http://doi.org/10.33698/NRF0245-Monika, Sukhpal Kaur, Amarjeet Singh
Introduction: ANMs are the main functionary at Civil dispensary of Chandigarh. Nowadays ANMs have wide spectrum of responsibilities to play under mother child tracking system as well as other national health programs. Objective: To determine workload of ANMs in implementing Mother Child Tracking System (MCTS) and calculating required number of ANMs at Civil dispensary Dhanas. Research methods:A quantitative research design was chosen. WISN (Workload Indicators of Stafng Needs) methodology was used to determine workload and to calculate required number of ANMs. All the procedures related to ANMs’ routine work (based on IPHA standards) were framed and content validity was established. One ANM was selected to calculate actual time in completing each procedure (activity standards) using purposive sampling technique. The selected ANM was demonstrated each procedure. After that three observations were made to record time in completing procedure using stop watch. The average was taken from the three values. Data related to MCTS of year 2016-17 was obtained from dispensary. After developing activity standards (Standard time to complete procedure) the percentage of total annual working time in performing different activities of ANMs was calculated. All the steps of WISN calculation was applied to determine required number of ANMs in implementing MCTS. Results:The study results revealed that existing number of ANMs at dispensary is 3. Two third (65%) of ANMs’ annual working time is devoted to activities under MCTS. ANMs have only 35% of annual working time left for doing all other work activities under various other national health programmes. As there are number of health programs in which ANM is supposed to function like NPCDCS, RNTCP, NLEP etc. Hence, there is shortage of ANMs to complete all the work responsibilities under MCTS as well as other national health programs. Conclusion: The study results are alarming indicating need of more ANMs at dispensary to complete all the tasks expected from ANMs.
KEYWORDS: Activity standards; Auxillary Nurse Midwife; Civil dispensary; Mother Child tracking system; WISN (Workload indicators of stafng needs)
Dr. Sukhpal Kaur Lecturer
National Institute of Nursing Education, PGIMER, Chandigarh
Mother and Child Tracking System (MCTS) a computerized IT enabled system launched in 2009 by Government of India. 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 mortality.1ANM is the nursing cadre of the public health system, technically trained in nursing and midwifery2. ANM is the main functionary at civil dispensary to provide maternal and child health services3. She plays a very important role in implementing MCTS among all the health care stakeholders. Different national health programs including National Rural Health Mission (NRHM) have resulted in increased workload on the ANM. In the light of this, the NRHM has recommended a second ANM/Health Worker Female at sub centre.4 Studies are also available which reported that the ANMs were not able to carry out even routine ante-natal care checkups in their allocated health centres like sub-centre (SC) areas5,6-9. There are many studies on ANMs and their workload. But very few of the study has reported on workload calculation based on standardized methodology l ike WISN (Workload Indicators of Stafng Needs) toolkit10. The present study was hence taken up t o d e t e r m i n e w o r k l o a d o f A N M i n implementing MCTS and calculating required number of ANMs at civil dispensary.
Material and Methods
Setting of the study was civil dispensary (CD) Dhanas, Chandigarh. There are total 22 allopathic dispensaries in Chandigarh. CD Dhanas was conveniently selected for the study. Dhanas is situated in west of Chandigarh with population of 16306(2016-17). Dhanas is semi- urban setting divided in different parts like Milk colony, Housing board-I & II, Aman colony, Chaman colony, Ambedkar colony, Kacchi colony and Dhanas village. Dispensary is situated in Milk colony of Dhanas. Residents of Dhanas are migrants from Punjab, Haryana, Bihar, UP, Rajasthan and Himachal Pradesh. The permission to conduct study was obtained from District Family Welfare Bureau, Chandigarh. Care was taken not to disrupt the routine activities of dispensary.The workload was determined using WISN toolkit. The WISN method calculates the number of health workers per cadre, based on health facility workload. It provides two indicators to assess stafng: the gap/excess between current and required number of staff, and the WISN ratio, a measure of workload pressure. The rst step in WISN methodology is choosing the staff category for WISN development: here, staff category is ANM working in dispensary of Dhanas, Chandigarh. The next s tep in WISN methodology is to estimate available working time, that is how much time an ANM has available for doing her work. The available working time can be expressed in days or hours per year. To calculate the available working time (AWT), add together the total days off and deduct that sum from total possible working days. The available working time of an ANM is 1686 hours /year. Then, for calculating workload all the activities of ANM was listed along with its frequency. There are three workload components of ANMs:Main health service activities of ANM are carried out by all the ANMs such as ANC-I, II, III, IV, weight recording and height recording of antenatal women, BP recording, TT vaccination of pregnant women, post natal care (excluding time to reach to home), neonatal care (excluding time to reach to home), weight recording and height recording of baby, immunization of child, Cu-T insertion and removal etc. For these activities regular statistics are collected; Important support activities are carried out by all ANM such as record maintenance, anganwadi visit, home visit, pulse polio immunization ; Other activities are carried out by ANMs such as monthly meeting, attending continuing education, reporting of data but regular statistics are not collected on these activities.
