https://doi.org/10.33698/NRF0281–Monika, Sukhpal Kaur, Amarjeet Singh
ABSTRACT:
Introduction: Female auxiliary workers also called as Auxiliary Nurse Midwives (ANMs) are signicant health care professional posted at Sub-centres and Civil duispensaries. Objective: To explore the perceptions of ANMs in implementing Mother Child Tracking System (MCTS) in Civil dispensaries of Chandigarh. Methodology: A qualitative research approach was chosen for gaining detailed insights related to ANMs perceptions in implementing MCTS. Questions for Focus Group Discussion Guide were developed on the basis of literature review and validated by experts in the eld of Nursing and Public health. Total 9 Focus group discussions (FDGs) were conducted with ANMs of different civil dispensaries till the data saturation was achieved. Each FGD consisted of 5-6 participants and lasted for 40-45 minutes. FGDs were recorded in writing by investigator as well by Note- taker (Investigator’s colleague). Data was analyzed through thematic analysis by reading all the written data noting of each FGD separately in order to determine central themes. Results: The subjects reported various issues in implementing MCTS such as both online entries and written entries leading to high workload, non-availability of DEO (Data entry operator) at their dispensary, scarce resources and facilities, poor infrastructure, reduced time for practical work and eld work. Conclusion: The ndings of the present study provided a great insight on impact of IT-enabled MCH tracking system on ANMs’ work and problems of ANMs. However, with the changing scenario and during the implementation of new programs it is necessary to explore the ANMs’ problems in relation to program implementation so as to identify their learning needs leading to the success of program and providing quality services to the community.
KEYWORDS: Auxiliary Nurse Midwife; Civil dispensary; Focus group discussion; Mother Child Tracking System; Workload
Correspondance at
Monika
Tutor, National institute of Nursing Education PGIMER, Chandigarh
Introduction
ANMs are the nursing cadre of the Indian public health system, technically trained in auxillary nursing and midwifery1. ANM is the main functionary at civil dispensary to provide maternal and child health services2. Over the period of time, different national health programs including National Rural Health Mission (NRHM) have resulted in increased workload on the ANMs 3 . Government of India launched Mother and Child Tracking System ( MCTS) – a beneciary – name based computerized system in 2009 to improve the Health management information system (HMIS) in the country.
Mother and Child Tracking System (MCTS) is an IT enabled application which will facilitate monitoring of universal access to maternal and child health services for all pregnant women and children. MCTS is designed to capture and track all pregnant women right from conception up to 42 days post partum and all new born up to ve years of age to ensure that the pregnant woman and children receive ‘full’ set of medical services thereby contributing to the reduction of maternal, infant and child mortality4. MCTS software generates workplan of all due vaccination of children and ANC and PNC services of each month which ease the work of ANMs despite of wasting time in making list of due vaccinations and ANC/PNC services by opening a number of registers. MCTS may or may not have decrease the workload of ANMs. Though, there are many studies on ANMs but very few studies were reported on exploring the Perceptions of ANMs in implementing this IT enabled application –MCTS. Hence, the present qualitative study was taken up for gaining detailed insights related to ANMs perceptions in implementing MCTS.
Material and Methods
Setting of the study was civil dispensaries of Chandigarh. There are total 22 allopathic dispensaries in Chandigarh. The permission to conduct study was obtained from District Family Welfare of Bureau, Chandigarh. There are total 66 ANMs working in civil dispensaries of Chandigarh. ANMs who met the inclusion criteria were selected for the study using convenient sampling technique. FGDs were thoroughly planned which was supported by Focus Group Discussion Guide consisiting of open- ended questions. Questions for discussion were developed on the basis of literature review and validated by experts in the eld of Nursing and Public health. The nature, scope of research and purposes of study was explained to the participants before the onset of FGD. The participation in the study was voluntary. The participants were given autonomy to withdraw from the study at any time. Participants were notied that FGDs would be recorded in written by Note-taker. The verbatim record of the discussion was done by investigator’s colleague (Note-taker) as the permission to audio-record of discussion was not given by the participants. Following the discussion with Medical ofcers of dispensaries arrangements were made to gather participants in a room. An utmost care was taken not to disrupt the routine activities of dispensary. Study participants were made to sit comfortably. A calm environment was maintained during FGDs. Data collection for was done from April-September 2017. Total 9 FGDs each of 40-45minutes were conducted. Each FGD consisted of 5-6 participants. FGDs were conducted till data saturation was achieved. The verbatim thus recorded was edited immediately after each FGD. The themes generated and inferences drawn from FGDs were given to the participants for content validation. The verbatim of FGDs were subjected to thematic analysis for generating central themes.
