Seye Abimbola and Aku Kwamie      

Seye Abimbola  KwamieFrom 3 to 7 February, two Emerging Voices had the privilege of being part of a meeting in the serene little town of Bellagio in northern Italy. We found ourselves among the winding streets steep with cobbled steps, lush gardens and grand villas overlooking Lake Como, surrounded by soaring snow-capped mountains which stretch from the Alps. When Russian writer Fyodor Dostoyevsky wrote in The Idiot (published in 1869), that “beauty will save the world”, he couldn’t have known that this declaration would find expression for two West Africans at the Rockefeller Foundation Bellagio Centre in 2014.

But how will beauty save the world? It seems, for the Rockefeller Foundation, it is about the power of beautiful surroundings to create the ambience within which to address some of the world’s most important problems. Since 1960, the residency and conference programme at the Rockefeller Foundation Bellagio Centre has offered scholars, artists, writers, scientists, policymakers and other professionals from around the world the opportunity to pursue and to share ideas, to debate and to collaborate. There’s something to be said for this understanding of Dostoyevsky’s idea of the link between beauty and global development.

Organised by the Health Governance Hub of the Public Health Foundation of India, and the Averting Maternal Death and Disability programme at the Columbia University Mailman School of Public Health, a three-day meeting was hosted at the Rockefeller Foundation Bellagio Centre to deliberate on the issue of posting and transfer of health workers and managers in low- and middle-income countries. The need to equitably and sustainably distribute the grossly insufficient volume of human resources for health across urban and rural settings makes posting and transfer an important issue. But beyond the challenge of supply, retention and distribution, posting and transfer could also be used as a tool to punish, to grant favour or reward political loyalty, or to get an incorruptible manager or administrator out of the way. We know that in settings where staff are over-worked, under-equipped, and little-supported, health workers understandably prefer to work in more comfortable locations, where they will have the opportunity to work with better equipment, progress in their careers, earn additional income (legitimately or not), and access good schools for their children and jobs for their spouse. We also know that inappropriate posting or transfer of health managers due to factors ranging from political concerns to poor prioritisation in the face of short supply, could compromise the quality of service delivery in health facilities or entire districts.

The negotiation spaces for posting and transfer are vast and range from advantages being gained from patronage networks and clientelism, to structural breakdowns in human resource management at different system levels. The layers of complexity seem endless.  These processes are referred to as the ‘open secret’ of posting and transfer, and as one discussant noted: there are open secrets which are more open than secret, and there are open secrets which are more secret than open! The mere act of studying posting and transfer practices has the potential to enhance transparency. However, important as it is, this issue of posting and transfer has hitherto been poorly discussed, analysed and studied.

We joined a panel of researchers, decision-makers and policy advocates (19 of us from 12 countries) to find ways of defining the issue, framing it and putting it on the global health agenda. It was exciting to be on such a distinguished panel, and to have the sense that we were somehow, in a small way, contributing to making the operations of health systems more equitable, transparent, and legible by exploring the power relations that define posting and transfer practices.

It was equally important to be as warmly received as we were, and we commend the meeting organisers for actively tapping into the Emerging Voices network – we hope there will be more such opportunities for our growing cohort. In a sense, we felt like torch-bearers at the meeting, people who will carry on with the posting and transfer research and advocacy agenda down the line. We felt our role at the meeting was not only to contribute, but to learn and be prepared for this role. We think this is one reason why it is so important to continue including emerging researchers in such agenda-setting meetings.  As Max Planck once said, a new idea does not triumph by convincing its opponents, but because a new generation grows up that is familiar with the idea. In this way, it is clear to us that emerging researchers need even more seats at even more tables.

We recognise that we were only representatives of other Emerging Voices at the meeting. And so, we would like this to be an opportunity to take the discussion further by asking you to share your own perspectives, experiences, and understandings, as well as your aspirations for a research and advocacy agenda on posting and transfer: what is necessary, what is feasible, what is utterly impossible?  Let us continue to ‘open the secrets’ of posting and transfer. After all, the Akan proverb states: the one who climbs a good tree is the one who is helped.

Beauty will continue to save the world.

