http://doi.org/10.33698/NRF0245-Monika, Sukhpal Kaur, Amarjeet Singh

ABSTRACT:

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 Stafng 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 stafng needs)

Correspondence at:

Dr. Sukhpal Kaur Lecturer

National Institute of Nursing Education, PGIMER, Chandigarh

Introduction

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 Stafng 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 stafng: 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.

Results

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

/patient)

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

minutes(hour)

% of total annual working time : 3 ANMs
1. Antenatal care(ANC)-I Including                           health

education

40minutes per patient (0.66hour) 2554 192 7680minutes (128hours) 2.5
2. Antenatal care(ANC)-II Including                           health

education

20 minutes per patient(0.33hour) 5109 135 2700minutes (45hours) 0.9
3. Antenatal care(ANC)- III    Including health

education

20 minutes per patient(0.33hour) 5109 147 2940minutes (49hours) 1.0
4. Antenatal care(ANC)-

IV    Including health education

20 minutes per patient(0.33hour) 5109 85 1700minutes (28hours) 0.6
5. Weight recoding of

antenatal women

3      minutes     per

patient(0.05hour)

33720 559 1677minutes

(28hours)

0.6
6. Height recording of

antenatal women

2      minutes     per

patient(0.03hour)

56200 192 384minutes

(6hours)

0.2
7. BP recording of antenatal women Including health

education

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

education

25     minutes    per patient(0.42hours) 4014 371 9275minutes (155hours) 3
10. Neonatal care(NNC) Including health

education

26     minutes    per patient(0.43hour) 3920 371 9646minutes (161hours) 3.2
11. Weight recording of

baby

6      minutes     per

patient(0.1hour)

16860 371 2226minutes

(37hours)

0.7
12. Length recording of

baby

3      minutes     per

patient(0.05hour)

33720 160 480minutes

(8hours)

0.2
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

education

3      minutes        per patient(0.05hour) 33720 1057 3171minutes (53hours) 1
15. Cu-T insertion and FP

counselling

10     minutes    per

patient(0.17hours)

9917 04 40minutes

(0.7hours)

0.01
16. Cu-T removal 8      minutes     per

patient(0.13hours)

12969 2 16minutes

(0.3hours)

0.006
% 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

time

1. Record maintenance 1.5 hour/day 25
2. Aanganwadi visit 1 hour/week 3
3. Home visit/Survey 6hours/week 18.5
4. Polio(National round)-2 rounds in year

each for 3 days (total 6 days/year)

54hours/year* 3.2
5. Polio(Sub-National round)-3 rounds in

year each for 2days((total 6 days/year))

54hours/year* 3.2
6. Travel time in the eld 3hours/week 9.3
% of total annual working time for important support activities

of ANMs

62.2%
Additional activities of ANMs in CD Allowance standard %       of       total annual working

time

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
4. Indenting 2 hours/month;1ANM 1.4
% 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

working time

Sum    of    all CAS

percentages

Category Allowance factor(CAF)
1. Record maintenance 1.5 hour/day 25 62.2 CAF=

1 divided by

1-62.2/100=2.6

2. Aanganwadi visit 1 hour/week 3
3. Home visit/survey 6hours/week 18.5
4. Polio(National

round)-2 rounds in year each for 3 days (total 6 days/year)

54hours/year* 3.2
5. Polio(Sub-National round)-3 rounds in year         each         for

2days((total                6

days/year))

54hours/year* 3.2
6. Travel time in the

eld

3hours/week 9.3

Table-4: Calculation of Individual allowance factor

S.No. Additional activitiesof Certain ANM      in

CD

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

60/1686=0.04

0.04+0.02+0.12+0.01=

0.19

2. Attending

continuing education

12 hours/year; 3ANM 12hours/year 12X 3ANMs=36

36/1686=0.02

3. Reporting of data 4 hours/week;1ANM 4hours x 52 weeks = 208 hours/year 208 X 1ANM=208

208/1686=0.12

4. Indenting 2 hours/month;1ANM 2 hours x12months = 24 hours year 24X1ANM=24

24/1686=0.01

 

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
1. Antenatal care(ANC)-I 2554 192 0.08  

0.08+0.03+0.03+0.02+

0.02+0.003+0.03+0.01+

0.14+0.14+0.04+0.01+

0.08+0.03+0.00+0.00

= 0.663=0.7

2. Antenatal care(ANC)- 5109 135 0.03
II
3. Antenatal care(ANC)- 5109 147 0.03
III
4. Antenatal care(ANC)- 5109 85 0.02
IV
5. Weight recoding of 33720 559 0.02
Adult
6. Height recording of 56200 192 0.003
adult
7. BP recording of adult 16860 559 0.03
8. TT immunization of 15327 300 0.01
pregnant women
9. Postnatal care(PNC) 4014 560 0.14
10. Neonatal care(NNC) 3920 560 0.14
11. Weight recording of 16860 742 0.04
baby
12. Height recording of 33720 371 0.01
baby
13. Immunization of child- 12969 1039 0.08
parental
14. Immunization of child- 33720 1057 0.03
oral
15. Cu-T insertion and FP 9917 8 0.00
counselling
16. Cu-T removal 12969 4 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 difcult      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.

Discussion

India has different cadres of community health workers auxiliary nurse midwife, ASHA, aanganwadi workers. Among these, ANM is most signicant 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 stafng 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 signicant 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 Stafng 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 stafng levels. The time required to perform necessary health care tasks was calculated. The calculations of the study indicate signicant 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 difcult 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 signicant numbers of new ANMs are required to deliver the services promised by the National health mission.

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