After that activity standards were developed. An activity standard is the time necessary for a well trained, skilled and motivated ANM to perform an activity to professional standards in the local circumstances. There are two different types of activity namely service standards and allowance standards. There are three ANMs posted in CD Dhanas. One ANM was selected to develop activity standards using purposive sampling technique. An informed written consent was taken from selected ANM. She was well informed about purposes of study. All the procedures related to ANMs’ routine work based on IPHA standards were framed and content validity was established by taking opinions from experts from eld of nursing and public health experts related to MCTS. The selected ANM was demonstrated every procedure. After that three observations were made to record time in completing procedure using stop watch. The average was taken from three values. Data collection for study was done in April-May 2017 with the objective to nd out the feasibility of the WISN toolkit and to estimate the time required and potential problems researcher may encounter during the actual study. The results of study revealed that it was feasible to calculate required number of ANMs using WISN toolkit. The time spent on each procedure done by ANMs was calculated along with the percentage of annual working time spent on each activity done by ANMs. Data related to MCTS of year 2016-17 was obtained from dispensary. After developing activity standards, the standard workload for each activity was calculated. Standard workload is the amount of work (within one main service activity) which one ANM can do in a year. Standard workload was calculated by dividing available working time in hours by unit time for each activity in hours depicted in table 1.
After that allowance factors were calculated (Calculations given in table 3, 4). After doing all the calculations, the required number of ANMs in implementing MCTS was calculated along with the percentage of total annual working time in performing main health service, important support and other additional activities of ANMs.
Standard workload is the amount of work (within one main service activity) which one ANM can do in a year. After that allowance factors were calculated. After doing all the calculations, the required number of ANMs in implementing MCTS was calculated.
All the calculations were made according to WISN methodology. All the main service activities of ANMs were listed and time needed to perform each activity was noted then standard workload was calculated. The given b e l o w i s t h e t a b l e – 1 s h o w i n g t i m e (minutes/patient) needed to perform different procedure with annual statistics and standard workload related to ANMs of routine work, total time needed to perform activity in a year and percentage of total annual working time. ANMs spent 18.3% of their total annual working time in performing main service activities.
There are some activities of ANM on which annual statistics are not calculated. For those activities allowance standards were calculated. The different allowance standards with their percentage of total annual working time are given in table-2. ANMs spent 62.2% of total annual working time in performing important support activities that is record maintenance ( 25 %), aanganwadi visit( 3 %), home visit/survey (18.5%), pulse polio duty ; national and sub-national round each (3.2%) and travel time in the eld (9.3%). Similarly for performing additional activities of ANMs they spent 18% of total annual working time in performing activities like monthly meeting (3.6%), attending continuing education (0.7%), reporting of data (12.3%) and indenting (1.4%)
Table-1: Activities of ANM with average time to perform activities and their standard workload
|S.No.||Main health service activity of ANM||Time needed to perform the activity (Minutes
|Standard workload AWT(Hours)in year/Unit time in hour for activity||Annual statistics at dispensary||Total Time needed to perform activity in year in
|% of total annual working time : 3 ANMs|
|1.||Antenatal care(ANC)-I Including health
|40minutes per patient (0.66hour)||2554||192||7680minutes (128hours)||2.5|