 

(For more information on posting and transfer, please read this background paper here (pdf)

 

Seye Abimbola is a researcher at the School of Public Health, University of Sydney, Australia and at the National Primary Health Care Development Agency, Abuja, Nigeria

Aku Kwamie is a researcher at the School of Public Health, University of Ghana, Accra, Ghana

6 Responses to Posting and Transfer in the Health Sector – The Bellagio Experience

  1. Remi Oyedeji says:

    Posting and transfer is a major problem in Nigeria especially at the sub-national levels where healthcare is controlled by the State governments. Let me tell you the story of Dr K, a staff of one of the health management boards in a state.

    Dr K was deployed to one of the hospitals controlled by the board at the beginning of his career. Some years down the line his immediate boss in the hospital was angry with him that he started a private hospital just like he the boss did. The boss decided to punish Dr K by transferring him to another hospital far from where he established his private practise. This was to make sure Dr K’s private practise collapses and thereby not be a competitor for his own!

    With a lot of manoeuvre and money changing hands, Dr K found his way back to the hospital in the where his private practise was located. Two years down the line after he had gone to plead with his boss with gifts, another issue cropped up. Dr K bought a flashy car, the kind his boss was not using. The boss made sure this time around Dr K was transferred to a remote place. He decided not to fight it. However, he arranged to be at his new duty post only twice week! This afforded him more time for his private clinic.

    A year down the line Dr K moved his family to the nearest town to the obscure locality. The schooling of his children was disrupted and his wife had to resign her job. After putting in another year and pressing that he be brought back to the city without any progress, he resigned and left for a Federal Government job!

    Two years after Dr K left the rural community, they are yet to find a replacement for him in the obscure village clinic because whosoever was posted there went back to the board to bribe their
    way out of it! The very first hospital where he worked is suffering the same fate, no one wants to live in a village! They are posted there and they quietly find their way back to the city. His boss who had qualms with him left 2 years after for the city. Today that hospital is almost dead, barely functional.

    Dr K was willing to stay back but…and the story keeps going on and on.

  2. Emmanuel says:

    Nice piece to read! the multiplel factors influencing posting and transfers are not all so obvious. Certainly calling for further research and analysis. Funding available for different disease control program also plays a role in ‘pushing and pulling’ personnel to ‘juicy’ program areas like the ATM (AIDS, TB & Malaria) which some of my colleagues commonly refer to as the Automated Teller Machines. I don’t think there are many persons interested or lobbying for positions in non-communicable disease programs when the ATM is still dispensing hard currencies.

  3. Thank you Seye and Aku for beautiful writeup which was a joy to read. I feel that we have barely scratched the surface in understanding the dynamics of transfers and postings. It such an important area in health system research; we can build hospitals in the far corners of the country but how do we ensure that there are health workers willing to be posted and those posted willing to work there.

    A vague system with undefined criteria which is currently the norm is among the biggest hurdles. Practices like higher allowances (financial and non financial) for those posted at the headquarters / capitals / big cities turn the idea of incentives on its head! It is so interesting (for the lack of a better word) to see the shape which policies take when implemented, no wonder the experts are left scratching their heads in despair!

  4. Valéria Campos da Silveira says:

    Congratulations Seye and Aku, for such a nice text!! Take care, Valéria

  5. Beverly Ho says:

    Congratulations Seye and Aku for this wonderful piece. The following questions have crossed my mind while reading this blog: is there such a thing as optimum posting time, after which a health worker ceases to or becomes less effective? Are health workers in a more disadvantaged state (i.e. with less leverage, less choice to move) in decentralized health system where the local government units employ them as opposed to a centralized system whey are in no way ‘indebted’ to the local chief executive? recognizing that in most countries, distribution is as important as supply, are health workers trained and prepared for the consequences of posting and transfers? Certainly, there are a wealth of human resource management lessons we can learn from other sectors which we haven’t quite mined yet.

  6. RICHARD says:

    Colleagues, I can agree no more. The concept of deployment and transfers has been little studied. I am happy that it has come to the fore. In Uganda at the school of Public Health we are studying deployment policies and systems in a post conflict situation of Northern Uganda together with our partners in the Liverpool school of Tropical Medicine and Hygiene. Ordinary search of the literature yields very little about deployment per se especially when you explore the internal labor market whereby managers are mandated to move staffs around; some of those concepts that you highlight come into play-paternalistic tendencies, rewards etc

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