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Year : 2021  |  Volume : 65  |  Issue : 3  |  Page : 275-279  

What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study

1 Project Coordinator, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Field Coordinator, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Additional Professor, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Lead Consultant (Health and Wellness Centres), Department of Health and Family Welfare, National Health Mission, Punjab, India
5 Economic Evaluation Specialist, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
6 Professor, Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission30-Dec-2020
Date of Decision11-Mar-2021
Date of Acceptance13-Aug-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Shankar Prinja
Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_1489_20

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Background: The Government of India introduced a new cadre of Community Health Officers (CHOs) in the primary health-care system through the Ayushman Bharat Health and Wellness Centres (HWCs) program. Objectives: The study aimed to assess the activities performed and time spent by the existing and new primary health-care team members at the HWC level. Methods: A time and motion study was undertaken in four HWCs in Punjab over a period of 3 months, to assess the time spent by auxiliary nurse midwives (ANMs) and CHOs on different services and activities. Data were collected through direct continuous observation of four CHOs and four ANMs during working hours for a period of 6 consecutive days of a week, along with structured time allocation interviews of all participants. Results: The CHOs spent 5.7 (5.6–5.9) hours per day on duty of which 57% was productively involved in service delivery. The average time spent by ANMs was 4.9 (4.5–5.3) hours per day, with nearly 62% productive time. While the CHOs spent nearly 40% of their time on services for non-communicable diseases (NCDs), the ANMs spent 51% of their time on maternal, infant, child, and adolescent health services. Conclusion: The introduction of HWCs and CHOs has nudged the health system toward comprehensive primary health care by placing a renewed emphasis on NCDs. The study provides useful evidence for staff, program implementers, and policymakers, to aid informed decision-making for human resource management.

Keywords: Auxiliary nurse midwife, Ayushman Bharat, community health officer, health and wellness centres, primary health care, time and motion study

How to cite this article:
Brar S, Purohit N, Prinja S, Singh G, Bahuguna P, Kaur M. What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study. Indian J Public Health 2021;65:275-9

How to cite this URL:
Brar S, Purohit N, Prinja S, Singh G, Bahuguna P, Kaur M. What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study. Indian J Public Health [serial online] 2021 [cited 2022 Sep 30];65:275-9. Available from:

   Introduction Top

Strengthening primary health care through investment in frontline health workers is cornerstone in achieving universal health coverage.[1],[2],[3],[4],[5] Low and middle-income countries (LMICs) face major challenges in adequacy and competency of health workforce.[6],[7],[8] In addition, India has significant problems related to workforce shortage, imbalances in work distribution, and addition of new programs.[9],[10],[11],[12] Several economic analyses have assessed the cost of service delivery through frontline workers but assessment of their time commitment for specific services to optimize the allocative efficiency had always been a neglected area.[13],[14],[15]

The Government of India launched the Ayushman Bharat Health and Wellness Centres (HWCs) program to provide comprehensive primary care for changing morbidity burden, improve utilization of government health facilities, reduce out-of-pocket expenditure, and ensure continuum of care.[16] Under the program, 150,000 existing subcentres and primary health centres are being strengthened into health and wellness centres (HWCs), and a new cadre of Community Health Officers (CHOs) is being introduced into the primary health-care system to enhance its capacity to offer an expanded range of services.[17] The existing human resources in primary health care in India include auxiliary nurse midwives (ANMs), male multipurpose health worker (MPHW-M), and Accredited Social Health Activist (ASHA).[18] A doctor from Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy background, a dentist or a nursing officer can be appointed as a CHO.

In view of these policies, the primary health-care staff will have to take on new roles in wellness, preventive care, outreach services, curative care, rehabilitative and palliative care, communication, and management. An Innovation Learning Centre (ILC) was established as a joint collaborative effort of the Punjab State Government, National Health Systems Resource Centre-technical assistance body to the Ministry of Health and Family Welfare, as well as the Postgraduate Institute of Medical Education and Research Chandigarh (PGIMER) to support the implementation of HWCs, test pilot interventions, and undertake implementation research. As part of the ILC activities, it was considered imperative to evaluate the time contribution of primary health-care team members for various services and activities which could help to establish the roles and responsibilities to improve the staff efficiency. Therefore, this time-motion study was undertaken to assess time spent by primary care health-care workers, ANMs, and CHOs, on different HWC activities.