Results
The investigator had undertaken analysis by reading all the written recording of each FGD in order to determine central themes. Two coders independently had read each FGD then, discussion was done and reaching to conclusion for generating theme.FGDs were subjected to thematic analysis. The altenate expalanations or interpretation of the data was done with the study participants to make sure that themes are accurate and supported by data. Various themes were emerged during FGDs conducted with the ANMs posted in various civil dispensaries of Chandigarh.
The themes generated are given as follows:
- Duplication of work, high workload and reduced time for practical work
- Unplanned and mismanagement of work
- Scarce resources and facilities
- Changes in records and reports and difculties encountered in MCTS
- Problems in lling records and ways to tackle problems
- Compromised quality of services
- Use of mobile phones
- Support from community leaders and relations with community
- Alternatives suggested by ANMs
Description of Themes along with Verbatim of ANMs
1. Duplication of work, high workload, and
reduced time for practical work
ANMs are the grass root level health workers in Indian Public health system. They are the main functionary for providing MCH care at civil dispensaries. ANMs reported that their workload has been increased due to more written work
One of the ANMs verbalized:
“Online/written reporting dono kar ke kaam jada hai. Overload hai, jo kaam ham register mein karte hain vo online bhi karwane padte hain, us ke liye hame dusre centre (Civil dispensary sector 42 Attawa)jana padta hai”. (The work has increased due to both online and written reporting. The work we do in the registers has to be made online too. For that, we have to go to another centre).
Another ANM said:
Jada workload bada hai, hmein computer milne chahiye, register band hone chahiye, double triple kam hota hia,ek bar ek nam panch bar likha gya. (Workload has increased, the computer should be provided to us, register work should be closed. There is double-triple work, and sometimes, the name of the one patient has to be entered at 5 places.)
Another ANM said:
“Written work bahut jada hai aur kam ghar vi leke jana painda hai. Homework vi karna painda hai, irritate ho jaande ha. Thoda kam hoye ta relax rende aa, 3 months bahut busy hai”. (The written work is that much that it also has to be taken at home. We get irritated. On completion of some work, we get relaxed, 3 months are very busy.)
As one ANM said:
“Kaam bekaar chal rha hai aur workload bahut jada hai. Assi Mentally disturb hunde ne, 10-10 jagah entries karni padti hai aur written work jada hai. Field bhi jaane ka time nhi hai”. (The useless work is going on and workload is too much. We get mentally disturb, entries are to be done at 10-10 places and written work is too much. Even there is no time to visit the eld.)
Another ANM said:
“Kaam jada hai, burden hai, practical kam hai, written record jada hai. Saare programs ek saath chal rhe hai”. (The work is too much, there is a burden, practical work is less, written record is too much. Many programs are going on together.)
Another ANM verbalized:
“Kaam thik chal rha hai but workload jada hai,. Reports ka kaam jada hai, practical kaam kam hai, field mein home visit nhi ho paati”. (Work is going well but workload is too much. The work of maintaining reports is too much, practical work is less, and not able to make home visits in eld.)
