Dr. Suchitra Lisam, Sr. Consultant NHSRC

Multiple case studies in states for addressing diverse contexts of HSC for policy changes in Human Resources

How many is not enough? Human Resource Gaps against Requirements for Health Sub-Centers:

Global Public Health Conference,

3rd to 5th January, 2013, Kochi Kerala

Study Rationale

• Evolving roles and changing nature of Health Sub-centers (HSCs)across states in last few years (Source: 4th CRM Report)*

• SCs has become more of a center for delivering ANC &immunization services during OPD/ANC days and immunizationsessions (VHND) and played less role in institutional deliveries*

• SCs are no longer an institutional delivery sites in Kerala, TN, Punjabwhere major proportion of ANC/immunization services are provided atPHCs and vacuum in work-load is filled with NCD & school healthprograms. High proportions of home deliveries reported in Punjab andNagaland with limited role of SCs in institutional deliveries. 10% of SCsin Chhattisgarh, Jharkhand, Maharashtra, U.P, Rajasthan and M.Pconducted deliveries*

• Key policy documents (HLEG, IPHS, NRHM-WG) recommended asingle nation norms for SCs overlooking different types of SCs(documented in CRM reports) 2

Research Questions

• Under what contexts the SCs across states arefunctioning?

• What is the current scenario of SCs in terms ofpopulation served, accessibility, staffing, servicedelivery?

• What is the work pattern, work-load and work-allocation between staffs on weekly basis?

• Is there any variations or similarities on above factorsbetween SCs within contexts and/or between states?

• Need of a flexible HRH norms for SCs?

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• To document the emerging patterns and diverse contexts ofSCs with respect to geographical location, populationserved and public health systems

• To assess the ranges and quantum of health servicesdelivered by SCs

• To study the work-pattern and work-load of serviceproviders at SCs.

• To study the human resource (HR) structure and availabilityas against those prescribed by IPHS, HLEG for UHC for SCs

• To describe the need for a flexible HR norms within diversecontexts of SCs

Study Objectives

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Study Methodology• Mix approach using qualitative and quantitative components

used for the study. Qualitative case study design adopted to explore variations/similarities across SCs supplemented with review of secondary data.

• HMIS data of 1 year (Aug’10-July ‘11) used to choose districts based on 3 key RCH performance indicators

• Review of district records of sampled SCs on parameters i.e. population served, HR status, performance indicators etc

• In-depth Interviews of service providers of sampled SCs in each selected state

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Study SamplePurposive Sampling method used for selection of states/districtsand SC

I. Selection of States 7 states comprising of 5 EAG and 2 non-EAG states and regional

representation (North, South, East, NE and West)

EAG states (Chhattisgarh, Assam, Rajasthan, UP, Meghalaya)

Non EAG states (Kerala and Haryana)

II. Selection of Contexts /Districts Certain contexts identified in each state (Total contexts=13)

Districts falling under each context selected

Each district graded based on key RCH performance indicators obtained by: summing up of points given against ranges of percentage on performanceindicators viz. % of pregnant women with 3 ANC check up, % ofinstitutional delivery and % of immunized children l< 1 year for measlesagainst estimated live births

The district with an average score was purposely selected6

Study Sample III. Selection of SCs:

SCs in selected district based on RCH performance, availabilityof staffs and feasibility of data collection.

Overall, 7 states across 5 regions including EAG /non-EAG stateswere finally chosen. Identified contexts were

• Haryana: near urban and far areas

• Chhattisgarh: tribal /forest hamlets, agricultural areas and nearurban areas

• Assam: rural, median and riverine in remote areas

• Kerala: semi-urban area

• Rajasthan: desert and densely populated area

• Uttar Pradesh: Bundelkhand region with poor health indicators

• Meghalaya: hilly areas

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Grading of DistrictsSr. No.

