Mapping Adequacy of Staffing to Ensure Service Guarantees for Maternal and Child Health: A Study of Ganjam District in Orissa using WISN Method By Dr.

Mapping Adequacy of Staffing to Ensure Service Guarantees for Maternal and Child Health:

A Study of Ganjam District in Orissa using WISN MethodBy

Dr. Manmath K. Mohanty, Head, HRUHuman Development Foundation (HDF)

In collaboration with Washington University, CHSJ, UNFPA22nd July 2009

Context and Background

NRHM has provided certain CSG It also promises CGS for each level SC, PHC, CHC MCH is important for IMR/MMR reduction JSY increased Ins. Delivery Demand vs. Supply of workforce is verifiable

Research Question:

Is there adequate staffing for Maternal and Child Health (MCH) Services in government health care facilities to meet the service guarantees under NRHM in Ganjam district of Orissa?

About WISN Method

WISN- Workload Indicators of Staffing Need A method of setting the correct Heath Facility staffing

levels. Developed by Shipp (1998) and popularized by WHO Tried in Tanzania, Papua New Guinea, Kenya, Hong

Kong, Turkey and Bangladesh No previous work in India

Advantages Optimal Allocation and deployment of current staff

geographically according to volume of services Optimal Allocation and deployment of current staff functionally

between the different types of health facilities or different health services in district or state

Staffing patterns and levels (categories and numbers) in individual health facilities according to local conditions (morbidity, access, attitudes) and not based on national averages (population ratios and standard staffing schedules)

Useful for both medical and non-medical administrators at all levels of the health service

Simple to operate and use, technically acceptable, comprehensible and realistic so that results are acceptable by non clinical manager.

Limitations of the Study Actual time requirements could be different from the

estimates of practitioners, for a variety of reasons. We did not directly calculate time standards of the MCH

activities through time/motion observation Other scopes of observation may have generated

different conclusions. There may be activities involved in MCH care that we

did not capture in our lists, which would understate the gap in service availability.

WISN Steps Chart

X

Time required for procedure

Service guarantees

Proportion of population requiring MCH

Total deman

d

Time available per worker

Personnel strength

Total supply of staff

time

Surplus/Gap

Total deman

d

Total supply of staff

time

Interview & FGD

IPHS HMIS & Secondary data

Interview & FGD

HMIS/Record review

X X =

=

_ =

Step-I

Step-II

Step-III

FINDINGS

Extent of Shortage or Surplus of Health Workers in Ganjam for providing MCH services

Staff Category (a) Number of workers in our study area devoted to MCH care (b)

Total Demand in Hours (c)

Total Supply in Hours (d)

Gaps/Surplus in Hours (e=c-d)

Number Additional Staff Required to Meet Gap (f=e/hours worked per year per worker)

Ratio of Staff Supply/Required (WISN)* (g=d/c)

Doctors 45 104859 25272 -79587 42.51 0.24

Staff Nurses 21 43535 15725 -27810 14.86 0.36

ANMs 173 375739 226699 -149040 79.62 0.60

Lady Health Visitors

16 19055 23587 4532 -2.42 1.24

Lab Staff 11 23257 2622 -20635 8.66 0.11

Male Health Workers

91 137729 68141 -69588 37.17 0.49

Totals 357 704174 362046 -342128 180.39 0.51

*Note: When supply meets demand, the WISN number is 1.0; when demand exceeds supply, the WISN score falls below 1.0. Severity of shortage or surplus can be measured by the distance from 1.0

Staffing Requirement Staffing Requirement for MCH at Ganjam

-20%0%

20%40%60%80%

100%

Do

cto

rs

Sta

ff N

urs

es

AN

Ms

LH

Vs

La

b S

taff

He

alt

hW

ork

ers

(M)

Category of Staff

Pe

rce

nt

of

He

alt

h

Wo

rke

rs

Proportion of Additional Staff Required to Meet the Gap

Proportion of workers available for MCH care

Staff Requirement at Block Level Facilities

Staffing Requirement at Block Levels for ANMs

0%

20%

40%

60%

80%

100%

Pa

tra

pu

r B

loc

kP

HC

Ba

da

ga

da

Blo

ck

UG

PH

C

Po

las

ara

Blo

ck

UG

PH

C

Bu

gu

da

Blo

ck

PH

C

Ko

da

la C

HC

Ja

ga

nn

ath

pra

sa

dB

loc

k P

HC

Health Facilities

Pe

rce

nt

of

He

alt

h W

ork

ers

Proportion of Additional Staff Required to Meet the Gap

Proportion of workers available for MCH care

Staff Requirement at PHC New Level

Staffing Requirement at PHC (New) Level for ANMs

0%20%40%60%80%

100%

Ba

ran

ga

PH

C N

ew

Go

ud

ag

oth

aP

HC

Ne

w

Ka

rch

uli

PH

C N

ew

Be

gu

nia

pa

da

PH

C N

ew

Ra

ha

da

PH

CN

ew

Ba

rag

ao

nP

HC

Ne

w

Health Facility

Pe

rce

nt

of

He

alt

h

Wo

rke

rs

Proportion of Additional Staff Required to Meet the Gap

Proportion of workers available for MCH care

Staff Requirement at Sub Centre Level

Staffing Requirement at Sub Centre Level

0%20%40%60%80%

100%

Go

ud

ag

oth

aS

C

Ko

nk

ora

da

SC

Bir

an

ch

ipu

rS

C

Bu

gu

da

-II

SC

Ko

da

la-I

I

Kh

am

arp

ali

SC

Health Facility

Pe

rce

nt

of

AN

Ms

Proportion of Additional Staff Required to Meet the Gap

Proportion of workers available for MCH care

Conclusion To meet the requirements of the NRHM service guarantees,

the 18 health facilities would need to supply an additional 342,128 hours, translating to about 181 additional FTE workers.

Additional staff required to the extent 80 ANMs, 37 male HW, 43 physicians, 15 staff nurses and 9 lab staff.

However the supply of LHV is 16, which is about 2.4 more than required to meet the demand.

In case of ANMs Badagada Block UGPHC has the largest shortfall of staff, requiring an additional 13 FTEs to meet the SG in the NRHM.

The WISN ratio for that center is 0.52, indicating the supply of hours of care is only slightly better than half of that required.

Recommendations In the presence of government promises to deliver a minimum

package of services, the WISN method should be used as a methodology to calculate the expected demand as well as supply and the gap.

Government health planners should use WISN data to consider the magnitude of staffing increases that would be needed to meet service guarantees.

Our study generated time standards in minutes for each MCH activity promised by the NRHM. These standards could now be applied to other districts in India with slight modification if required.

WISN, then, can provide a useful tool for civil society advocates who seek to hold governments accountable for their health service guarantees.

THANK YOU