|2.||Antenatal care(ANC)-II Including health
|20 minutes per patient(0.33hour)||5109||135||2700minutes (45hours)||0.9|
|3.||Antenatal care(ANC)- III Including health
|20 minutes per patient(0.33hour)||5109||147||2940minutes (49hours)||1.0|
IV Including health education
|20 minutes per patient(0.33hour)||5109||85||1700minutes (28hours)||0.6|
|5.||Weight recoding of
|3 minutes per
|6.||Height recording of
|2 minutes per
|7.||BP recording of antenatal women Including health
|6 minutes per patient(0.1hour)||16860||559||3354minutes (56hours)||1.1|
|8.||TT immunization of pregnant women
Including health education
|7 minutes per patient(0.11hour)||15327||254||1778minutes (30hours)||0.6|
|9.||Postnatal care(PNC) Including health
|25 minutes per patient(0.42hours)||4014||371||9275minutes (155hours)||3|
|10.||Neonatal care(NNC) Including health
|26 minutes per patient(0.43hour)||3920||371||9646minutes (161hours)||3.2|
|11.||Weight recording of
|6 minutes per
|12.||Length recording of
|3 minutes per
|13.||Immunization of child-
parental Including health education
|8 minutes per patient(0.13hours)||12969||1039||8312minutes (139hours)||2.7|
|14.||Immunization of child- oral Including health
|3 minutes per patient(0.05hour)||33720||1057||3171minutes (53hours)||1|
|15.||Cu-T insertion and FP
|10 minutes per
|16.||Cu-T removal||8 minutes per
|% of total annual working time for Main service activities||18.3%|
AWT=1686 hours; AWT of 3ANMs=3 X 1686=5058 hours
Table-2: Allowance standards for a ANM in Dispensary
|S.No.||Important support activities of all ANMs||Allowance standard||% of total annual working
|1.||Record maintenance||1.5 hour/day||25|
|2.||Aanganwadi visit||1 hour/week||3|
|4.||Polio(National round)-2 rounds in year
each for 3 days (total 6 days/year)
|5.||Polio(Sub-National round)-3 rounds in
year each for 2days((total 6 days/year))
|6.||Travel time in the eld||3hours/week||9.3|
|% of total annual working time for important support activities
|Additional activities of ANMs in CD||Allowance standard||% of total annual working
|1.||Monthly meeting||5 hours/month;1 ANM||3.6|
|2.||Attending continuing education||12hours/year;3ANM||0.7|
|3.||Reporting of data||4 hours/week;1ANM||12.3|
|% of total annual working time for Additional activitiesof ANM||18%|
*Polio round 9 hours per day(6daysX9=54hours)
The category allowance factor and individual allowance factors were calculated based on allowance standards as given in table-3 and 4.
Table-3: Calculation of Category Allowance factor
|S.No.||Important support activities of all ANMs||Allowance standard||Category Allowance standard(CAS) in percentage % of total annual
|Sum of all CAS
|Category Allowance factor(CAF)|
|1.||Record maintenance||1.5 hour/day||25||62.2||CAF=
1 divided by
|2.||Aanganwadi visit||1 hour/week||3|
round)-2 rounds in year each for 3 days (total 6 days/year)
|5.||Polio(Sub-National round)-3 rounds in year each for
|6.||Travel time in the
Table-4: Calculation of Individual allowance factor
|S.No.||Additional activitiesof Certain ANM in
|Allowance standard||Individual allowance factor(IAF)||IAF as Whole time equivalent staff(WTE):ANMs|
|1.||Monthly meeting||5hours/month;1 ANM||5hoursx12months=60hours/year 60 X 1ANM=60
|12 hours/year; 3ANM||12hours/year 12X 3ANMs=36
|3.||Reporting of data||4 hours/week;1ANM||4hours x 52 weeks = 208 hours/year 208 X 1ANM=208
|4.||Indenting||2 hours/month;1ANM||2 hours x12months = 24 hours year 24X1ANM=24
After that ANMs required for dispensary was calculated. The number of ANMs required for dispensary was calculated separately for the three different types of activities. For main service activities: Divide the annual workload of each activity by its respective standard workload. It will give the health workers required for that activity. Add the requirements of all activities together to get total staff requirement for all main service activities. The table -5 showing the ANMs required for all Main service activities.
Important support activities done by all ANMs: Multiply the ANMs required for main service activities by Category allowance factor(CAF). This gives the ANMs required for all service and important support activities as shown in Table-6.