Type of key RCH Performance Indicators Range of Percentage

1. % of pregnant women with 3 ANC check up against estimated pregnancies

≥80% ≥60%-<80% <60%

Point Given 3 2 1

2. % of immunized children less than 1 yr against estimated live births

≥80% ≥60%-<80% <60%

Point Given 3 2 1

3. % of institutional deliveries against estimated deliveries

≥60% ≥40%-<60% <40%

Point Given 3 2 1

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Sample Size

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Study Limitations

• Study findings may not be robust and valid for generalizationand for arriving at objective conclusions.

• Study relied on descriptive information provided by serviceproviders which might leave room for important details to beleft out during interviews.

• Moreover, much of information collected were retrospectivedata, recollection of past events and may therefore subject torecall bias or problems inherent to memory.

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Key Findings

I. Evolution of SCs

• Nature of SCs has evolved over years

• SCs were differentiated into “Delivery Points” and “Non –Delivery Points” in Haryana, Chhattisgarh, Rajasthan

• Few SCs were “Co-located SCs” in Haryana and Chhattisgarh- focused primarily on outreach activities

• While Assam had deployed an additional health worker in the form of RHP (Rural Health Practitioners) towards strengthening SCs

• Kerala SCs run an NCD clinic once in a week

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Key Findings

II. Service Delivery at SCs

• Majority of SCs functioned primarily as sites for ANC,immunization services, treatment of minor ailments,outreach activities during VHSND and institutional deliveriesalong with minimal laboratory functions (Hb, urine tests,preparation of peripheral slides)

• Less role of SCs in implementation of NHP (National HealthProgramme), disease surveillance etc

• Limited role in delivery of preventive, promotive healthservices in majority of SCs

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Key FindingsII. Service Delivery at SCs

• Kerala and Assam SCs showed variations in service delivery.

• SCs in Kerala provided basic care; hardly OPD/ANC services provided, no delivery took place, SCs undertook health prevention, promotion, nutrition sessions on weekly basis, run 1 day NCD clinic; implemented school /adolescent health programs and provision of palliative care services.

• SCs in Assam were upgraded with addition of RHPs to improve service ranges, quantity and quality of OPD/ANC services.

• Value addition of MPWs observed as there was increasing trend in blood slides collected for M.P (malarial parasites); disease surveillance, screening /detection of NCD etc at some Assam SCs.

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Key FindingsIII. Overall Work-pattern and Work-load of SCs:

• ANMs shared similar work-pattern across SCs in Haryana, Rajasthan within diverse contexts and population served though SCs in Chhattisgarh had slight variations within 3 geographical contexts. Variations also observed in SCs of Assam/Kerala unlike other SCs.

• All SC provide symptomatic OPD and ANC services in the morning half on 3 days with average OPD/ANC load of 1-5 cases/day.; and conduct VHNDs once or twice a week, attended meetings at PHC once in a month. Majority of ANMs in Haryana SCs conducted deliveries (3-20 cases) per week while ANMs in Chhattisgarh (1-3 cases) and Rajasthan (3-5 cases) per week.

• ANMs undertook outreach/field work on 2-3 days or in afternoon of OPD days. ANMs spent ½ day on documentation once in a week. MPW performed laboratory tests i.e. hemoglobin, urine tests, slides preparation.

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Key FindingsIII. Overall Work-pattern and Work-load of SCs:

• ANMs in Kerala SCs organized school health programs (Monday), took health promotion/nutrition sessions for AWW, home visits (Tuesday), organized VHND (Wednesday), run NCD clinic (Thursday) for screening/detection of Hypertension, Diabetes, Cancer, lifestyle counseling, palliative care services and provided OPD/ANC services on 2 days (2-3 cases/day on (Friday/Saturday) in week.

