Analytic Case Study: Promotion process for Specialists in AJK Health Service. Dr. Mohsin Shakil

1/7/2011

Subject: An Analytic case study of promotion process for specialists in AJK Health Service.

Back ground information:

Azad Kashmir is suffering from chronic shortage of the doctors due to reasons ranging from

budgetary constrains to poor working conditions in hospitals, Minimal job and career opportunities due

to lack of teaching institutes, Medical colleges and tertiary care hospitals, Low salaries, excessive

workload and scarce medical supplies just add to the frustration of available doctors. Situation is

worsening as more doctors find it convenient to work abroad to earn better, about five times what they

earn at home. Govt. of AJK does recognize the situation and took measures to solve the problems of

specialist doctors that include creation of 13 posts in BPS 20 for senior specialists who went to protest

strike about a year ago.

Recently a meeting of the Selection Board was held to promote the specialist doctors but the

decisions taken were not very pleasant for many doctors due to ambiguity of the selection process and

doubts about the decisions taken, specialist doctors took action through Medical Association resulting in

a “halt “on the implementation of the decisions.

Situation demands “An analytic study of the rules related to promotion (into BPS 20) of the

Specialist doctors of AJK Health services” for better understanding of rules especially those being

practiced in AJK and its comparison with those under consideration or applicable elsewhere in Pakistan.

A- Review of Existing & Proposed Rules.

1. Existing Rules for Promotion of the Specialist Doctors in AJK from BPS-19 to BPS-20:

1.1. Minimum Qualification required for the purpose of promotion are as under 1.1.1. MBBS with MD or M.Phil, DSc, FRCS, PhD, MSc, FCPS, MS, MRCP, MRCOG or

equivalent qualification. (Colum 7 no. ii of present service rules dated March 13, 1989) OR

1.1.2. Post graduate qualifications like MCPS, DGO, DO, DOMS, DA, DMRD, DCH or equivalent qualifications. (Colum 7 no. ii of present service rules dated March 13, 1989) 1.1.3. recognized by Pakistan Medical & Dental Council (PM&DC). . (Colum 7 no. ii of present service rules dated March 13, 1989)

1.2. Method of Recruitment: Promotion on the basis of selection 1.2.1. on MERIT from amongst specialist in B -19 with. (Colum 8 no. ii of present service rules

dated March 13, 1989) 1.2.2. 17 yrs of service in B-17 and above in the respective functional unit. . (Colum 8 no. ii of

present service rules dated March 13, 1989)

2. Pakistan Medical & Dental Council’s classification & ranking of the Medical Qualification:

2.1 Pakistan Medical & Dental Council (PM&DC )classify different qualifications in different types depending upon the period of training in years for a particular qualification termed as Learning Level. (Ref:-Attached as Annexure 2)

Learning Level Duration Clinical Med/Dental Qualification Basic Science Quaklification

Level-I 5 – 6 yrs MBBS / BDS

Level-IIa 1 year after Level-I Diploma / MPH

Level-IIb 2 years after level-I MCPS / M.Sc / MSPH M.Phil

Level-IIIa 3 years after level-I MD / MS / MDS M.Phil

Level-IIIb Minimum of 4 years after level-I

MD / MS / FCPS / MDS Diplomat American Board & Other Nomenclatures

Ph.D / other Nomenclature

Level-IV 2 years after level-III Sub-Specialty Fellowship

3. The Career Structure for Health Personnel (CSHP): According to an office memorandum

issued on May 1, 2011, the federal Ministry of Health states, “The Career Structure for Health Personnel (CSHP) is design to reform and improve the quality of service delivery system in health sector and it is decided to introduce CSHP serving the public sector of federal government w.e.f. July 1, 2011. In line with the principle of pay for performance and its linkage with improvement of qualification by delinking health personnel / professionals from basic pay scale (BPS) structure“. Qualification levels, post qualification experience/length of service and evaluation of Merit is easy to understand by considering the example of proposed federal service structure for the specialist doctors in non teaching hospital.

[Career Structure for Health Personal (CSHP) Under the federal Govt.(2011)(Annexure;

working paper NCCSHR, career structure for doctors working in specialized fields in non teaching hospital ( group1) Non teaching Specialist cadre.)]

Qualification levels, post qualification experience/length of service and evaluation of Merit is easy to understand by considering the example of proposed federal service structure for the specialist doctors in non teaching hospital. According to CSHP criteria

3.1. Service Structure proposed by Federal Govt. for Non Teaching Specialist Cadre: Study of proposed service structure revealed that it is based upon the type & level of qualification with due consideration to post qualification experience/length of service. (Annexure 3; working paper NCCSHR, career structure for doctors working in specialized fields in non teaching hospital ( group1) Non teaching Specialist cadre.)