Over the period of time many health programs have emerged and it has increased the workload of ANMs. There is duplication of work of ANM. They have to do online reporting of MCH data along with the written recording of data. Number of entries of same patient in the different registers has increased their work reducing the time for eld and practical work. Moreover, the online entries have to be made in another centre as DEO (Data entry operator) is not available in all the dispensaries. Hence, reducing the time of ANMs for direct patient care activities. Implementation of number of programs has increased paper work of ANMs thus no time left for practical work like giving care to the patients and working in eld with the patients. The stress level has been increased due to so much work.Some time they have to carry their job related work at their homes.
2. Unplanned and mismanagement of work
The workload is not high rather it is unsystematic. A number of programs are being implemented through ANMs but unsystematic and mismanaged work leads to high workload status of ANMs. Though, there is separate ofcer for each program but all the pragams are being implemented byANM at grass root level.
One ANM verbalized:
“Ham jitna bhi kaam kr rhe hai ham sochte hai ki sahi hai but kaam jada nhi par systematic nhi hai.Wahan par(District family welfare Bureau) 3 officers hai- 1 family welfare officer, 1 immunization ofcer, 1 lepsosy officer hai but kaam to ek ANM ne hi karne hai”.(Whatever work we are doing we think that it is right, the work is not much but it is not systematic. There are 3 ofcers, i.e one family welfare ofcer, one immunization ofcer and one leprosy ofcer but the work is done only by one ANM.)
Another ANM said:
“Jo ham planning karte hai, vo hota nhi ha. Field mein jate hai to vapis aana padta ha. Kaam pending bhi chalta hai. Abhi polio duty ki thi to kehte reports bhi abhi do. Aanganwadi worker bhi jada help nhi karte, agar vo cooperate karte hai to unke pas helper nahi hai to vo bhi kya help kare”. (What we do plan that does not happen. If we go for visit in the eld we have to come back. The work remains pending. Now the Polio duty was done, we were asked to send the repost just now. Aanganwadi workers do not help much, even if they cooperate, they do not have any helper, then what help they can do. )
Another ANM said:
Ek to agar hamari clinic ho to beech mein kabi bi phone aa jata hai aur ham distract ho jate hai. Workload ke karan kaam ghar par le kar jate hai. Yahan par bhi hame extra time dena padta hai, kuch bhi systematic nhi hai, unplanned ha. Reports ke bare mei kehte hai ki abhi k abhi reporting karo, sir par danda hai hamare. (On our day of clinic duty, we get distracted whenever there is a call from the authorities. The work has to be taken at home because of workload. We have to give extra time here, nothing is systematic but unplanned. Regarding reports, they ask us to report immediately, pressure is on our heads.)
At times ANMs are not able to complete their tasks because of frequent and unplanned meetings called by the authorities. Their whole work schedule is disrupted when they are called for unplanned meetings. ANMs have 3 clinic days per week. Usually there is huge crowd in dispensaries on the clinic days. But despite of that they are called for meetings on their clinic days. So, it is really difcult for one ANM at the dispensary to run the clinic.
3. Scarce resources and facilities
The ANMs are to provide health services to people who visit dispensary for certain reasons but ANMs lacks basic facilities at the centre making them unable to provide proper care to the patients. .
As one ANM said:
“Room space jiada nhi hai, pani ki problem hai, cooler nahi hai, ventilation nhi hai, photocopy nhi karwa ke dete”. (Room space is not enough, there is problem of water, no cooler is available, and no ventilation and they do not even get the photo copy done.)
As one ANM mentioned that there is lack of even basic facilities like portable water supply at dispensary. The ANMs have to perform certain nursing procedures like assessment of pregnant women and children, administering vaccines and so on. Hand hygiene is an important part of any procedure to prevent cross infection but they don’t have facility for hand washing. They don’t have proper water supply nor do they have hand sanitizer.
In an Interview One ANM said:
Medicine di supply regular nhi aandi hai. Leprosy survey vi sanu keh rhe ne. Extra kam vi sanu dende ne. Urine Sugar kits v de diti hai. Furniture, chair nhi hai, handwashing layi paani nhi hai. Almirah nhi hai, tuti huyi hai. (The supply of medicine is not regular. They are also asking us to conduct the Leprosy survey. Extra work is also assigned to us. Urine sugar kits have also been given to us. There is no furniture such as chair, no water for hand washing. There is no almirah, it has been broken.)
