An assessment of “Organization Culture” in District Program Management Units established under National Health Mission in a western state of India

Abstract

Background

State programme management unit and District Programme Management Units (DPMU) are established under National Health Mission with an expectation to strengthen the management structures at the state and district levels, respectively. This is a major initiative to bring change in organisation structure and an effort to embrace change in working culture. The study was undertaken in a western Indian state to assess and compare the organisation culture in DPMUs.

Methods

Districts of the state were divided into three strata based on the geographical and demographic features. One district from each stratum was randomly selected for the study. In-depth interview of nine key officials in each sampled DPMU was conducted with the use of standardised questionnaire—openness, confrontation, trust, authenticity, proactiveness, autonomy, collaboration and experimentation (OCTAPACE), developed by Pareek.

Results

Values of OCTAPACE were diversely distributed with significant difference in distribution of scores between these domains (p < 0.05). Pro-action and Trust scores were relatively higher and consistent in the study units. Values of experimentation were lower and inconsistent. There was no significant difference in the distribution of scores between three sampled DPMUs for openness, confrontation, trust, authenticity, pro-action, autonomy and experimentation (p > 0.05). However, the distribution of collaboration score was significantly less in DPMU of desert district in comparison to DPMU of plain and tribal district (p < 0.05).

Conclusion

The lacuna in values of organisation culture should be addressed to strengthen the existing management structures at the state and district levels.

Introduction

The National Rural Health Mission (NRHM) was launched in 2005 by the Government of India to provide equitable, affordable, accessible and quality health services to vulnerable rural population. Later, National Health Mission was launched in 2013 subsuming the erstwhile NRHM and newly conceptualised National Urban Health Mission. National Health Mission embraced all national programmes under one umbrella with an objective to strengthen the health system. It provided the opportunity to the Centre and the State Governments for carrying out necessary reforms in the health sector. The reforms are necessary for reframing the mechanism of health care delivery system to address contemporary needs and demands of population. Functioning of mission was initiated through a logical frame approach developed through critiquing of existing structure and initiating a constructive change.^1,2,3

To augment the management capacity for implementing National Health Mission, State Programme Management Unit (SPMU) and District Programme Management Units (DPMU) are established with an expectation to strengthen the existing management structures at the state and district levels, respectively. New initiatives in human resource development like induction of professionals qualified in management studies into Program Management Units have driven rapidly changing work culture for which organisation has to adopt.

Delivering high quality comprehensive health care services to vulnerable population is the main goal of health care delivery system. Achieving this goal requires a committed and motivated work force. A good human resource management is backbone of all organisations to effectively deliver the services. Hence, it is essential that all factors that affect the behaviour of employees are analysed. Organisation culture for effective human resource management rests on strong pillars of ethos like openness, confrontation, trust, authenticity, pro-action, autonomy, collaboration and experimentation (OCTAPACE). An Organisation that encourages OCTAPACE values widely and effectively in work environment has the greater chance of keeping employees healthy and satisfied.

Objectives of the present study were to identify and measure the perceived practices and beliefs of organizational ethos/culture and its various dimensions at DPMUs established at district level in National Health Mission in a western Indian state and to compare the differences of these perceptions within DPMU between different geographic and demographic zones.

Material and methods

The present study was undertaken after administrative clearance from state health authorities. The western Indian state where study was planned constituted thirty three districts. Districts of the state were then divided into three strata based on the geographical and demographic features (Desert, Plain and Tribal). There were twelve District districts and twelve notified Tribal districts in the state. The remaining nine districts were labelled as plain districts. One district from each stratum was randomly selected for the study. DPMU of each of selected districts was visited by the investigator to conduct in-depth interview of nine key officials in DPMU of three sampled districts. An informed consent was undertaken from the participants for participation in the study. The participants of study in each district were holding key administrative appointments in DPMUs of National Health Mission. These participants comprised Chief Medical and Health Officer (CMHO), three Deputy Chief Medical Health Officers (Dy CMHO), District Program Manager (DPM), District Account Manager, District Data Assistant, Information Education Communication coordinator and Accredited Social Health Activist coordinator.

