Auxiliary Nurse Midwife: What Determines Her Place of Residence?

Journal of Health & Population in Developing Countries / URL: http://www.jhpdc.unc.edu/ Date Published 23 June, 2003 Auxiliary Nurse Midwife: What determines her place of residence? Pavitra Mohan Sharad D Iyengar Sanjana Brahmawar Kalpana Sen Abstract Large numbers of health workers in rural areas of developing countries are not available to the communities they are supposed to serve. In India, large numbers of female extension health workers (auxiliary nurse midwives or ANMs) do not reside within their work area, limiting the communities’ access to health services. This study was conducted to understand the factors that an ANM considers in deciding where to reside and the interplay of these factors in influencing the decision. The study was conducted in a district of southern Rajasthan, India. Secondary data was reviewed to identify the availability of basic amenities and infrastructure— this was supplemented with self-administered questionnaires; and in-depth interviews on a sub-sample. Analysis revealed that age of the ANM <30 or more than 45 years, presence of a middle or high school within the sub-center area, and distance of the place of posting being more than 20 kilometers from the city were significantly associated with residing within the sub-center area. Non-availability of education facilities for children and perceptions of insecurity seem to be major factors that deter ANMs from staying in a village. Supervisors or the community neither assist them in facing these difficulties nor enforce accountability for not residing. Recent devolution of administrative control of ANMs to local self-governments could be helpful in ensuring that they reside within the work area provided these local bodies are also entrusted with responsibility to ensure their safety and comfort. Formation of a committee at the district level, with suitable representation of the civil society, will provide the ANMs a platform to air and redress their problems related to living and working. There is also an urgent need to have an explicit human resource policy for the health sector that addresses issues such as recruitment, posting, career path, supervision, and accountability of health workers. Key words: Human resource, ANMs, India Address for correspondence: Dr Pavitra Mohan, Action Research and Training for Health (ARTH) 39, Fatehpura, Udaipur, India-313004E-mail: [email protected] The Journal of Health and Population in Developing Countries (ISSN 1095-8940) is a publication of the Department of Health Policy and Administration, School of Public Health University of North Carolina at Chapel Hill. Journal of Health & Population in Developing Countries / URL: http://www.jhpdc.unc.edu/ Date Published 23 June, 2003 Introduction Health workers, different kind of clinical and paraclinical workers have been increasingly recognized as the most important inputs in a health system. The World Health Report (2000) notes “performance (quality and efficiency) of a health system depends ultimately on the knowledge, skills and motivation of the people responsible for delivering services”. However, health workers in many developing countries are poorly motivated, inadequately trained and unproductive. Their poor motivation is often ascribed to poor living conditions, low salaries and low social and professional recognition. In face of these factors, health workers adopt coping strategies that further limit their access to communities they are supposed to serve. (Alwan & Hornby, 2002; Lerberghe, Conceicao, & Ferrinho, 2002; Lerberghe et al., 2002). Despite recognition of centrality of health workers in performance of a health system, the reform agenda often bypasses the difficult issues involved in optimizing the potential of these human resources. While this is partly because of sensitive nature of issues involved, it is often also because of limited understanding of factors that affect the motivation and performance of health workers, and even less of the ways and means to address them (Lerberghe et al., 2002). In India, performance and quality of health system in rural areas is significantly dependent on Auxiliary Nurse Midwives (ANMs), the multipurpose extension health workers who works at the interface between the community and public health system. While a team of physicians and paramedical workers staff the primary and community health centers, a single ANM manages the sub-center, mandated at a population of 3,000-5,000 for rural areas.1 She is expected to perform a large number of diverse preventive and curative functions such as motivation for family planning, immunization, conducting deliveries, and treatment for childhood illnesses. She is expected to reside in the subcenter village and remain available round the clock. Several studies have however shown that they are often not available to the communities they are supposed to serve. The reasons cited for the ANM’s non-availability include the large population that she has to cover, her restricted mobility and the fact that she does not stay in the sub-center village or area (Gupta and Walia, 1981; ICMR, 1991; DANIDA, 1996). A study conducted by Indian Council of Medical Research in 1997 in 23 districts of the country showed that only 57% of all ANMs stayed at their place of posting, while the rest commuted to their place of work (ICMR, 1997). Given the centrality of ANMs in performance of public health system in rural India, it is important to identify the reasons for limited availability and the ways and means to address this issue. In this paper, we examine the reasons for poor availability of ANMs to the rural communities in a district of Rajasthan, where conditions are typical of large parts of northern and central India. In doing so, we focus on identifying the determinants that affect their decision on residing (or not residing) within their work area, a decision that significantly affects their availability and performance. Based on analysis of the study findings we then propose a framework that could be useful in understanding this issue in other settings. We also propose directions for policy and programs in India, so that more ANMs might live within their work areas and thereby enhance access to primary health care at the village level. Methods The study was conducted in Udaipur, a primarily rural district located in southern Rajasthan, India with a population of 2,632,210. For purposes of administration, Udaipur is divided in to eleven blocks with population in each block ranging from 150,000 to 350,000. A network of 538 sub-centers and 1 Though the staff at the sub-center also includes a Male Multipurpose Worker, in the recent years, they are being phased out. Even where they are currently present, the responsibility of running the sub-center on the day to day basis rests with the ANM 2 Journal of Health & Population in Developing Countries / URL: http://www.jhpdc.unc.edu/ Date Published 23 June, 2003 92 Primary Health Care Centers provides primary health care in the district. The district has over 650 auxiliary nurse-midwives. As in other parts of North India, communities are divided on lines of caste, gender, and socioeconomic status. Income opportunities are few and there is widespread poverty as evidenced by the fact that almost 50% of the district population lives below poverty line. We hypothesized that the decision of an ANM to reside in her work area is dependent on her interaction with the environment and the system. “Environment” includes the physical environment (such as terrain, connectivity, availability of amenities, etc.) as well as social environment (such as support by the community) of her work area. “System” refers to the support that the health department provides her and the accountability that it enforces on its workers to reside. Response of an ANM to the environment and the system would be dependent on her personal needs and support systems. Based on developmental parameters, we categorized all 11 blocks of the district into “more developed” and “less developed”. Two blocks were randomly selected from each of these strata. The study was conducted in three distinct phases. In the first phase, we collected secondary information on the physical environment of place of posting of all the ANMs of the sampled blocks, such as availability of electricity, water, and schools. In the second phase, ANMs attending monthly meetings at their block PHCs were requested to fill a written, confidential questionnaire after taking their consent. In this phase, information was collected on individual factors that could affect their place of residence, such as socioeconomic background, availability of family support, needs for healthcare, etc. The third phase consisted of semi-structured interviews with a subset of ANMs. This was aimed to understand how various personal, environmental, and systemic circumstances affect the decision regarding the place of stay. For this “qualitative phase”, twenty-five ANMs were randomly selected from among the resident (an ANM that resides within her work area was defined as resident) ANMs. For each resident ANM so selected, the nearest non-resident ANM was also enrolled: the final sample consisted of 25 resident and 23 non-resident ANMs. Two women investigators trained in social sciences interviewed them at their place of work or at home after seeking appointment. Quantitative data was entered and analyzed in Epi-info (version-6) software. Bivariate analyses were conducted to identify the factors associated with residential status of ANMs. Responses of ANMs to the in-depth interviews were analyzed manually by collecting all statements on a particular subject, identifying constant themes that emerged in the interviews, noting the range of responses on the themes, and then selecting illustrative comments for inclusion in the report. Information from these interviews was triangulated with findings from the earlier quantitative phase. Classifying ANMs on residential status Residential status was assigned on the following criteria: 1. When an ANM herself reported that she does not reside in the sub-center area, she was considered as non-resident.

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