Keywords
Healthcare delivery system, Primary health care, Sub-centers, Healthcare service delivery, Grassroot level work in healthcare, Grassroot level.
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Garghate R and Choudhari DS. A study protocol of assessing grass root level health care service delivery system in Wardha District, Maharashtra [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:125 (https://doi.org/10.12688/f1000research.143421.1)
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Study Protocol
A study protocol of assessing grass root level health care service delivery system in Wardha District, Maharashtra
[version 1; peer review: awaiting peer review]
PUBLISHED 19 Feb 2024
OPEN PEER REVIEW
REVIEWER STATUS
This article is included in the Datta Meghe Institute of Higher Education and Research collection.
Abstract
Corresponding author:
Rutuja Garghate
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2024 Garghate R and Choudhari DS.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Garghate R and Choudhari DS. A study protocol of assessing grass root level health care service delivery system in Wardha District, Maharashtra [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:125 (https://doi.org/10.12688/f1000research.143421.1)
First published: 19 Feb 2024, 13:125 (https://doi.org/10.12688/f1000research.143421.1)
Latest published: 19 Feb 2024, 13:125 (https://doi.org/10.12688/f1000research.143421.1)
Introduction
India has tried many models for delivering primary care to its vast population through many mechanisms of human resource allocation. All these documents stressed the necessity of workers at the community level who would serve as the system’s main points of contact. Numerous initiatives have been put into place, but because they are voluntary, community health workers (CHVs) and the most recently Accredited Social Health Activists (ASHA) deserve special attention. The Community Health Volunteer Scheme (CHV Scheme) was a significant intervention in the history of the development of health services in the nation. It puts people’s health in their hands by having a community representative handle basic health care in rural areas and acts as a conduit between public and health services.1 The six building components contribute to the strengthening of health systems in various ways. Several cross-cutting components, such as leadership/governance and health information systems, serve as the foundation for overall policy and regulation of the health system. Finance and health personnel are two important inputs in the health system.2
This involves more unswerving arrangements to improve one’s health and initiatives to affect health determinants. The initial result of many inputs into the health system, such as health staff, purchasing and supplies, and funding, is service delivery. It is vital to monitor these factors to track the delivery of healthcare services.3 The Hon’ble Prime Minister established the National Rural Health Mission (NRHM) to offer quality healthcare to the rural population, especially the most disadvantaged segments.4
The part of the health system that patients and the general public are most aware of is the delivery of health care. The primary areas of concentration are the planning and provision of all services associated with the identification and treatment of diseases, as well as the promotion, maintenance, and restoration of health. Public health, primary care, specialized care (often divided into secondary and tertiary care), urgent and emergency care, pharmaceutical care, rehabilitation/intermediate care, long-term care, services for informal carers, palliative care, mental health care, and dental care are some of the major service provision areas covered.5
As they gained more knowledge and experience, Community Health Workers (CHWs) were taking larger tasks and obligations. Research is therefore deemed necessary to comprehend the workflow, workload, and effects on the service delivery of CHWs. Through the elimination of waste and the interpretation of work, the time interval of each activity of a subject is recorded as part of the methodology known as “Time Motion Study,” which aims to establish the workflow and ensure efficiency and effectiveness. In hospitals and clinics, time motion studies have been widely utilized to measure the time usage and workflow of chemists, doctors, and nurses.6
Rationale
In accordance with the Indian Constitution, only the Parliament of India has authority to establish new states and union territories. This can be accomplished by declaring the creation of states or union territories, dividing territories from a standing state, or combining two or more states, territories, or portions of them. There are various proposed additional states and union territories, in addition to the current 28 states and 8 union territories. There are various gaps and barriers to CHW performance. Social, organizational, and interpersonal issues can hinder or support CHWs’ programmes. The goal of the current study was to evaluate the eminence of healthcare provided at the lowest point of care in a Community Development Block in the Wardha District.
Here, a time motion study of these community health workers is carried out to quantify the time utilization and workflow in providing health services to check the efficiency of their work and perform necessary improvements. And to know the effective health services are provided to the admirable population of society in the interior of time.
Need to conduct the study:
1. In order to achieve universal health coverage, it is important to understand the CHW resource outputs, motives, and problems in providing medical treatment.
2. To calculate the prospect costs sustained by CHW.
3. To identify elements that influence CHW motivation, work satisfaction, and service delivery both favourably and unfavourably.
