1) The study examined the evolving roles and contexts of health sub-centers (HSCs) across seven Indian states, finding variations in staffing, service delivery, and workload. 2) Key findings include that most HSCs function primarily as sites for antenatal care, immunization, and minor treatments. However, some states like Kerala and Assam showed variations, with expanded service ranges. 3) Work patterns varied across states but were similar within. Most ANMs provided OPD/ANC services 3 days per week, with caseloads of 1-5 patients daily, plus weekly village visits. However, staffing levels often did not align with population size or service loads.

1. Dr. Suchitra Lisam, Sr. Consultant NHSRC
Multiple case studies in states for addressing diverse
contexts of HSC for policy changes in Human Resources
How many is not enough? Human Resource Gaps
against Requirements for Health Sub-Centers:
Global Public Health Conference,
3rd to 5th January, 2013, Kochi Kerala

2. Study Rationale
• Evolving roles and changing nature of Health Sub-centers (HSCs)
across states in last few years (Source: 4th CRM Report)*
• SCs has become more of a center for delivering ANC &
immunization services during OPD/ANC days and immunization
sessions (VHND) and played less role in institutional deliveries*
• SCs are no longer an institutional delivery sites in Kerala, TN, Punjab
where major proportion of ANC/immunization services are provided at
PHCs and vacuum in work-load is filled with NCD & school health
programs. High proportions of home deliveries reported in Punjab and
Nagaland with limited role of SCs in institutional deliveries. 10% of SCs
in Chhattisgarh, Jharkhand, Maharashtra, U.P, Rajasthan and M.P
conducted deliveries*
• Key policy documents (HLEG, IPHS, NRHM-WG) recommended a
single nation norms for SCs overlooking different types of SCs
(documented in CRM reports) 2