A pre-tested and standardised questionnaire OCTAPACE developed by Pareek was the study tool to assess the organisation culture of the study unit in eight values. The OCTAPACE is a 40-item study instrument that assesses the profile of organization's ethos in eight values. These values are openness, confrontation, trust, authenticity, pro-action, autonomy, collaboration and experimentation.⁴

The study instrument OCTAPACE consists of two sections. In the first section, there are three statements for each value of OCTAPACE i.e. 24 statements. The participant of the study is required to check (on a 4-point scale) how much each item is valued in his organization. The second section consists of sixteen statements on beliefs, two each for eight values of OCTAPACE. The participant mentions (on a 4-point scale) how a particular value is widely shared in the organization. Few questions in OCTAPACE mandated to reverse the scores during data entry, so that score 4 becomes 1, score 3 becomes 2, score 2 becomes 3 and score 1 becomes 4. These specific items were marked with an Asterix. This made all items unidirectional. The rows are then added. The eight rows represent the eight aspects OCTAPACE in the same order. The scores on each aspect can range from 5 to 20. The split half reliability of the questionnaire is tested to be 0.82 and validity of this questionnaire is tested to be good.

A mixed method of quantitative and qualitative approach was adopted to analyse OCTAPACE values. The responses by the participants in the score form was entered into Microsoft excel spread sheet. Statistical Package for the Social Science (IBM SPSS Statistics for Windows, Version 25 Armonk, New York: IBM Corp) was used for quantitative analysis of scores. The distribution of OCTAPACE scores in three sampled DPMUs were expressed in median, range and interquartile range. Kruskal Wallis test was applied for comparison of the distribution of scores between study groups. Box plot was drawn to depict the distribution of scores among study units. Each component of OCTAPACE instrument was qualitatively inferred based on the study findings. The study was approved by Institute Review Board and was not referred to Institute Ethical Board as the nature of study was descriptive involving observation of perception pattern of public domain officials and did not pose any risk to participants.

Results

Overall duration of work experience of DPMU members was closely similar in 03 sampled DPMUs. There was no significant difference (p > 0.05) in work experience of study participants at Plain (M = 13.33, SD = 7.86), Desert (M = 13.22, SD = 8.03) and Tribal district (M = 12.11, SD = 6.79). Most of the participants of the study were native of same district except for DPM of desert district.

The values of OCTAPACE were diversely distributed in the study. Pro-action and trust scores were relatively higher and consistent in the study units. The values of experimentation were lower and inconsistent with a wide range of distribution in the study units (Fig. 1). The distribution of scores of various domains of OCTAPACE, i.e. openness, confrontation, trust, authenticity, pro-action, autonomy, collaboration and experimentation was significantly different (p < 0.05) in the study as shown in Table 1.

Fig. 1.

OCTAPACE culture in sampled District Programme Management Units. OCTAPACE, openness, confrontation, trust, authenticity, proactiveness, autonomy, collaboration and experimentation.

Table 1.

OCTAPACE distribution in District Program Management Units.

OCTAPACE SCORES	Mean	Standard error	Median	Range	Interquartile range	Statistical significancea
Openness	13.60	0.33	14	8 (09–17)	1.0	P < 0.05
Confrontation	12.76	0.43	12	9 (09–18)	3.0
Trust	13.72	0.33	13	7 (11–18)	2.5
Authenticity	12.08	0.29	12	6 (09–15)	2.0
Pro-action	14.24	0.35	14	8 (11–19)	2.0
Autonomy	12.60	0.47	13	9 (07–16)	4.0
Collaboration	12.64	0.31	12	6 (10–16)	2.5
Experimentation	11.08	0.55	11	8 (07–15)	5.5

^aKruskal Wallis Test for independent samples.