In many dispensaries the workplace of ANMs is so congested that they are neither able to breathe fresh air nor there is provision of direct sunlight. They even don’t have Xerox machine at the dispensaries. For taking photocopies of some reports they have to go outside the dispensary.
4. Changes in records and reports and difficulties encountered in MCTS
Under MCTS, there is recording and reporting of all pregnant women and under ve children.
One ANM said:
Jada information likhni padi thi, par jo likha us se fayda bhi hua hai. (We had to write too much, but what had been written is also benecial.)
One ANM verbalized problems in relation to records:
Reports change ho gayi thi. Pahle reports limited thi, fir jada ho gyi to reports ka kaam badh gya, papers bhi nahi milte, apne level par ham photocopy karwate hai. (Reports had been changed. Earlier, the reports were limited, it had been increased later, then the work of reports has been increased, papers are not provided, get the photocopy at our own level.)
Another ANM said:
Hame system-wise karna pada tha sab kuch, data entry-recording, reporting phir-MCTS aane par naye registers samajhne mein time laga tha aur records bhi jada ho gye the, Reporting mein phi. Data entry operator ko dena padta hai, entries karwani padti hai. (We had to do everything according to system such as entry recording and reporting, then at the implementation of MCTS, it has taken so much time in understanding the new registers and the records had increased so much. Data has to to be given to DEO during reporting, it has to get the entries.)
Another ANM narrated the process of change:
Changes to dekho sab se pahle vo number dete hai vo hame cards par daalna padta. Hame apna DEO dedo, ham apna kaam khud kar lenge. (Regarding the changes, rst of all, they give the number, then we have to put on cards. Give us our own DEO, we will do our own work.)
One ANM said:
Hame workplan mil jata hai, hame online entries karwani padti hai, Unique ID mil jati hai usi ID se ham tarck krte hai, nahi to ham har mahine due list nikaalte the, MCTS mein written work jada hua hai. (We get the workplan, we have to get online entries, get unique ID and track with that ID, otherwise, we had to draw the due list every month. There is so much written work in MCTS.)
One ANM mentioned:
Samjh nhi ata tha pehle baad mein fayda lagta hai, koi bhi nya programme ata hai to thoda to time lagta hai smjhne mein, fir theek ho jata hai. Pehle hum yahan registration krte the fir data entry operator ko smjhate the recording or reporting ke liye. (Earlier, it was not understood, now seems to be benecial, if a new program is introduced, it takes a little time to understand, then it gets better. Earlier, the registration was done here by us, and then we have to make DEO understand for recording and reporting.)
Another ANM said:
Online entries ki problem hai, special jana padta hai, DEO (Data entry operator) yahi ho to easy ho jata hai par 1-2 ghante lag jate hai, 2 hours waste ho jate hai. (There is a problem of online entries, we have to go specially. If DEO (Data entry operator) would be here, it will become easy, but it takes1-2 hours which gets wasted.)
5. Problems in filling records and ways to tackle problems
There were also certain problems in lling the registers.
One ANM mentioned:
Registers mein handwritten columns bnane padte ha. Data entry krte huye problem aati hai, time short hota hai. Ek DEO (Data entry operator) k pas 5-5 centres(5 civil dispensaries) hai, un ke pas time short hota hai, kaam ho to jata hai par time lagta hai. (We have to make hand written column in the registers. We come across problem at the time of data entry, there is shortage of time. One DEOhas 5-5 centres each, they have shortage of time, the work gets completed but it takes time.)
One ANM mentioned:
DEO(Data entry operator) k pas jana padta hai, Sector 8 (Civil dispensary sector 8 Chandigarh) mein hame weekly jana padta hai entries karwane, special jana padta hai. Tracking registers uthane padte hai sare. (We have to go to the DEO in the dispensary of Sector 8 ( Civil dispensary sector 8 Chandigarh) every week for getting the entries done. For this, we have to carry all tracking registers with us.)