3.2. Qualifications: It identifies qualification as

3.2.1. Minor Diploma corresponding with PMDC level-IIa 3.2.2. Middle Diploma corresponding with PMDC Level-IIb 3.2.3. Major Diploma corresponding with PMDC Level-IIIa 3.2.4. Doctorate Corresponding with Level-III b & IV

3.3. Qualifying length of service for promotion in grade 20 based upon post qualification experience,

3.3.1. Doctorate... 3 yrs 3.3.2. Major Diploma… 5 yrs 3.3.3. Middle Diploma… 8 yrs

(In this services structure specialists with minor diploma are eligible for promotion up to B-19, other with middle, major diploma and doctorate can get promotion up to B-21)

4. Relevant Judgments of the Supreme Courts of AJK. 4.1. Merit: According to judgments /rulings made over the definition of the merit in different courts and cited in decisions of the AJK Supreme court; [(“The mere qualification is not the sole criteria for determination of the comparative merits of the contender for promotion. The Merit undoubtedly includes Experience, Seniority, Competence, Rectitude, and Antecedent in service record, .None of these constituents are less important than the academic qualifications in the assessment of the suitability or merit for promotion to higher post or grade.”) The criteria of merit mentioned above are as defined by court in Case reported as NWFP through chief secretary and others Vs Dr. Ifan Mir and other. [NLR1996 Services 56] also cited in judgment by AJK Supreme court in civil appeal no. 09’2006,Dr. Sadiq Hussain vs AJK govt & other).

So Merit is not a single entity rather it evolve by considering multiple aspects of the same phenomenon.

4.2. OR: IN Law; Or means equal = , used for different option of equal standing ,[as reported in S Muhammad Din & Sons Ltd Vs Assistant Director Labor welfare (conciliation), Lahore region Lahore and Other. [ PLD 1968,Lah. 1012] also cited in judgment by AJK Supreme court in civil appeal no. 09’2006,Dr. Sadiq Hussain vs AJK govt & other]

B- Observations:

5. Internationally accepted package of specialist doctor remuneration depends upon the level of qualification and post qualification experience. Higher qualification and more work experience place higher in the ladder. (Ref. Faculty Positions -- Emergency Medical Services Umm Al-Qura University, academickey.com)

6. Evaluation of the Qualification: 6.1. The evaluation of qualifications does need attention to keep in line with the policy and guideline

of the PM&DC to define its level. Its apparent from comparison of 1.2.1/1.2.2 with 2 /2.1 that 6.1.1. Minimum qualification mentioned in service rules (type 1) is equivalent to Level-III & IV. 6.1.2. Qualification presented in 1.2.2 (type2) is equivalent to Level- II. 6.1.3. Qualification needs due recognition by PM&DC.

7. Evaluation of the Merit 7.1. The criteria for promotion according to AJK health services rule is “Merit”.

7.1.1. Some people Define merit as the level of qualification achieved. 7.1.2. Many suggest including performance evaluation (ACRs) for determining the merit. 7.1.3. Many consider the length of service as merit. 7.1.4. According to legal explanation by court of Law, Along Qualification “Merit undoubtedly

includes Experience, Seniority, Competence, Rectitude, and Antecedent in service record”.

8. Length of service :

8.1. Minimum length of service to qualify for the promotion is 17 yrs of service in B-17 and above in the respective functional unit. . (Colum 8 no. ii of present service rules dated March 13, 1989)

8.2. There is no consideration of Post qualification experience or qualifying service in promotion into grade 20 as in 3.2.

9. Poor drafting of the rules, qualification types mentioned are not in accordance with levels of

qualifications by PM&DC. Poor drafting created ambiguity by use of the word Merit without elaboration and use of the word ‘’OR’’ making both level of qualification equal, which is against the intended meaning.

10. Specialist Doctors of AJK are not satisfied with the decisions taken in meeting of the Selection Board held in Muzaffarabad. 9.1. Pakistan Medical Association (PMA), the representative body of doctors in AJK after consultation among themselves went on token strike to record their protest and doubts about the selection criteria allegedly based upon Nepotism, Pick & Chose. 9.2. Many doctors approached different courts for suspension of the proceedings on recommendations of selection board. 9.3. Doctors are also concerned about the quality of performance evaluation of the specialists and others influenced by personal biases of the reporting officer. For many performance evaluation is nothing to do with actual performance rather its better indicator of someone’s ability to make evaluator happy. 9.4. Evaluation of performance is usually not performed as prescribed by rules rather it is written at convenience of the evaluator and need of the person being evaluated. (Ref:- Daily Siasat, Muzaffarabad, Daily Jammu Kashmir , Muzaffarabad)

