How might we improve the performance monitoring

and assessment system of Auxiliary Nurse Midwife and

Supervisory Staff in primary health care and design an
evidence-based capacity building and performance
incentive system for effective health care delivery in
Assam?
Overview:
Over 80% of health conditions the world over can be handled with good quality and timely primary
healthcare. Countries that are doing well on public health indicators, have all focused on strengthening
their primary healthcare delivery. There is ample evidence to suggest that investing in primary
healthcare gives maximum social returns on investment i.e. “lives saved”. National and state
governments are the most important stakeholders as far as public health in India is concerned. Among
many gaps that need to be plugged in the domain of public health, a few important ones that merit
the government’s attention are— innovation, accountability, monitoring, evaluation and capacity
building. Though primary healthcare can cater to a range of health issues, the most crucial ones for
India to tackle at this point are maternal & child care and non-communicable diseases.

• Maternal Health
Maternal health is an important gauge for effective health services to the poor, and in turn,
acts as one of the composite measures to assess the country's progress. Accessibility of
maternal and child health services remains to be an intractable problem in the developing
world. The same can be said about India’s largest north-eastern state of Assam. However,
what’s most tragic is that a majority of maternal and under-five deaths could be prevented
with interventions and treatments already available.

Table: Health Indicators of Assam (Assam Annual Report 2018)

Particulars Source Assam

General Indicators
Total Population Census 2011 3,12,05,576

Maternal Mortality Ratio (MMR) SRS 2014-16 237

Infant Mortality Rate (IMR) SRS 2017 44

Neonatal Mortality Rate SRS 2017 23

U5 Mortality Rate SRS 2017 52

Sex ratio at Birth NFHS 4 929

Health and Nutrition Indicators

Mother who had antenatal checkup in first Trimester NFHS 4 55.1

Mothers who had at least 4 antenatal care visits (%) NFHS 4 46.5

Mother who received full Antenatal care NFHS 4 18.1

Home delivery conducted by skilled health personnel NFHS 4 3.9

(out of total deliveries) (%)

% of Institutional Delivery NFHS 4 70.6

% of New Born Breastfed within 1 hour of Birth NFHS 4 64.4

Children under 5 years who are underweight (weight- NFHS 4 29.8

for-age) (%)
 Children under 5 years who are stunted (height-for- NFHS 4 36.4
age) (%)

Children under 5 years who are wasted (weight-for- NFHS 4 17

height) (%)

Children under 5 years who are severely wasted NFHS 4 6.2

(weight-for-height) (%)

Breastfeeding children age 6-23 months receiving an NFHS 4 8.7

adequate diet (%)

Non-breastfeeding children age 6-23 months NFHS 4 10.8

receiving an adequate diet (%)

Children age 12-23 months fully immunized (BCG, NFHS 4 47.1

measles, and 3 doses each of polio and DPT) (%)

Children with diarrhea in the last 2 weeks who NFHS 4 51.9

received oral rehydration salts (ORS) (%)

Children with diarrhea in the last 2 weeks who NFHS 4 22

received zinc (%)

Children with fever or symptoms of ARI in the last 2 NFHS 4 46.8

weeks preceding the survey taken to the HF (%)

• Sub-Health Centres (Sub-centres)

In the public sector, a Sub-Health Centre (Sub-centre) is the most peripheral and first point of
contact between the primary health care system and the community. In order to provide
quality care in these Sub-centres, Indian Public Health Standards (IPHS) are being prescribed
to provide basic primary health care services to the community and achieve and maintain an
acceptable standard of quality of care.

During the course of revision of current IPHS for Sub-centre, feedback through interactions
with Health Worker Females/Auxiliary Nurse and Mid-wife (ANMs) was taken regarding the
wide spectrum of services that they are expected to provide, which revealed that most of the
essential services enumerated are already being delivered by the Sub-centres staff. However,
the outcomes of health indicators do not match with services that are said to be provided.
Therefore, it is desirable that manpower as envisaged under IPHS should be provided to
ensure delivery of full range of services. Monitoring of services may be strengthened for better
outcomes.

Sub-centres are categorized into two types— Type A and Type B.