One ANM verbalized:
Roz ki dikkato ko aapas mein solve krte hai. Medical officer ki help lete hai, Idhar udhar ki ANM or dispensariyon se puch lete hai. (We solve day to day’s issues among ourselves, seek the help from Medical Ofcer, and ask from the surrounding ANMs or dispensaries.)
Another ANM said:
Ham aapas mein support krte hai, Agar hamare se na ho to Medical officer se help lete hai, Photocopies bhi khud karwate hai. (We support each other, if we are unable to do, then we seek help from Medical Ofcer. We get the photocopy done ourselves.)
An ANM in an interview said:
Medical officer kafi help krte hai, baki aapas mein hi adjustment hai, ham share kar ke kaam kar lete hai. (Medical ofcer do a lot of help, we adjust with each others, we share our works.)
Another ANM said:
Aapas mei adjust krte hai, 26 (26 kind of reports) reports jati hai, ikathi bhi hai or worker-wise bhi hai. Doubling bahut jada hai, aur entry bhi nahi krte , fir dobara se bejni padti hai. (We adjust amongst ourselves, 26 (26 kind of reports) reports are sent, which are joint and worker-wise also. There is so much doubling and, many times it has to be sent again.)
6. Compromised quality of services
The increased paper work of ANMs had reduced the time for practical work. As one ANM mentioned:
Quality of services par farak padta hai, likhne ka kaam jada hai, to field ka kaam reh jata hai. (It affects the quality of services, written work is so much, due to which the eld work remains pending.)
Another ANM said:
Quality par farak padta hai, Par ham koshish karte hai, counseling ke liye time nhi hota. (It affects the quality but we try, no time is left for counseling.)
They are not able to listen to the problems of patients. They don’t have time for counseling the patients when any women wants to discuss family planning issues. It is very disgraceful for the Indian public health system that although we have number of health programs being implemented at dispensaries but the quality of health services are compromised.
One ANM felt helpless and said:
Kayi bar busy hote hai to patient se bhi irritated ho kar baat krte hai, kaam ek hi hai usko 100 time entry karte hai. (Sometimes we are busy, talk to the patient with irritated way. Entry of one work has to be done 100 times.)
Another ANM said:
Bilkul padta hai, apni health par bhi effect padh rha hai, hame health problem bhi ho rhi hai, doctors ne kaha screening yearly karwao, agar pay ke liye bolo to kehte hai job chodh do. (Exactly it affects the quality, it also affects our health, we are getting health problems also, doctor said get the screening done yearly, if ask about the pay, then they say to quit the job.)
One ANM had freely talked on quality:
Bilkul painda hai, jab hame time hi nahi denge to quality ta kam hogi, kayi bar sanu patients nu 1-1 ghanta bithana painda hai, saadi family life bhi effect ho rhi hai. (Exactly it affects the quality, when the time is not given, then quality will be decreased, sometimes we have to ask the patients to sit for 1-1 hour. Our family life is getting affected also.)
Another ANM said:
Hanji affect karti hai quality of services, ham koshish karte hai, but jaldi mei karna padta hai sab kuch, record incomplete reh jaate hai, ham agar overburden hote hai to quality bhi kam hoti hai, koi mistake ho jati hai. (Yes, quality of services gets affected, we try, but everything has to be done in hurry, the records remain incomplete, if we are overburdened then the quality is decreased, any mistake could happen.)
But despite of that Few ANMs had given neutral responses.
Another ANM said :
Chahe hame harrasment kitni bhi ho but ham quality kam nhi hone dete. Immunization bhi one by one karte hai, Immunization bhi sensitive issue hai ham dhyan se kaam krte hai. (Even though, we get any kind of harassment, but we do not let the quality decrease. Even immunization is done one after the other. Immunization is a sensitive issue, we do our work carefully.)