   Materials and Methods Top

A descriptive, cross-sectional time-motion study was conducted in four HWCs of one community development block of Sahibzada Ajit Singh Nagar district, in the Indian state of Punjab. A multistage stratified random sampling was used to select 4 out of 26 HWCs in the block. A selection criterion was developed to select diverse centres covering all different operational setups of HWCs in Punjab state. The first criterion was availability of both ANM and CHO at the centre. One of the HWCs did not have a CHO, and another two did not have a permanently posted ANM, therefore three HWCs were excluded from the study. Second, six HWCs with footfall lower than 200 were excluded based on performance in terms of average monthly outpatient department (OPD) visits. Third, 17 high-performing centres which were accessible for data collection and had both staff members present were stratified into two groups based on status of colocation with Zila Parishad Subsidiary Health Centres (SHCs). The status of colocation with SHCs was important from the State's perspective as colocated centres had additional human resources such as a doctor, which could significantly alter the nature of services delivered and the time spent on various activities by the staff. Finally, two HWCs were randomly selected from each group. At HWCs with two or more ANMs, one of them was randomly selected as the study participant.

A tool was developed for recording observations comprising a list of activities undertaken by CHOs and ANMs. The tool was developed using inductive research by prior field visits and interaction with staff members, leaving sufficient flexibility to include new activities during the observation period. The tool was piloted in one HWC among one ANM and CHO, after which it was refined. This centre was included in the final sample of selected HWCs. Any additional data which was required as a result of revision of the tool was subsequently collected in this HWC.

Data collection

Data were collected through direct continuous observations,[19],[20],[21] of one CHOs and one ANMs at each of the four HWCs, between January and March 2020. The participants were shadowed by trained data collectors during working hours (9 a.m.–3 p.m.) for a period of 6 consecutive days of the week (Monday–Saturday). If any participant was not available for a particular day, she was observed on the same day of the next week. The start and end time of each activity were noted by using a stopwatch. When participants were multitasking, the observers noted the direct service delivery-related task as the primary one and the other coincident tasks as secondary. The observers validated the data captured by observation by interacting with study participants at the end of each day. Observation data were supplemented with structured time allocation interviews of all participants to capture the time spent on activities performed at a frequency of less than a weekly basis. Standard time allocation interview methodology was utilized, which has been used in several previous costing studies in India.[13],[22],[23],[24] The self-reported data including meetings, trainings, outreach sessions, camps, etc., were further validated through review of records and registers.

Data analysis

Quantitative data generated from direct continuous observations were descriptively analyzed in MS Excel 2016, for time duration per participant, per week, and per activity in predefined categories, by computing mean, range, and median. The activities were categorized into different health packages and service type. Activities which could not be clubbed under a service but were performed on a regular basis were classified at “General Activities,” such as opening and closing of the centre, cleaning, and arrangement of furniture. Similarly, the activities which could not be clubbed under a certain health package were classified as “Non-package specific activities.” Two subactivities, namely non-communicable diseases screening camps (NCD camp) and the weekly outreach sessions for pregnant women, lactating mothers, and children under 5 years, where antenatal, postnatal, and immunization services are provided (Mamta Diwas) were analyzed separately in terms of time spent since these were outreach activities and received significant program focus.

Ethical considerations

Ethics approval was obtained from the Institutional Ethics Committee of PGIMER (IEC-08/2019-1308, dated October 01, 2019). Administrative approval for the data collection was obtained from the Punjab State Health Department. All the respondents were informed about the purpose of the observational study, and a verbal consent was taken from them before observations and interviews.

   Results Top

Profile of participants

The mean age of participating CHOs (n = 4) and ANMs (n = 4) was 30.5 and 49.0 years, respectively. The mean years of work experience of CHOs and ANMs were 3.0 (range: 0.5–5) and 18.9 (11.5–23) years, respectively. All CHOs had the highest qualification of a graduation in Nursing while ANMs had a diploma course in auxiliary nursing midwifery.

Time spent on activities

A CHO spent on an average 5.7 (5.6–5.9) h per day on duty of which 57% was productively involved in service delivery. The average time spent per outpatient by a CHO was 4.9 (3.3–6.6) min. The ANMs spent on an average 4.9 (4.5–5.3) hours on duty daily, with nearly 62% productive time. Unproductive time included time spent on waiting for patients, tea breaks, and phone use for personal purposes.

[Table 1] shows the time utilization pattern of CHOs and ANMs across different health service packages in a week. CHOs spent nearly 40% of their time on services for NCDs followed by 18% on maternal health. ANMs spent 51% of their productive time on maternal health, infant health, and child and adolescent health (22%, 15%, and 14%, respectively).
Table 1: Time spent on activities under different health packages and service type in a week

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[Table 1] also depicts the pattern of time utilization of CHOs and ANMs on different types of services. The CHOs spent more than one-third of their productive time per week on providing clinical care as compared to ANMs who spent 23%. Both CHOs and ANMs spent considerable amount of time on recording of data, i.e., 29% and 35%, respectively. Of this time, CHOs spent most time on the NCD register (33%) and outpatient register (16%), while ANMs spent most time on the immunization due list and tally sheet (25%) and maternal and child health registers (19%).