• In Assam SCs with RHP, the ANM/MPW assisted RHP in delivery of OPD/ANC services on 5 days/week (by registering OPD clients,

dispensing of IFA tablets/other drugs, T.T immunization and issuing JSY

cheques) Average OPD load of 20-30 cases/ day and ANC load of 5-10 cases/ day on (Tuesday/Friday); VHND (Wednesday); assisted MMU (Saturday), conducted outreach work/home visits (Thursday); documentation took 3-4 hrs in a week.

• MPW conducted Hb, urine tests, disease surveillance in households;

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Key Findings

III. Overall Work-pattern and Work-load of SCs:

• In SCs with 2 ANMs, population coverage and field visits were divided between them

• Location of SCs and population served had no linkage with work-pattern or workload of ANM

• Clear work division between 2 ANMs (regular/contractual) was in terms of organizing VHSND and deliveries

• ANM ( C ) coordinated VHND sessions while ANM (R ) conducted institutional deliveries and prepared slides for suspected malaria cases

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Key Findings

IV. Staffing at SCs• Staff pattern of 69 SCs ranged from 1 ANM or 2 ANMs with or

without MPWs - 37 (53.6%) had only 1 ANM and 32 (46.4%) had 2 ANMs. Of the 32 SCs with 2 ANMs; 6 (18.7%) had an additional MPW and 26 (81.2%) had no MPW. In Assam, an additional worker in the form of RHP was deployed.

• In Haryana, single ANM SCs were handling higher case-loads as compared to SCs with 2 ANMs

• In Assam, an additional worker “RHP” was available in 7/15 SCs. In Chhattisgarh, 14 /15 SCs in different geographical contexts had single ANMs though institutional deliveries took place in 11 of them

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Key Findings

IV. Staffing at SC• 6 (25%) SCs serving ≥ 5000 population had 1 ANM while 11

(28%) SCs serving <5000 population had 2 ANMs

• In Haryana, Rajasthan and U.P, SCs where ANMs resides in SC campus or nearby villages performed better. Duration of ANM’s posting at same SC was directly proportional to case-loads.

• Rational deployment still remains an issue as 26 of 35 SCs conducting deliveries had single ANM. E.g. In Udaipuria SC (Rajasthan) serving 7717 population had 1 ANM only though the performance is high (ANC load of 119, ID of 164)

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Key Findings IV. Staffing at SCs• Average distance from SC to farthest villages in desert areas

(Rajasthan) is relatively higher (10-15km) compared to that in densely population areas having average distance of 5 km though population covered by SCs in desert areas (Rajasthan) was lesser than densely populated areas. Farthest villages from SC in Meghalaya ranges from 20-25 km. Out of 69 SCs, 24 (35%) of them served >5000 population

• Out of 13 contexts chosen in 7 states, SCs located in median area of Assam served 10 villages (on an average), while the SCs in desert area of Rajasthan served only 1 village. SCs in near urban areas of Haryana served an average 7661 population (maximum) while SCs in tribal areas of Chhattisgarh served an average of 2543 population (minimum).

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STUDY CONCLUSIONSI. Differential Staffing Norms for SCs

States had posted health workers without taking into account population served, geographical location, accessibility, service delivery or caseload

Rationalization of ANM/MPW

• SCs covering larger population; SCs in difficult geographical terrain having dispersed population

• SCs conducting institutional deliveries

• SCs with relatively higher case/work loads; weekly work-pattern

II. Training & Capacity Building

• CB to handle emerging NCD required for SCs oriented towards screening/detection of NDC

• Prioritize training needs for ANMs, MPW20

STUDY CONCLUSIONSIII. Retention Strategies

• locality-based “selection of candidates”

• Post training placements

• Clear posting & transfer policies

IV. Defining the additional skilled health worker

• Presence of an additional skilled health worker translates into higher footfalls

• AYUSH graduates/allied medical sciences training in public health; new cadre of B. Sc, in line with RHP

• Define career development paths

V. Mechanism for Support Supervision:

• PRI participation/accountability to local based selection/supervision along with community monitoring

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