7. Use of mobile phones
Mother and Child Tracking System is a beneciary-specic database for MCH services delivered through the Indian public health system. It was launched as part of a global trend towards harnessing e-health innovations in improving service delivery. ANM as MCH care provider has role to play under MCTS utilizing the mobile health.
Few ANMs had given mixed response regarding use of mobile phones in delivering health services.
As one ANM said:
Mobile phones ke fayde ye hai ke kayi bar hamare patients shift ho jate hai, to ham call kar lete hai, negative ye hai ke unnecessary call krte hai, watts app message krte hai . (The benet of mobile phones is that, sometimes our patients get shifted, then we make the call. Negative thing is that people do the unnecessary calls and watsapp messages.)
In an interview few ANMs had thrown light on negative aspects of mobile phones.
As one ANM said:
Hame mobile phone se kafi help milti hai but 10 mein se 5 number sahi hote hai, 5 wrong hote hai. Or log unnecessary calls krte hai. (We get so much help from mobile phone but 5 out of 10 numbers are genuine and 5 are fake. People do unnecessary calls.)
In one interview ANMs said Mobile phones are really benecial. People are now a days aware about their own health status and visit dispensary and asked about health services. If people do not come then they call people by using mobile phones.
Another ANM said:
Chhoti chhoti baaton par bhi log phone kar dete hai, 12-1 bje raat ko bhi phone kar dete hai. Bache ke pain hai phone par hi treatment lete hai. (People do the calls on small things, even at 12-1 O’clock in the night. The child is suffering from a pain and taking treatment on phone.)
One ANM verbalized many people gave fake phone numbers. Fifty percent of phone numbers are found to be wrong.
8. Support from community leaders and relations with community
The success of any program is all upon community participation. “ Alma ata declaration of Health for All” – stated the importance of community participation in achieving health Goals. Majority of ANMs in interviews had given positive response regarding support from community and community leaders of areas.
As one ANM said:
Patients jo attend karde ne unha nal relations thik ne, patients kende ne ki PGI(PGIMER ), 32(Govt. medical college and hospital) ch problem hundi hai. (They have good relations with the patients; patients say that they face the problems while visiting PGIMER, 32- Govt. medical college and hospital).
Another ANM stated:
Relations achhe hai, support bhi krte hai.
(Relations are good, they support also.)
One ANMs said:
Every month 7th ko ek meeting hoti hai community leaders ke saath, Community leaders se achhe relation hai, counsellor hai, president hai, school teachers bhi hai, Kuch community leader- religious leader hai, kuch aur hai aur ye log to cooperate karte hai, relations bhi achhe hai. (A meeting is held also good.)
Community leaders play important role in achieving health goals. ANMs in an interview said they hold monthly meetings with leaders and discuss about the health issues.
Another ANM in an interview said:
Support bhi karte hai, polio mein bhi karte hai. (They do support, even in Polio duty.)
They got support from community leaders, they also help in Pulse polio rounds. But, few ANMs had given negative statements about leaders and said they are not much supportive.
As one ANM said:
Koi support nhi karde, or na support karde ne na ASHA workers hai. (Nobody does support. Neither are they supporting nor are ASHA workers there.)
9. Alternatives suggested by ANMs
With all the problems being faced by the ANMs, they were asked to provide suggestions for their problems. The ANMs have high workload. Many responsibilities are laid down on their shoulders. Following suggestions were given by ANMs.
Suggestion for facilities and supplies: One ANM said:
Entries ek jagah honi chahiye aur time sufficient hona chahiye. Online entries ke liye building choti hai. Bethne ki problem hai, samaan rkhne ki problem hai. Medicine time par aani chahiye, gap aa jata hai. Medicine ki supply puri honi chaihye”. (Entries should be with Community Leaders on 7th of every at one place and time should be sufcient. The month, they have good relations with community leaders, there is a Counselor, President, School Teacher, some Community Leaders, Religious leaders and some more people, these people cooperate, relations are building is small for online entries. There is a problem of sitting, keeping the materials. Medicine should arrive at time, otherwise gap comes. The supply of medicine should be adequate.)