The distribution pattern of OCTAPACE scores between sampled study units for each component are shown in Fig. 2, and the comparison of scores is shown in Table 2. The openness score in study participants at DPMU of desert and tribal district was consistent. There was no similar consistency in this score at DPMU of plain district. The difference in distribution of openness value between groups was statistically not significant (p > 0.05). Confrontation values were relatively high in DPMU of plain district in comparison to DPMUs of tribal and desert district and scores ranged from 11 to 18 in plain district. However, this difference in distribution of values of confrontation was statistically not significant (p > 0.05). Trust values were relatively low in desert district in comparison to DPMUs of plain and tribal district. However, the differences in distributions of this value among 3 sampled DPMUs were statistically not significant (p > 0.05). Authenticity values were more consistent among DPMU members of desert district and the distribution pattern of scores of this value among three sampled districts was closely similar with no statistical difference (p > 0.05). Pro-action scores were relatively high among DPMU of plain district in comparison to DPMU members of tribal and desert district and scores ranged from 11 to 17 in plain district. However, this difference in distribution of this value between 3 sampled units was statistically not significant (p > 0.05). The distribution of autonomy scores among DPMU members of tribal district was relatively lower than plain and desert district. The difference in distribution of this value between study groups was statistically not significant (p > 0.05). The distribution of collaboration score was significantly less in DPMU of desert district in comparison to plain and tribal district (p < 0.05). Experimentation score was relatively higher in plain district and the difference in distribution of scores among sampled DPMUs was statistically not significant (p > 0.05).

Fig. 2.

Comparison of OCTAPACE scores between sampled DPMU. DPMU, District Programme Management Units.

Table 2.

Comparison of OCTAPACE score distribution between sampled DPMUs.

Scores		DPMU Plain district	DPMU Tribal district	DPMU Desert district	Statistical test of significancea
Openness	Median	13.50	14	14	p > 0.05 (NS)b
	Interquartile Range	10.5 to 15.75	13 to 14	13.5 to 14
	Range	9 to 17	13 to 15	12 to 15
Confrontation	Median Score	13.50	12.5000	12.00	p > 0.05 (NS)
	Interquartile Range	12 to 16.5	11 to 13	11 to 13
	Range	11 to 18	11 to 15	9 to 16
Trust	Median Score	14	15	13	p > 0.05 (NS)
	Interquartile Range	12.25 to 15	13.25 to 15	12 to 13.5
	Range	12 to 15	11 to 18	11 to 16
Authenticity	Median Score	12	12.50	12	p > 0.05 (NS)
	Interquartile Range	10.25 to 12.75	11 to 13	12 to 13
	Range	9 to15	10 to 15	10 to 13
Proactiveness	Median Score	14	14	14	p > 0.05 (NS)
	Interquartile Range	14 to 16	13 to 14.75	13 to 14.5
	Range	11 to 17	12 to 19	12 to 17
Autonomy	Median Score	13	11	13	p > 0.05 (NS)
	Interquartile Range	11.25 to 15	10 to 13.75	12 to 15
	Range	11 to 16	9 to 15	7 to 16
Collaboration	Median Score	14	12.50	12	p < 0.05 (Significant)
	Interquartile Range	11.5 to 14.75	12 to 14.5	11 to 12
	Range	11 to 16	12 to 15	12 to 13
Experimentation	Median Score	13.50	10	10	p > 0.05 (NS)
	Interquartile Range	10.25 to 15	7.25 to 11.75	8 to 13
	Range	9 to 15	7 to 15	8 to 15

^aNon-parametric statistical test - Kruskal Wallis test was applied to compare the distribution of scores between study groups.

^bNS = Non-significant.

Discussion

Health is a state subject in Indian federal policy. Status of public health ranges widely between Indian states. National Health Mission is working in the direction to reduce the differences between different states. DPMU was created in each of the district to enhance the effectiveness of health care delivery system. It has brought a new culture in the public health systems which have a complex matrix of health care facilities.

In our study, instrument proposed by Pareek was used to assess the organization culture of DPMUs in eight values, i.e. OCTAPACE. We could not find similar studies done on DPMUs for comparison of OCTAPACE culture values with our study findings. However, few research studies are available with OCTAPACE assessment done in other organisations.

A study of functioning of DPMUs and their role in the delivery of services in various districts of Madhya Pradesh was conducted under the sponsorship of National Institute of Health and Family Welfare department revealed that DPMU members are now better accepted in the health system after initial resistance from field staff as well as administrative staff at district level.⁵ There was similar response from study participants in our study.

Mufeed assessed the organisation culture among employees of one of hospitals of Jammu and Kashmir. The study assessed the perception of the clinical and non-clinical employees of hospital towards the Human Resource Development climate and the study found that the value of experimentation is not encouraging. The leaders and managers in the hospital never encouraged the potential employees sharing their new ideas.⁶ In our study, most of the study participants were of the opinion that there was application of traditional, tried and tested ways of dealing with problems in DPMU set up. However, there was inconsistency in this response among DPMU members.