4. To designate standpoints of CHWs on tactics for improved fulfilment and service delivery.
5. To offer logical and practical enhancements to village-level health programs that might enhance circumstances and fairness for individuals using and delivering community health worker systems.
Objectives
Primary objective
1. To study the roadmap of the community health workers in central rural India.
2. To investigate the characteristics that promote better utilization of community health workers’ working hours in central rural India.
3. To identify the challenges in better utilization of the working hours of the community health workers in central rural India.
Methods
Study design
A mixed method study will be conducted through a combination of free-listing, time motion study, and in-depth interviews.
Study setting
Wardha District is located in the Vidarbha region of Maharashtra. The Amravati division to the west and north, Yavatmal to the south, Chandrapur to the southeast, and Nagpur to the east encircle the Wardha District. The district covers an area of 6,310 square kilometers. The Wardha District has 1296157 residents. It is the 29th-largest district in the state in terms of population. Three subdivisions—Wardha, Hinganghat, and Arvi— and eight talukas—Wardha, Deoli, Selu, Arvi, Ashti, Karanja, Samudrapur, and Hinganghat— constitute the district.
Inclusion
ANM, ASHA and Anganwadi workers who are present at their respective sub-centre. All the Sub-centres are selected randomly and the data will be collected after two months (January 2024).
Exclusion
Participants will be excluded if they refuse to give their consent or are not available after two consecutive visits.
Study’s variable
The study will assess the frequency of the work flow and the time management to perform their activities such as:
▪ ANC registration
▪ Training
▪ IEC activities
▪ Workforce availability
▪ ANC counselling, assessment and examination
▪ LBW management
▪ PNC registration and assessment
▪ ANM - No of cases registered/assisted
▪ No of institutional and home deliveries
▪ No of cases registered of Tb, leprosy and Malaria
▪ IUCD and MTP registration
▪ Indent order of immunization and training of immunization
▪ BMW training through IPHS
▪ Monthly review meetings at PHC level
▪ Drug kit records
Data source
Wardha district comprises a total of 181 subcentres, each staffed with three grassroots level workers, amounting to an estimated population coverage of 543. The sample for this study consists of 226 participants, including ASHA workers, ANMs, and Anganwadi Sewikas. Significant questions will vary across these roles, with 14 questions for ASHA workers, 11 for ANMs, and 3 for Anganwadi Sewikas demonstrating statistical significance.
The research study, will work on a mixed-methods approach involving free-listing, time motion studies, and in-depth interviews. A cross-sectional observational design will be applied to the randomly selected 181 Wardha district subcentres, focusing on three evaluation dimensions: service delivery, service provision, and facility assessment.
Several variables were considered, ranging from ANC registration to immunization and drug kit records, to assess service delivery, service provision, and facility aspects. To identify potential roadblocks in community health worker workflows, three distinct questionnaires on Google Forms will be used. In-depth interviews were conducted to gather insights into variations in time allocation among workers.
The facility assessment instrument addressed infrastructure, medications, records, and Information, Education, and Communication (IEC) activities.
Measurements
Analysis plan
The data will be recorded using a Google Excel sheet. The responses will be assessed for the outcome results performed under various skills pertaining to ANC, Immunization, and PNC. A score of 1 will be given to the correct step, and 0 will be given to the incorrect step. Summation will be assessed for a particular domain score. Ordinal data will be marked as per category (yes, no, not available, available, functional, etc). A positive response will be given 1 mark and a negative response will be given 0 marks.
The analysis will be performed using SPSS software version 27. Non-parametric tests will be used to evaluate the significant differences for ordinal data example for inter analysis comparison Mann-Whitney for two groups Kruskal-Wallis for more than two groups, for intra analysis comparison Wilcoxon test for intra and Friedman test for more than two groups.
Descriptive variables will be assessed and reported in terms of counts, frequencies, and for continuous data, mean, standard deviation (SD), median, and interquartile range (IQR). Inferential statistics will be performed using Kolmogorov–Smirnov test to assess the normality of the data. Based on the normality of distribution, ANC, PNC, Immunization, and facility level assessment scores will be reported as mean and SD or median and IQR. Correlations between different assessment scores and the total score will be done, and Spearman’s rank order correlation coefficients will be calculated.