Suggestions given to reduce written work: One ANM said:
Jada workload bada hai, hmein computer milne chahiye, register band hone chahiye, double triple kam hota hai, ek bar ek naam panch bar likha gya. (Workload has increased, the computer should be provided to us, register work should be closed. There is double-triple work, and sometimes, the name of the one patient has to be entered at 5 places.)
Another ANM said:
Online entries ki problem hai, special jana padta hai, DEO (Data entry operator) yahi ho to easy ho jata hai par 1-2 ghante lag jate hai, 2 hours waste ho jate hai. (There is a problem of online entries, we have to go to DEO especially. If DEO (Data entry operator) would be here it becomes easy, but it takes 1-2 hours for data entries which is wasted.)
Suggestions for manpower One ANM said:
Ek to DEO (Data entry operator) hamari dispensary mein posted hona chahiye, agar ye nhi ho skta hai to petrol charges dena chahiye. Salary ki problem hai contractual staff ki. (First, DEO (Data entry operator) should be posted in our dispensary, if not, the conveyance allowance should be given to us. There is problem of salary of contractual staff.)
Another ANM said:
ASHA worker honi chahiye. Rural area mein ANMs jada honi chihye. Har centre mein ek DEO (Data entry operator) ho or computer system. Jo ANM ka kaam hai vo apne kaam k One DEO (Data entry operator) should be posted at every centre with computer system. ANMs should be responsible for their own work. It should not be like, that if pharmacist is not available then, depute the ANM in lieu of him.)
Duplication of work and number of entries of same patients in different registers resulted in high workload. ANMs said the entries of a patient should be made at one place in register. They said if one patient come to us we have to open 8-10 registers in order to enter data. Written work should be reduced. More over there should be uninterrupted supply of medicines, availability of other material should be made available to them or else they should give money to take photocopies and buy stationary items. Computer should be there at dispensaries for online data entry. Regarding infrastructure, they said the room size should be appropriate to accommodate huge crowd for ANC and child immunization. Most of the time they are expected to give better services but with lack necessary facilities it is difcult to do so. This ultimately affects the quality of care delivered. The authorities must co-operate with them because even after repeatedly informing the authorities regarding the problems they face and their requirements the authorities don’t pay attention to them.
Discussion
Auxiliary Nurse Midwives (ANMs) are also known as Female Multipurpose Health Worker under Multipurpose Health Worker Scheme (MPHW Scheme) launched in 1974 by Kartar Singh Committee to ensure essential primary health care services at every liye responsible honi chahiye, aisa nhi hai k corner of the country.5-7 ANMs receive a pharmacist nhi hai to ANM ko bitha dena hai. (ASHA workers should be posted, more ANMs should be posted in the rural areas. vocational training of 18 months and subsequently operate from sub-centres which are the most peripheral formal health outposts. Catering to 5000 population in conducted by Nagarajan P9 et al in which plains and 3000 population in hilly, tribal and backward areas they are aided by MPHW (M), Village Health Guides, Trained dais, skilled birth attendants and Accredited Social Health Activists ( ASHA). They are immediately supervised by Health Supervisors who are in charge of at least four to six subcentres. Acting as interface between people and organization, needs and services, consumers and providers they serve as the rst contact point of rural India with the formal health care delivery system of the country6.
Mother Child Tracking System is an initiative of Ministry of Health and Family Welfare to utilize information technology for ensuring delivey of full spectrum of health care and immunization services to pregnant women and children up to 5 years of age. It is an innovative, web- based application, developed by National Informatics Centre (NIC), to facilitate and monitor service delivery as well as establish a two way communication between the service providers and beneciaries8.