Table-5: Calculation of ANMs required for Main service activities of ANMs
|S.No.||Main health service activities of ANM||Standard workload||Annual workload Units/year||ANMs required to perform the activity =
Annual workload/standard workload
|Total ANMs required to perform all Main service activities|
|5.||Weight recoding of||33720||559||0.02|
|6.||Height recording of||56200||192||0.003|
|7.||BP recording of adult||16860||559||0.03|
|8.||TT immunization of||15327||300||0.01|
|11.||Weight recording of||16860||742||0.04|
|12.||Height recording of||33720||371||0.01|
|13.||Immunization of child-||12969||1039||0.08|
|14.||Immunization of child-||33720||1057||0.03|
|15.||Cu-T insertion and FP||9917||8||0.00|
Table-6: Determining ANMs required for all service and important support activities
|ANMs required for main service activities||Category allowance factor(CAF)||ANMs required for all service and important support activities=
ANMs required for main service activities X CAF
|0.7||2.6||0.7 X 2.6= 1.82= 1.8 i.e annual working time of 1.8 number of ANMs|
Additional activities of Certain ANMS : Add the IAF to the above number given in table 6 1.8+0.19=1.99= 2.0 i.e Annual working time of 2 ANMs Hence, the existing number of ANMs in implementing mother child tracking system at dispensary of Dhanas is 3. It indicates that 65% of annual working time of ANMs is spent on performing activities under MCTS.
But ANMs have many more activities to perform under other national health programs. ANMs are left with only 35% of total annual working time in performing other activities apart from MCTS. It may create a difcult s i t u a t i o n f o r A N M s t o f u l l l o t h e r responsibilitiesin just 35% of total annual working time. The time constraints and variety of roles to play in other national health programs will ultimately affect the quality of health services.
It indicates high workload of ANMs at dispensary and need for more ANMs in order to complete all the activities expected from them.
India has different cadres of community health workers auxiliary nurse midwife, ASHA, aanganwadi workers. Among these, ANM is most signicant health worker which form an important part of health team. ANM is the main functionary at civil dispensaries and only care p r o v i d e r a t s u b – c e n t r e s . A l l t h e implementation programs in public health coverage at the grass root level are mainly through ANM. She is responsible to provide a wide spectrum of services to people in the community. The health status of Indians has improved markedly. However, despite rapid growth in GDP, India has consistently failed to meet national and international health targets, and it has improved its health status more slowly than most other Asian countries11. To achieve health targets a name based Mother child tracking system was launched by Govt. of India to provide full spectrum of services to pregnant women and children. ANM has broad set of responsibilities in MCTS. Various studies indicated that heavy job responsibility rests on ANM’s shoulder. Based on the literature review and researcher’s own observation the present study was undertaken to assess the workload of ANMs in implementing MCTS in Civil dispensary of Dhanas, Chandigarh.
Literature revealed that different researchers have used different methods to assess the workload of ANMs. As per literature time motion and work sampling have been widely used to calculate workload of health workers. In present study, the workload was determined on the basis of WISN methodology given by WHO. Very few studies have been reported from Northern India on workload calculation of ANMs based on standard methodology like WISN. Although there were few studies on workload of ANMs. A study on workload of health workers from Kerala used self administered questionnaire, indepth interview and case study along with Role Overload Distance Stagnation scale(RODS) to assess workload12. In another study conducted in Kerala, household surveys were used to compare the actual delivery of services at the door steps with that reported by female health workers, focus group discussions and personal interviews were also conducted to assess the workload of female health workers13. Whereas in a study from West Bengal only one method(observation of work sessions) was used 14 .
Dearth of literature is available about increased workload of ANMs. In the present study workload was calculated based on WISN methodology and to nd out difference between ideal number and current stafng levels of ANMs. This methodology is different from other workload calculation methods because all the calculations are done based on the annual statistics of activities and procedures done by ANMs. Moreover, the time standards in minutes were generated for each maternal and child health activity.
The existing number of ANMs for performing all the activities at dispensary of Dhanas is 3. But ANMs have many more responsibilities and duties under other national programmes. It indicates the workload is high and signicant number of ANMs are required to deliver services promised by National health mission. The results are consistent with a study done in one district of Orissa state15 using World Health Organization’sWorkforce Indicators of Stafng Need (WISN). In this study researchers calculated the number of health workers required to achieve the maternal and child health. The difference was measured between ideal number and current stafng levels. The time required to perform necessary health care tasks was calculated. The calculations of the study indicate signicant numbers of new health workers are required to deliver the services promised by the NRHM.