Bias
Confounding bias can be detected here, as sometimes ASHA workers or ANM may not be found at a given time. Sometimes, they may lie about given activities.
Sometimes, they may include false information and can be detected as, or they may not be able to complete the given target. They can also misplace records.
To avoid such kind of bias applying restrictions and checking recorded data at the time of visit.
Study size
Population size (for finite population correction factor, fpc) (V): 543
Hypothesized % frequency of outcome factor in the population (p): 50%+/-5
Confidence limits as % of 100(absolute +/- %) (d):
Design effect (for cluster surveys-DEFF).
Sample Size (n) for Various Confidence Levels
Results from OpenEp., Version 3. open-source calculator--§SPropor.
Discussion
Literature review
This study will help to compares how reported time deviates from the expected amount of time. It will help us recommend various policies, programs, and improvements needed to remove the barriers (organizational, social, interpersonal, etc.) in implementing CHW programs in rural India. With the help of this study, village-level health programming might be improved in a way that would promote equity for individuals who provide and use the CHW system while also improving conditions. This study will help to evaluate CHW opportunity costs. It will analyse the effectiveness of the community health worker (CHW) program. The knowledge that could be gained in this investigation would help rural populations take certain preventive measures and guide policymakers and health authorities to plan, design, and initiate initiatives, programs, and policies.4
Another study focused on the awareness and skills of Anganwadi workers conducted by Tara Gopal Das Conducted a study (1998) on Anganwadi Workers’ awareness and skills and activities in Baroda City slums through the adoption of the interview and participatory observation methods.5
In a study by Kumar, it was demonstrated that the provision of preventative and promotional services, as well as the suitability of primary health care’s features, are related to the quality of primary health care services. Health outcomes are directly correlated with the caliber of basic health care services. Studies have shown that specialized primary healthcare helps people achieve better health outcomes and can be obtained with relatively little money. In the current situation, Uttar Pradesh (UP) has the lowest health outcomes. Poor health status exemplifies the low quality of healthcare services provided by the health system.6
Vietnam presently employs a strategy that prioritizes disease prevention while also encouraging the early identification of COVID-19 infection, efficient isolation, and prompt treatment for inveterate cases. This strategy has shown outstanding results in the early stages of the COVID-19 pandemic. With 239 confirmed cases and no known deaths as of April 2020, Vietnam had a substantially lower overall number of confirmed cases than other nearby nations.7
In Madhya Pradesh’s rural Integrated Child Development Service block, Sangita Trivedi conducted research to assess how well the integrated child development service program was being used by children aged 1-6. This study evaluated nutritional and vaccination services in five randomly chosen matched non-Integrated Child-Development Service rural areas (500 children) and six Anganwadi locations in the Integrated Child Development Service block (709 children). This demonstrates how community-based workers assess and keep track of the requirements of both rural and urban populations in the population they serve.8
Key results
The study’s findings will address facility evaluation, service delivery by frontline healthcare staff, and daily workflow. to understand the challenges and conflicts encountered at work and how they affect work productivity at the community level.
Limitations
The study is limited to the Wardha district, so it cannot be used for national implementation. Only three participants will be drawn from each PHC, so we will not be able to measure full members’ time movements.
Implication/generalizability
This study will help to formulate policies that will inculcate grass-root-level health care services to gain insight into how many services need to be improved and its implications for everyone in the community. Its significance in public health will pave the way for service screening and testing of healthcare delivery systems. Additionally, it will show that the system for delivering healthcare performs better. Future research should concentrate on identifying localized deficiencies and developing console indicators to estimate healthcare delivery systems objectively.
Ethical considerations
The Datta Meghe Institute of Higher Education and Research (DU) Institutional Ethics Committee approved the study protocol Ref. No. DMIHER (DU)/IEC/2023/631. The date of approval is 11/02/2023. Additionally, prior to beginning the study, we will obtain written informed consent that will include the study’s objectives, clearly state that it is being conducted for research purposes, and ensure that you understand that your response to the survey will remain anonymous. We will also use participant numbers for all the research notes and documentation. Participants’ data will be kept private. Throughout the interview, we’ll take steps to safeguard the interviewee’s privacy and confidence.
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how to cite this article
Garghate R and Choudhari DS. A study protocol of assessing grass root level health care service delivery system in Wardha District, Maharashtra [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:125 (https://doi.org/10.12688/f1000research.143421.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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