3. Research Questions
• Under what contexts the SCs across states are
functioning?
• What is the current scenario of SCs in terms of
population served, accessibility, staffing, service
delivery?
• What is the work pattern, work-load and work-
allocation between staffs on weekly basis?
• Is there any variations or similarities on above factors
between SCs within contexts and/or between states?
• Need of a flexible HRH norms for SCs?
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4. • To document the emerging patterns and diverse contexts of
SCs with respect to geographical location, population
served and public health systems
• To assess the ranges and quantum of health services
delivered by SCs
• To study the work-pattern and work-load of service
providers at SCs.
• To study the human resource (HR) structure and availability
as against those prescribed by IPHS, HLEG for UHC for SCs
• To describe the need for a flexible HR norms within diverse
contexts of SCs
Study Objectives
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5. Study Methodology
• Mix approach using qualitative and quantitative components
used for the study. Qualitative case study design adopted to
explore variations/similarities across SCs supplemented with
review of secondary data.
• HMIS data of 1 year (Aug’10-July ‘11) used to choose
districts based on 3 key RCH performance indicators
• Review of district records of sampled SCs on parameters i.e.
population served, HR status, performance indicators etc
• In-depth Interviews of service providers of sampled SCs in
each selected state
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6. Study Sample
Purposive Sampling method used for selection of states/districts
and SC
I. Selection of States
 7 states comprising of 5 EAG and 2 non-EAG states and regional
representation (North, South, East, NE and West)
 EAG states (Chhattisgarh, Assam, Rajasthan, UP, Meghalaya)
 Non EAG states (Kerala and Haryana)
II. Selection of Contexts /Districts
 Certain contexts identified in each state (Total contexts=13)
 Districts falling under each context selected
 Each district graded based on key RCH performance indicators obtained by
: summing up of points given against ranges of percentage on performance
indicators viz. % of pregnant women with 3 ANC check up, % of
institutional delivery and % of immunized children l< 1 year for measles
against estimated live births
 The district with an average score was purposely selected
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7. Study Sample
III. Selection of SCs:
 SCs in selected district based on RCH performance, availability
of staffs and feasibility of data collection.
Overall, 7 states across 5 regions including EAG /non-EAG states
were finally chosen. Identified contexts were
• Haryana: near urban and far areas
• Chhattisgarh: tribal /forest hamlets, agricultural areas and near
urban areas
• Assam: rural, median and riverine in remote areas
• Kerala: semi-urban area
• Rajasthan: desert and densely populated area
• Uttar Pradesh: Bundelkhand region with poor health indicators
• Meghalaya: hilly areas
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8. Grading of Districts
Sr.
No.
Type of key RCH Performance Indicators Range of Percentage
1. % of pregnant women with 3 ANC check up
against estimated pregnancies
≥80% ≥60%-<80% <60%
Point Given 3 2 1
2. % of immunized children less than 1 yr against
estimated live births
≥80% ≥60%-<80% <60%
Point Given 3 2 1
3. % of institutional deliveries against estimated
deliveries
≥60% ≥40%-<60% <40%
Point Given 3 2 1
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9. Sample Size
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10. Study Limitations
• Study findings may not be robust and valid for generalization
and for arriving at objective conclusions.
• Study relied on descriptive information provided by service
providers which might leave room for important details to be
left out during interviews.
• Moreover, much of information collected were retrospective
data, recollection of past events and may therefore subject to
recall bias or problems inherent to memory.
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11. Key Findings
I. Evolution of SCs
• Nature of SCs has evolved over years
• SCs were differentiated into “Delivery Points” and “Non –
Delivery Points” in Haryana, Chhattisgarh, Rajasthan
• Few SCs were “Co-located SCs” in Haryana and
Chhattisgarh- focused primarily on outreach activities
• While Assam had deployed an additional health worker in
the form of RHP (Rural Health Practitioners) towards
strengthening SCs
• Kerala SCs run an NCD clinic once in a week
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12. Key Findings
II. Service Delivery at SCs
• Majority of SCs functioned primarily as sites for ANC,
immunization services, treatment of minor ailments,
outreach activities during VHSND and institutional deliveries
along with minimal laboratory functions (Hb, urine tests,
preparation of peripheral slides)
• Less role of SCs in implementation of NHP (National Health
Programme), disease surveillance etc
• Limited role in delivery of preventive, promotive health
services in majority of SCs
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13. Key Findings
II. Service Delivery at SCs
• Kerala and Assam SCs showed variations in service delivery.
• SCs in Kerala provided basic care; hardly OPD/ANC services
provided, no delivery took place, SCs undertook health
prevention, promotion, nutrition sessions on weekly basis,
run 1 day NCD clinic; implemented school /adolescent health
programs and provision of palliative care services.
• SCs in Assam were upgraded with addition of RHPs to improve
service ranges, quantity and quality of OPD/ANC services.
• Value addition of MPWs observed as there was increasing
trend in blood slides collected for M.P (malarial parasites);
disease surveillance, screening /detection of NCD etc at some
Assam SCs.
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14. Key Findings
III. Overall Work-pattern and Work-load of SCs:
• ANMs shared similar work-pattern across SCs in Haryana,
Rajasthan within diverse contexts and population served though
SCs in Chhattisgarh had slight variations within 3 geographical
contexts. Variations also observed in SCs of Assam/Kerala unlike
other SCs.
• All SC provide symptomatic OPD and ANC services in the morning
half on 3 days with average OPD/ANC load of 1-5 cases/day.; and
conduct VHNDs once or twice a week, attended meetings at PHC
once in a month. Majority of ANMs in Haryana SCs conducted
deliveries (3-20 cases) per week while ANMs in Chhattisgarh (1-3
cases) and Rajasthan (3-5 cases) per week.
• ANMs undertook outreach/field work on 2-3 days or in afternoon
of OPD days. ANMs spent ½ day on documentation once in a
week. MPW performed laboratory tests i.e. hemoglobin, urine
tests, slides preparation.
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15. Key Findings
III. Overall Work-pattern and Work-load of SCs:
• ANMs in Kerala SCs organized school health programs
(Monday), took health promotion/nutrition sessions for AWW,
home visits (Tuesday), organized VHND (Wednesday), run NCD
clinic (Thursday) for screening/detection of Hypertension,
Diabetes, Cancer, lifestyle counseling, palliative care services and
provided OPD/ANC services on 2 days (2-3 cases/day on
(Friday/Saturday) in week.
• In Assam SCs with RHP, the ANM/MPW assisted RHP in delivery
of OPD/ANC services on 5 days/week (by registering OPD clients,
dispensing of IFA tablets/other drugs, T.T immunization and issuing JSY
cheques) Average OPD load of 20-30 cases/ day and ANC load of
5-10 cases/ day on (Tuesday/Friday); VHND (Wednesday);
assisted MMU (Saturday), conducted outreach work/home visits
(Thursday); documentation took 3-4 hrs in a week.
• MPW conducted Hb, urine tests, disease surveillance in 15