11. It has been realized in CSHP that routine structure & rules of Public sector organization are not applicable to Health Services, especially to highly skilled health professionals. (Ref:-Career Structure for Health Personal (CSHP) Under the Federal Govt.(2011)

C- Discussion:

12. It is clear from review of literature and observations that the rules involved are based upon 12.1.1. Qualification i.e., Type I (1.1.1) or Type II (1.1.2). 12.1.2. Recognition of qualification by PMDC (1.1.3) 12.1.3. Merit (1.2.1) …. Relevant decisions of the courts have already defined the MERIT. 12.1.4. Length of Service (1.2.2)

12.2. Qualifications level or types are very clearly defined by PM&DC:

12.2.1.1. Doctorate: PMDC Level-iv 12.2.1.2. Doctorate: PMDC Level-IIIb 12.2.1.3. Major Diploma: PMDC level-IIIa 12.2.1.4. Middle Diploma: PMDC Level-IIb 12.2.1.5. Minor Diploma: PMDC Level-IIa.

12.3. Quantification of qualification: Allocation of certain number to certain qualification can

value the qualification quantitatively for simple & better evaluation eg, Doctorate: PMDC Level-iv 5 Doctorate: PMDC Level-IIIb 4 Major Diploma: PMDC level-IIIa 3 Middle Diploma: PMDC Level-IIb 2 Minor Diploma: PMDC Level-IIa. 1

12.4. Quantification of Post Qualification Experience & qualifying length of service. Post Qualification Qualifying service for promotion into B-20 is 3, 5 & 8 yrs respectively for Doctorate, Major Diploma and Middle Diploma(3.3). 12.4.1. Post Qualification experience can be quantify by allocating a score of 1 for post

qualification experience of 3, 5 or 8 yrs for specialist with Doctorate, Major Diploma and Middle Diploma respectively up to maximum of 5 point. e.g for a specialist with 15 yrs of post qualification service is quantify as described; he may get 5, 3 and 2 points according to the qualification he posses.

12.5. Quantification of Performance evaluation (ACR ) evaluation based specifically on the quality and quantity of the worked performed. Grading /quantification’s method to make the score compatible with qualification & post qualification experience. Overall quantification of ACR grading should be between 01 to 05.

12.6. Evaluation of Merit: By Calculating the total score achieved in each category i.e., qualification, post qualification experience, qualifying length of service and overall performance evaluation in service.

D- Recommendation

13. Keeping in view norms of career progression/promotion in health sector, existing rules mean,

13.1. Minimum Qualification as: “Preferably MBBS with Postgraduate qualification Level- III/level-IV or equivalent recognized by PM&DC, Otherwise MBBS with Postgraduate qualification level-II or equivalent recognized by PM&DC.

13.2. Method of Recruitment: “Promotion on the basis of selection on merit from amongst the specialist of grade 19. Merit is determined by quantification of level of qualification, post qualification experience, qualifying length of service and performance evaluation.

13.3. The Qualification level, post qualification experience, length of service and performance evaluation are the key factors and should be given due and equal consideration to determine the merit. e.g. by allocating equal marks to all four categories and determining the score attained by every contender and considering the sum of score of every individual as his/her merit for promotion.

14. Due consideration for adopting CSHP (Career Structure for Health Professionals) in AJK by concerned authorities, as the objectives of this structure are very much relevant for improvement in quality of service delivery in health sector.

References:-

1- Colum 7 no. ii , AJK Health Services Rules for promotion of specialist into Grade 20, dated March 13, 1989. Annexure I.

2- Pakistan Medical & Dental Council’s classification & ranking of the Medical Qualification vide letter dated June 3, 2011. Annexure II.

3- Career Structure for Health Personal (CSHP) Under the Federal Govt.(2011) 4- Working paper NCCSHR, career structure for doctors working in specialized fields in non

teaching hospital ( group1) Non teaching Specialist cadre. Annexure III. 5- [NLR1996 Services 56] also cited in judgment by AJK Supreme court in civil appeal no.

09’2006,Dr. Sadiq Hussain vs AJK govt & other.

6- [ PLD 1968,Lah. 1012] also cited in judgment by AJK Supreme court in civil appeal no. 09’2006,Dr. Sadiq Hussain vs AJK govt & other]

7- Faculty Positions -- Emergency Medical Services Umm Al-Qura University, Makkah, academickey.com) Annexure IV

8- Daily Siasat, Muzaffarabad, Daily Jammu Kashmir , May 28, 2011, Muzaffarabad.