Particular Type A Type B

Differences in All services as envisaged for All recommended services
services the Sub-centre except the including facilities for conducting
provided facilities for conducting deliveries at the sub-centre itself. This
delivery will not be available sub-centre will act as Maternal
 and Child Health (MCH) centre with basic
facilities for conducting deliveries and
new-born care at the sub-centre.
Recommended - One ANM (Essential), - Two ANM (Essential)
Staff - Two ANMs: (Desirable to - One Health Worker (Male):
split the population (Essential)
between them and one - One Staff Nurse or ANM (if Staff
of them provides Nurse not available) (Desirable, if
outreach services and number of deliveries at the Sub-
the other is available at centre is 20 or more in a month)
the Sub-centre) - Sanitation services should be
- One Health Worker provided through outsourcing on full
(Male) (Essential) time basis
- Sanitation services
should be provided
through outsourcing on
part time basis
Guidelines - The facilities for - Such sub-centres should be
conducting delivery will developed as a delivery facility and
not be available at these should also cater to adjacent Type A
sub-centres and patients subcentre areas for delivery
may usually be referred purposes.
to nearby centres - Type B sub-centre, will provide all
providing delivery recommended services including
facilities. facilities for conducting deliveries at
- If the requirement for the sub-centre itself.
delivery services goes - These will be expected to conduct
up, the sub centre may around 20 deliveries in a month.
be considered for - These should be provided with all
upgradation to Type B. labour room facilities and equipment
- These sub-centres including new-born care corner.
should provide all other - ANMs of these sub-centres should be
recommended services SBA trained. These centres may be
and focus on outreach provided extra equipment, drugs,
services, prevalent supplies, materials, 2 beds and
diseases, tuberculosis, budget for smooth functioning.
leprosy, non- - If number of deliveries is 20 or more
communicable diseases, in a month, then additional 2 beds
nutrition, water, will be provided.
sanitation and
epidemics.
- It is also to be ensured
that the staff of these
sub-centres is provided
training in all new
programmes on priority
basis and refresher
training is provided
regularly.
- Extra payment should be
provided to Staff posted
 in difficult areas.
- If there is shortage,
Health Worker male
should be posted on
priority basis in areas
endemic for vector
borne diseases.

Image: A sub-centre in Assam with poor delivery case load (may serve as Type A sub-centre)

Image: A sub-centre with heavy case load (may be developed as an MCH/type B sub- centre)
• Health and Wellness Centres
In order to ensure delivery of Comprehensive Primary Health Care (CPHC) services, existing
Sub-Health Centres covering a population of 3000-5000 would be converted to Health and
Wellness Centres (HWC). HWCs’ principle is “time to care” shouldn’t be more than 30 minutes.
Primary Health Centres in rural and urban areas would also be converted to HWCs. The HWC
at the Sub- Health Centre level would be equipped and staffed by an appropriately trained
Primary Health Care team, comprising of Multi-Purpose Workers (male and female) & ASHAs
and led by a Mid-Level Health Provider (MLHP). Together they will deliver an expanded range
of services.

• Availability of doctors: India and Assam

In India, there is one government doctor for every 10,189 people (WHO recommends a ratio
of 1:1,000), or a deficit of 600,000 doctors, and the nurse to patient ratio is 1:483, implying a
shortage of two million nurses.

A study published in the Indian Journal of Public Health in 2017[2] states that India needs 2.07
million more doctors to serve its population by 2030. More than 8% of PHCs (Primary Health
Centres) in the country are without a doctor. In Community Health Centres, there is a huge
shortfall of specialist doctors— 83% surgeons, 76% obstetricians and gynaecologists, 83%
physicians and 82% paediatricians [3]. While WHO and Ministry of Health data shows 7 doctors
per 10,000 people, a study titled “Aggregate Availability of Doctors in India 2014-30” by FORE
School of Management [4] found the ratio of practising doctors per population of 10,000 to be
4.8. This dip is attributed to two main causes of attrition of doctors- retirement and
emigration.

The story is not any different in Assam. The state today makes do with 44 percent of total
requirement of doctors and health officers. The doctor-patient ratio currently stands at
1:1800. The Assam Medical Service Association (AMSA) has pointed out that around 11,000
doctors are needed to adequately staff state health services, but only 2,517 doctors are
working vis-a-vis the sanctioned strength of 4,667.

As per the 2017 Bulletin on Rural Health Statistics in India, Assam has a total of 1048 allopathic
doctors in its PHCs and 136 specialist doctors in its CHCs. With MBBS seats now increased
across the six medical colleges, Assam has a total of 900 MBBS seats yet the gap between
doctors produced and doctors required is wide. The strength of faculty at these medical
colleges also falls short of meeting the Medical Council of India norms.

According to ASMA (Assam State Medical Association) sources, around 100 specialist doctors
in the State want voluntary retirement. This is part from the trend among many doctors opting
to be with private hospitals.
 Image: Shortage of Healthcare Professionals [Source: RHS 2017]

Image: Challenges faced by Health workforce

Context:
As per Sample Registration System (2014-16), Assam has the highest Maternal Mortality Rate in the
country i.e. 237/100000 live births. India’s average is 130/100000 live births. Several studies from the
state investigated the context-specific reasons behind such high rates of MMR in the country.

