The document discusses the failure of the cluster health system in Andhra Pradesh, which was established in 2011 to provide supportive supervision and guidance to primary health care units but has now been abolished. It provides an analogy comparing the relationship between policymakers and implementers to a one-way bridge between two cliffs, with only the policymaking side able to pass orders down. It argues the cluster system was weakened due to a lack of capacity building, administrative powers, managerial support, financial support, and infrastructure for deputies. Abolishing the cluster system after only 5 years reflects a lack of trust in the system, failure to address issues, and flawed reasoning as public health outcomes take a long time to be seen.

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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 . . .