In the present study, FGDs were conducted with ANMs to explore their perceptions in implementing Mother Child Tracking System. FGDs were conducted at Civil dispensaries. Sixty six ANMs were recruited in the present study. The subjects reported various issues in implementing MCTS such as both online entries and written entries leading to high workload, non-availability of DEO(Data entry operator)at their dispensary, scarce resources and facilities, poor infrastructure, reduced time for practical work and eld work.
Almost, all the ANMs reported that their workload have been increased under MCTS. The results are consistent with a study ANMs reported that they have to spent 6 hours every week towards MCTS which put additional burden in routine activities. Nearly
85 % of ANMs reported the MCTS had increased their workload whereas 71% were of opinion that it has beneted clients.
Most of the ANMs during FGDs in the present study reported that they have scarce resources and facilities in the civil dispensaries which hinders the delivery of quality services to the people. They also reported they are overburdened because of data entry and reporting under MCTS. Few ANMs also reported that they have to draw columns in the registers for entering data. The study ndings are consistent with study conducted by Gera R et al on in-depth assessment of India’s MCTS in Rajasthan and Uttar Pradesh. In this study two assessment methods were used. First method was Data Quality Assessment (DQA) to evaluate data quality and another method was assessment survey to identify implementation challenges. As a result, FHWs were overburdened with data documentation work, and there were long delays in data capturing. FHWs and block level health ofcials were not adequately trained in using the MCTS. UP staff reported unreliable internet and electricity availability, lack of dedicated data entry personnel, and a shortage of consumables such as MCTS registers10.
The ndings in the present study revealed that ANMs even lack basic facilities at dispensaries like availability of safe drinking water, hand washing facilities etc. A similar nding was reported by the facility survey conducted by NRHM in Uttar Pradesh where only 54% sub-centers had drinking water facility.11,12 A signicant problem faced by the ANMs that came to light during FGDs was the difculty in covering large areas assigned to them for conducting home visits that too during the hours of intense heat during day time. Most of ANMs reported they do not have own vehicles to travel in the eld and they have to go on foot. Some of ANMs working in rural and slum settings of Chandigarh stated that they had to walk long distances just to visit a single house due to the population being scattered over a large areas. Similar ndings were also found in a study conducted in rural Maharashtra where the ANMs had conrmed walking long distances under the blazing sun as a major problem13.
The change in the planned activity is quite common in any organization. The ndings in the present reect that ANMs routine got disrupted because of change in their duty schedule. Few ANMs reported, the reason for change in duty was mainly due to sudden unplanned ofcial meetings, report submission etc. Similar to these ndings a study reported that work schedule of female health workers changed due to unplanned activities like special health campaigns and co-ordination for other activities.14
During FGDs, ANMs in the present study reported that they have to carry heavy registers and travel to other dispensaries to get the data entered under MCTS. They have to spent from their pocket for paying travel expenses. Similar results were obtained in a study done by Nagarajan P on assessing the MCTS on right track in Ambala, Haryana. The ANMs in the study reported, they have to go to PHC several times to get the data entered which impede the work and unable them to complete eld visits targets. Most of the ANMs also reported that they have to travel to the PHCs every week to submit registers and work plans, which not only puts the nancial burden due to transportation cost, but also their routine work remains pending due to wastage of time9.
ANMs had also given suggestions to reduce written work, availability of medicines, supplies, facilities at dispensaries. They also talked about to increase their salary and improve population to ANM ratio.
The ndings of the present study provided a great insight on impact of IT-enabled MCH tracking system on ANMs’ work and problems of ANMs. However, with the c h a n g i n g s c e n a r i o a n d d u r i n g t h e implementation of new programs it is necessary to explore the ANMs’ problems in program implementation in order to identify their learning needs leading to the success of program and also providing quality services to the community.
Conclusion: FGDs conducted with ANMs revealed that they spend more time in maintenance of records, online data entry, and attending ofcial meetings. They are unable to do practical work in the eld which compromises the quality of services being given to the clients. ANMs also reported about the scarce resources and facilities at dispensaries.
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