Panchamia et al assessed OCTAPACE culture in a civil hospital at Gujarat. In their study, autonomy and authenticity scores were less among health care workers in the hospital whereas collaboration and trust scores were higher.⁷ In the present study, autonomy, authenticity and collaboration scores were less and inconsistent. However, trust score was higher and consistent.

In the present study, openness in DPMU of plain district was marginally less with relatively less free interaction between CMHO and other members of DPMU. These members were of the opinion that the CMHO often behaves like dictator. The culture of receiving suggestion without reservation, taking steps to encourage more feedbacks or suggestions from customers, colleagues and others seemed to be comparatively less. Similarly exchange of ideas, information and feedback between subordinate staff and seniors was absent. Similar gap in free interaction between Reproductive and Child Health Officer with CMHO and DPM was observed in DPMU of desert district. However, in DPMU of Tribal district interaction amongst employees seemed to be better and mutual respect for each other's feelings.

Qualities indicative of good confrontation skills like taking up challenges, bold actions, better role clarity, improved problem solving and willingness to deal with problems and ‘difficult’ employees and customers appeared to be more with CMHO of plain district DPMU. These qualities were observed more in contractually recruited members than the mainstream DPMU in all sampled districts.

Trust among some of DPMU members appeared to be less in DPMU of desert district and also in DPMU of plain district. It might be due to unresolved interpersonal problem between the members. In DPMU of plain district, there was more paper work and stress at work. This could be because of less trust over subordinates by seniors. However, in DPMU of Tribal district, trust between members of DPMU was best when compared to DPMU of plain and desert district.

In our study, there seemed to be distortion of communication between DPMU members of plain district and desert district. Unreserved sharing of feelings was also lacking in some members of DPMU of plain district and to a lesser extent in DPMU of desert district. In general, it appeared that officers at district level fail to exercise authenticity.

Most of interviewed DPMU members in sampled units were of the opinion that the launch of National Health Mission with changes in organisation structure to encourage proactive action plans. Accordingly, higher pro-action scores were observed in all study units.

In the present study, the contractual staff members in DPMU of Tribal district were of the opinion that there was not enough freedom to plan and act in one's own sphere, hence lower score when compared to DPMU of plain district and DPMU of desert district.

Collaboration and team spirit was comparatively poor in DPMU of desert district. There was an unresolved interpersonal problem among DPMU members of desert district. Office of Dy CMHO (FW) in DPMU of desert district was about 7–8 km away from the rest of DPMU members and physical distance seems to be prime factor in failing to generate collaboration.

In our study, most of the respondents at DPMU of Tribal and desert district were of the opinion that innovative approaches to solve problems, taking a fresh look at things, encouraging creativity were poor in the organisation.

Management of human resource is the integrated use of procedures, policies, and practices to recruit, sustain and develop employees in order to meet its desired goals in the organization.⁸ In National Health Mission, contractual management staff were inducted in DPMUs and SPMUs at district and state level, respectively. They were integrated with mainstream permanent staff for effective functioning of these management units. This change in human resource management polity to reframe health service delivery system is bringing a change in organisation culture.

Limitations of present study

The finding of the study may not be the same all over India since the perception of OCTAPACE values is likely to vary depending on the prevailing working environment. The present study is restricted only to eight elements of culture; the other domains of organisation culture were not studied.

Conclusion

Launch of National Health Mission with new initiatives in human resource management policies has encouraged the proactive work culture and has provided adequate autonomy to health care managers in decision making. However, leaders of the health department should also focus and put more efforts to accelerate openness, collaboration, trust and authenticity at work for building up of faith in the organisation. Similarly, innovative approaches to solve problems and taking a fresh look at things with enough creativity needs to be encouraged at these management units.

OCTAPACE organisation culture differs from place to place. Assessment of these cultural values in organisation and timely addressal of lacunas will create a healthy and happy working environment. Health care managers must put efforts to enhance employee satisfaction in health sector; in succession, it will improve the outcome and productivity of organisation.

Disclosure of competing interest

The authors have none to declare.