:10.1016/S0140 6736(10) 61888-0 IntraHeath's Goba HRH Capacity anayses adapted to each context. In India, IntraHeath eads the USAID-funded Vistaar Project, which focuses on taking heath care knowedge to practice at scae. The Project assists the Government of India and the State Governments of Jharkhand and Uttar Pradesh in improving materna, newborn, and chid heath and nutrition. The Project aso provided assistance to the State Government of Bihar for strengthening its human resources information system. HRH Goba Resource Center http://www.hrhresourcecenter.org/ The HRH Goba Resource Center is a goba ibrary of HRH resources, incuding HRIS focused on deveoping countries. The Center is a knowedge management service of IntraHeath s CapacityPus Project IntraHeath Internationa, Inc. is the ead agency for the Vistaar Project. For more information on the Vistaar Project, see: www.intraheath.org/vistaar Technica Assistance Partners: Strengthening Human Resources Information Systems: Experiences from Bihar and Jharkhand, India. Vistaar Project, IntraHeath Internationa, Inc. Technica Brief, January 2012. Discaimer: This brief is made possibe by the generous support of the American peope through the United States Agency for Internationa Deveopment (USAID). The contents are the responsibiity of IntraHeath Internationa and do not necessariy refect the views of USAID or the United States Government.