One such reason is poor skilled birth attendance (SBA). With efforts like January Suraksha Yojana
(through cash) and Janani Shishu Suraksha Yojana (cashless incentive), there has been an increase in
SBA from 22.4% to 70.6% in 10 years’ time period (NFHS 3-4).
However, improved skilled birth attendance has not translated in reduced maternal and new-born
mortality rates. In fact, ineffective and poor quality of care (due to lack of skills, dearth of skilled
medical personnel, insufficient infrastructure and outdated medical equipment) has exacerbated the
problem.

Moreover, health workers operate in a constrained institutional setup (constraints like lack of say in
program design, budgetary limitations— lack of budget or not getting the budget in time). Since they
have to operate in teams when on the field, a health worker doesn’t even have the choice to form his/
her own team. They are transferred frequently to different teams on the basis of capabilities required.

To monitor performance, there is a system of reviews and individual performance assessment in place.
But, to improve the effectiveness of health workers and the health system, there is an urgent need to
strengthen the system of performance monitoring, assessment and review. Also, designing an
evidence-based capacity building, and performance incentive system is the need of the hour.

Challenge:
Health workers have to multi-task most of the times. Though ANMs are allocated mainly for mother
and child care, her duties extend to health and non-traditional health activities over a period of time,
which are not defined for her.

And she also reports to different authorities’/vertical heads of various programs about the progress
of different projects. There is no clear-cut work allotment for each program and the program
supervisors/ managers have difficulty in assessing her performance.

When each health worker (ANMs and supervisory staff) works in a different institutional environment
and setup, it is difficult to distinguish between personal and institutional determinants of an
individual’s performance. This makes assigning appropriate weightage to both determinants
extremely difficult for assessing overall individual performance. Additionally, the complexity of various
projects and problems makes disaggregation of individual level tasks from program level objectives
and departmental/ institutional level objectives very tough.

Case Question:
How can we—

• Improve the performance monitoring and assessment system of Auxiliary Nurse Midwife and
Supervisory Staff in primary health care to identify training and capacity building needs for
healthcare professionals in Assam
• Design an evidence-based capacity building and performance incentive system for effective
health care delivery in Assam

About Piramal Swasthya:

Piramal Swasthya is focused on bridging public healthcare gaps by supplementing and complementing
Government of India’s vision to meet Universal Health Care for all. Piramal Swasthya is one of the
largest not-for-profit organizations in India in the primary public health care space with a focus on
Maternal health, Child and Adolescent Health, Non-communicable diseases. Piramal Swasthya has
over a decade-long experience in operating several healthcare innovations at scale, which are
addressing the primary health care needs of most underserved and marginalized populations across
India. Piramal Swasthya is operational in 20 states in India through 35 innovative public health care
delivery programs and has served more than 10.7 crore beneficiaries so far. Piramal Swasthya employs
2500+ employees (including over 250 medical doctors) who work with Seva Bhav.

To know more, visit our official website.

Additional Links:
Availability of doctors in India and Assam

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2
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3
Sharma, D.C.(2015). India still struggles with rural doctor shortages. The Lancet, Volume 386, Issue
10011, 2381 - 2382
4
Basant, P. (2017). Aggregate availability of doctors in India: 2014–2030. Indian Journal of Public
Health. Vol. 61

On Performance Review

https://www.researchgate.net/publication/295955623_Salve_A_Kavita_Singh_A_and_Saini_S_Work
load_and_Performance_of_Auxiliary_Nurse_and_Midwives_at_Selected_Health_Care_Settings_in_
North_India_International_Journal_of_Public_Health_Research_2015_5_553-5

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1004&context=jam

https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-015-0021-7

https://nhm.gov.in/images/pdf/NUHM/ANM_Guidebook_under_NUHM.pdf

https://pdfs.semanticscholar.org/baba/57ae55817fde0b1a6136b3ace2a9bc5f1d1e.pdf?_ga=2.2678
45126.901224420.1568026888-1144581131.1568026888

http://www.ijamhrjournal.org/article.asp?issn=2349-
4220;year=2019;volume=6;issue=1;spage=18;epage=23;aulast=Bhombe

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2033-6

https://www.downtoearth.org.in/dte-infographics/61322-not_enough_doctors.html
https://www.researchgate.net/publication/46437209_The_Changing_Role_of_Auxiliary_Nurse_Mid
wife_ANM_in_India_Implications_for_Maternal_and_Child_Health_MCH

https://www.who.int/bulletin/volumes/89/1/09-070862/en/

https://scroll.in/article/900012/why-women-serving-as-frontline-health-workers-in-india-do-not-
even-get-the-minimum-wage

On Incentives

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3984877/

https://clinicaltrials.gov/ct2/show/NCT03561012

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673775/

https://www.devex.com/news/is-incentive-based-pay-for-india-s-community-health-workers-
working-90502

https://www.frontiersin.org/articles/10.3389/fpubh.2016.00038/full

https://www.povertyactionlab.org/evaluation/incentives-nurses-public-health-care-system-udaipur-
india