[Table 2] depicts a breakdown of time distribution specifically for NCD camps. These camps were primarily led by CHOs with little or no involvement of ANMs. A large component of time was spent on recording history and counseling (40%), followed by data entry (21%).
Table 2: Time distribution at an non-communicable diseases camp led by community health officers

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The Mamta Diwas activities had an equal involvement of CHOs and ANMs. The ANMs were observed to be responsible for immunization and MCH cards, while the CHOs recorded history, checked reports, and measured blood pressure. All other activities were shared by both staff members, including measuring height, measuring blood pressure, entry in register, counseling, dispensing medicines, and camp preparations.

   Discussion Top

To the best of our knowledge, this is the first attempt to understand service provision and time utilization by CHOs at HWCs. We observed that CHOs had a focus on the delivery of NCD-related services, accounting for 40% of their time, indicating that NCD services are being mainstreamed in primary care. The CHOs spent 57% of their time in service provision, the rest of the time was spent on waiting for patients, informal conversations among staff, and breaks. While more unproductive time was observed on OPD days wherein service provision is dependent on patient load, the study showed scope for better utilization of working hours. The ANMs spent a majority of their time (51%) on maternal and child health, this was in keeping with other studies where ANMs were observed to spent 45% and 33% time on the same.[25],[26] It was observed that an ANM spent 4.9 (4.5–5.3) hours on duty, this was similar to the findings of another study which reported 4.3 (3–5.5) hours on an average per day.[27]

A major amount of time was spent by both staff members on data recording and reporting. CHOs spent 33% of the data recording time on the NCD register, for which an application is available with the ANM. There is a need to streamline the use of existing information management systems for efficient data keeping. It has been reported in other studies that health workers worked on an ad hoc basis as per the priorities set by supervisors and leaders.[28] These findings highlight the need to address such ad hoc prioritization in service delivery as well as making better utilization of IT-enabled management information systems.

There was a clear division of priorities among the two cadres, wherein CHOs focused on new services such as NCDs and ANMs continued to provide the traditional services of a subcenter such as immunization and antenatal care. While synergy between ANMs and CHOs was observed during Mamta Diwas, ANMs had limited or no involvement with NCD services. This sort of division is opposed to a holistic approach envisaged by the Indian Government's Comprehensive Primary Health-care guidelines.[17]

Optimal service delivery which is effective and resource efficient is based on a strong human resource team. In LMICs like India with limited human resources for health and dual burden of disease, prioritization and planning with rational distribution of tasks are of paramount importance.[28] The National CHO Induction training module illustrates a weekly schedule for HWCs.[29] It was observed that the current operations at the HWCs were aligned with the proposed schedule as it had a designated NCD screening day, ANC and immunization day and outpatients were catered to on all other days. A focus on incorporating new activities within the HWC other than maternal and child health and NCDs, optimal utilization of existing staff through rational task distribution, involvement of MPHW-M, and regular monitoring of all HWC activities to prevent focus on limited services would help streamline service delivery at the newly developed HWCs. The tasks of CHOs and ANMs need to be delineated to ensure teamwork and optimal utilization of working hours to maximize quantity and quality of services.

The study had certain limitations. Observation-based studies are known to be affected by Hawthorne bias, however, establishing a rapport with the participants is useful in overcoming it and collecting quality data.[30] This study was conducted by ILC staff with whom the participants were already well acquainted due to prior interactions, thus decreasing the risk of Hawthorne bias. A longer duration of observation with larger sample could be useful; however, with the supplementary time allocation interview at the end of each observation week, we were able to capture all routine and non-routine activities which could not be captured through direct observation. This is a standard methodology used in other time allocation studies nested with cost analyses.[13],[22] Many supply and demand-side factors could impact the external validity of the findings since we observed only four HWCs. Supply-side factor such as level of funding, human resource capacity and motivation, level of monitoring, and supervision and similarly demand-side factors such as sociodemographic characteristics, income, distance from health facility, and access to metaled road could affect the generalizability of the findings. Hence, it would be prudent to carry out a larger study with a larger sample size and longer duration of observation to make estimates more representative.

The main strength of this study lies in the observation-based methodology, which is known to deliver the most reliable results.[19] Data quality was ensured through validated data collection tools, training of data collectors, and regular data triangulation. The data on work time distribution of health-care workforce are a prerequisite for health-care costing and cost-effective analysis studies.[13],[14],[15],[31],[32],[33],[34],[35],[36],[37] Time allocation data is important for routine program evaluation and development of cost function for predicting health-care costs.[38],[39]

   Conclusion Top

The introduction of HWCs and the incorporation of a new cadre of CHOs have nudged the health system toward comprehensive primary health care by placing a renewed emphasis on NCDs. The findings of our study may be utilized to inform future assessments of distribution of resources in primary health care, as well as estimations in national health accounts and disease-specific health accounts, taking into consideration the changed work patterns and time distribution across different primary care activities since the rollout of HWCs. More research is recommended to capture the diversity of work patterns of health-care workers by covering larger samples and geographical locations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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