ANMs spent 65% of total annual working time in performing activities under mother child tracking system. They are left with 35% of time for doing activities under different national health programs like RNTCP, Adolescent health, school health, NPCDCS and so on. It is difcult to complete other tasks in 35 % of annual working time. They spent 25% of total annual working time in record maintenance which reduces the time for direct patient care activities and patient counseling. A lot of time is wasted in traveling in the eld(9.3%). The results are consistent with one of the study conducted on female health workers in 2 districts of West Bengal,14 India, to quantify their workload and identify determinants of good performance. In this study researcher recruited 42 female health workers. The results revealed female health workers spent 26% of their time in documentation. The study concluded female health workers spent excessive time in documentation which left less time for service delivery
Conclusion: ANMs spent 65% of their time in implementing MCTS and they are left with less time (35%) to complete other tasks which they are expected to perform under other national health programs. It indicates the workload of ANMs is high as they have lot many responsibilities to play at workplace. On the basis of conclusion the study recommended for equal distribution of work among all health professionals. Policy makers should take efforts to reduce the written work and recording of data of ANM so that she can spend more time in eld and at health centers in providing direct care to clients. The data management system needs revision to avoid duplication of records and registers. The calculations indicate signicant numbers of new ANMs are required to deliver the services promised by the National health mission.
- Kumar S, Bhatnagar S, Saxena Mother and child tracking system. Informatics, 2012; 20:4-8 (Accessed on 19th December 2 0 1 8 ) a v a i l a b l e a t https://informatics.nic.in/index.php.
- Ahmad J, Bhatnagar I, Khan ME. Increasing access to family planning and reproductive health services through community health workers: a case study of a dual cadre model in India.Population council, New Delhi India.
- Garg S, Laskar AR.Community- based monitoring: Key to success of National Health Programs. Indian Journal of Community Medicine, 2010; 35: 214- 216.
- Draft, Indian Public Health Standards (IPHS) for Subcentres Guidelines. (March 2006). Directorate General Of Health Services Ministry Of Health And Family Welfare, Government of India. (Accessed on 21st July 2012) available at http://mohfw.nic.in/NRHM/Documents/Ipdf.
- Accredited Social Health Activist (ASHA) Guidelines, NRHM. New Delhi, Ministry of Health & Family Welfare, Govt ofIndia.2006
- Prasad B, Gupta VM. A qualitative assessment of antenatal care provided by auxiliary nurse midwife. Indian Journal of PublicHealth.1999;43:140-143
- Srivastava DK,Prakash S,Adhish V,Nair K,Gupta S, Nandan D. A study of interface of ASHA with the community and theservice providers in Eastern Uttar Indian Journal of Public Health,2009;53:133-136
- Singh AJ, Kaur A. Community based estimation of perinatal mortality through record linkage. Indian Paediatrics,1996;33:367-72.
- Singh A, Arora AK. The changing proles of pregnant women and quality of antenatal care the rural north India. Indian Journal of Community Medicine, 2007; 32:135-136.
- WISN-Workload indicators of stafng need- User’s manual; [Cited 2016 July 9] available from: https://www.who.int/hrh/resources/WISN -Eng-usersManual.pdf?ua=1
- Scott K, Javadi D, Gergen J. India’s Auxiliary Nurse-Midwife, Aanganwadi worker, Accredited social health activist, Multipurpose worker, and Lady health visitor Programs. (Accessed on Jan 15 2019) available at https://www.chwcentral.org/blog/indias- auxiliary-nurse-midwife-aanganwadi- worker-accredited-social-health-activist- multipurpose
- Kannan S, Sarma S. Study on workload of public health nurses and other women health workers. MPRA; 2012 Jun 19 [cited 2015 June 7]. Available from: http://mpra.ub.uni-muenchen.de/39520/
- Nair VM, Thankappan KR, Sarma PS, Vasan Changing roles of grass root level health workers in Kerala, India. Health Policy and Planning [Internet]. 2001[cited 2016 July 9];16(2):171-9. Available from: http://www.researchgate.net/publication/ 11979005_Changing_roles_of_grassroot _level_health_workers_in_Kerala_India
- Maji D, Hutin Y, Ramakrishnan R, Hossain S, De S. Strategies to improve the performance of female health workers in West Bengal: a cross- sectional Natl Med J India [Internet]. 2010 May-Jun [cited 2017 Sep1];23(3):137-42. Available from:http://www.nie.gov.in/images/publi cation/Maji._Strategies_to_improve_the_ performance_of_female_health_2010_33 6.pdf
- Hagopian A, Mohanty M K, Das A and House P J. Applying WHO’s ‘workforce indicators of stafng need’ (WISN) method to calculate the health worker requirements for India’s maternal and child health service guarantees in Orissa Health Policy and Planning, 2012;27:11–18