16. Key Findings
III. Overall Work-pattern and Work-load of SCs:
• In SCs with 2 ANMs, population coverage and field visits were
divided between them
• Location of SCs and population served had no linkage with
work-pattern or workload of ANM
• Clear work division between 2 ANMs (regular/contractual)
was in terms of organizing VHSND and deliveries
• ANM ( C ) coordinated VHND sessions while ANM (R )
conducted institutional deliveries and prepared slides for
suspected malaria cases
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17. Key Findings
IV. Staffing at SCs
• Staff pattern of 69 SCs ranged from 1 ANM or 2 ANMs with or
without MPWs - 37 (53.6%) had only 1 ANM and 32 (46.4%)
had 2 ANMs. Of the 32 SCs with 2 ANMs; 6 (18.7%) had an
additional MPW and 26 (81.2%) had no MPW. In Assam, an
additional worker in the form of RHP was deployed.
• In Haryana, single ANM SCs were handling higher case-loads
as compared to SCs with 2 ANMs
• In Assam, an additional worker “RHP” was available in 7/15
SCs. In Chhattisgarh, 14 /15 SCs in different geographical
contexts had single ANMs though institutional deliveries took
place in 11 of them
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18. Key Findings
IV. Staffing at SC
• 6 (25%) SCs serving ≥ 5000 population had 1 ANM while 11
(28%) SCs serving <5000 population had 2 ANMs
• In Haryana, Rajasthan and U.P, SCs where ANMs resides in SC
campus or nearby villages performed better. Duration of ANM’s
posting at same SC was directly proportional to case-loads.
• Rational deployment still remains an issue as 26 of 35 SCs
conducting deliveries had single ANM. E.g. In Udaipuria SC
(Rajasthan) serving 7717 population had 1 ANM only though the
performance is high (ANC load of 119, ID of 164)
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19. Key Findings
IV. Staffing at SCs
• Average distance from SC to farthest villages in desert areas
(Rajasthan) is relatively higher (10-15km) compared to that in
densely population areas having average distance of 5 km
though population covered by SCs in desert areas (Rajasthan)
was lesser than densely populated areas. Farthest villages from
SC in Meghalaya ranges from 20-25 km. Out of 69 SCs, 24 (35%)
of them served >5000 population
• Out of 13 contexts chosen in 7 states, SCs located in median area
of Assam served 10 villages (on an average), while the SCs in
desert area of Rajasthan served only 1 village. SCs in near urban
areas of Haryana served an average 7661 population (maximum)
while SCs in tribal areas of Chhattisgarh served an average of
2543 population (minimum).
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20. STUDY CONCLUSIONS
I. Differential Staffing Norms for SCs
States had posted health workers without taking into account
population served, geographical location, accessibility, service
delivery or caseload
Rationalization of ANM/MPW
• SCs covering larger population; SCs in difficult geographical
terrain having dispersed population
• SCs conducting institutional deliveries
• SCs with relatively higher case/work loads; weekly work-
pattern
II. Training & Capacity Building
• CB to handle emerging NCD required for SCs oriented
towards screening/detection of NDC
• Prioritize training needs for ANMs, MPW
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21. STUDY CONCLUSIONS
III. Retention Strategies
• locality-based “selection of candidates”
• Post training placements
• Clear posting & transfer policies
IV. Defining the additional skilled health worker
• Presence of an additional skilled health worker translates
into higher footfalls
• AYUSH graduates/allied medical sciences training in public
health; new cadre of B. Sc, in line with RHP
• Define career development paths
V. Mechanism for Support Supervision:
• PRI participation/accountability to local based
selection/supervision along with community monitoring 21

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