Fixed Human Resource Norms in Indian Sub Centers - Does the Changing Times Necessitate Innovations?

This study was conducted to understand the existing workforce availability and need for differential staffing norms within diverse contexts of sub centers (SCs). This included documenting the emerging patterns of SCs, studying the existing staffing norms, and assessing the ranges, quantum of services, work-pattern and work-load of service providers. Multiple case studies were used to document the diverse contexts of SCs along with review of secondary data. In-depth interviews of 97 service providers including Auxiliary Nurse Midwives (ANM), Multi-purpose Worker Male (MPW-M) and Rural Health Practitioners (RHP) was conducted to assess the characteristics, work-pattern and work-load across 69 sub-centers in Haryana, Chhattisgarh, Kerala, Assam, Rajasthan, Uttar Pradesh (U.P) and Meghalaya. SCs across these states were differentiated into various types i.e. collocated in Primary Health Centers (PHC) or standalone, delivery huts or non-delivery huts and Non-Communicable Diseases (NCD) clinics. While SCs in most states were providing minor symptomatic treatment, Antenatal Care (ANC), immunization services through outreach work, in few states, the focus had shifted from Maternal & Child Health Care services to detection of NCDs and adolescent health. This study found inter- and intra- state variations on workload, work pattern, staff deployment, Out Patient Department (OPD) attendance and areas of work of the staff deployed in SCs. Similarities and variations on workload and work pattern across SCs were observed across the state. Majority of SCs showed variations in terms of average number of villages, population served and geographical contexts across states. Assam SCs had heavy OPD attendance of upto 33 cases per day due to deployment of an additional mid level health worker in the form of RHPs while other states (i.e. Haryana, Chhattisgarh and U.P) had relatively low OPD attendance of upto 5 cases per day. While the Indian Public Health Standards (IPHS) prescribed 2 ANMs and 1 MPW (M) at each SC, the study found that 37 SCs (53.6 percent) had only 1 staff in place as observed in 6 states except in Assam where 8 SCs had 1 RHP at each SC along with either 1 or 2 ANMs, out of total 15 SCs studied. Staffing pattern at SC did not consider the geographical, social and work characteristics of SC. Our study findings demonstrates that flexible staffing norms is necessary which should be based not only on caseloads, but certain factors i.e. population served, emerging characteristics of the SC and geographical accessibility should be considered for rational deployment of ANMs at SCs. Besides, skill building of staffs, deployment of secondth ANM and an additional health worker i.e. RHP are crucial for optimal delivery of assured services at SCs. It could be complemented by adoption of locally appropriate retention strategies for staffs