Mapping Adequacy of Staffing to Ensure Service
Guarantees for Maternal and Child Health:
A Study of Ganjam District in Orissa using WISN Method
By
Dr. Manmath K. Mohanty, Head, HRU
Human Development Foundation (HDF)
In collaboration with Washington University, CHSJ, UNFPA
22nd July 2009
Context and Background
 NRHM has provided certain CSG
 It also promises CGS for each level SC, PHC, CHC
 MCH is important for IMR/MMR reduction
 JSY increased Ins. Delivery
 Demand vs. Supply of workforce is verifiable
Research Question:
Is there adequate staffing for Maternal
and Child Health (MCH) Services in
government health care facilities to
meet the service guarantees under
NRHM in Ganjam district of Orissa?
About WISN Method
 WISN- Workload Indicators of Staffing Need
 A method of setting the correct Heath Facility staffing
levels.
 Developed by Shipp (1998) and popularized by WHO
 Tried in Tanzania, Papua New Guinea, Kenya, Hong
Kong, Turkey and Bangladesh
 No previous work in India
Advantages
 Optimal Allocation and deployment of current staff
geographically according to volume of services
 Optimal Allocation and deployment of current staff functionally
between the different types of health facilities or different health
services in district or state
 Staffing patterns and levels (categories and numbers) in
individual health facilities according to local conditions
(morbidity, access, attitudes) and not based on national averages
(population ratios and standard staffing schedules)
 Useful for both medical and non-medical administrators at all
levels of the health service
 Simple to operate and use, technically acceptable,
comprehensible and realistic so that results are acceptable by non
clinical manager.
Limitations of the Study
 Actual time requirements could be different from the
estimates of practitioners, for a variety of reasons.
 We did not directly calculate time standards of the MCH
activities through time/motion observation
 Other scopes of observation may have generated
different conclusions.
 There may be activities involved in MCH care that we did
not capture in our lists, which would understate the gap
in service availability.
WISN Steps Chart
Interview &
FGD
Step-I
Time required
for procedure
IPHS
X
Service
guarantees
Interview &
FGD
Step-II
Step-III
Time available
per worker
Total
deman
d
HMIS &
Secondary
data
X
Proportion of
population requiring
MCH
=
Total
deman
d
HMIS/Record
review
Personnel
strength
X
_
Total
supply
of staff
time
=
=
Total
supply
of staff
time
Surplu
s/Gap
FINDINGS
Extent of Shortage or Surplus of Health Workers in
Ganjam for providing MCH services
Staff Category (a)
Number of
workers in our
study area devoted
to MCH care (b)
Total
Demand
in Hours
(c)
Total
Supply in
Hours (d)
Gaps/Surplu
s in Hours
(e=c-d)
Number
Additional
Staff Required
to Meet Gap
(f=e/hours
worked per
year per
worker)
Ratio of Staff
Supply/Required
(WISN)* (g=d/c)
Doctors
45
104859
25272
-79587
42.51
0.24
Staff Nurses
21
43535
15725
-27810
14.86
0.36
173
375739
226699
-149040
79.62
0.60
Lady Health
Visitors
16
19055
23587
4532
-2.42
1.24
Lab Staff
11
23257
2622
-20635
8.66
0.11
Male Health
Workers
91
137729
68141
-69588
37.17
0.49
357
704174
362046
-342128
180.39
0.51
ANMs
Totals
*Note: When supply meets demand, the WISN number is 1.0; when demand exceeds
supply, the WISN score falls below 1.0. Severity of shortage or surplus can be
measured by the distance from 1.0
Staffing Requirement
Category of Staff
Proportion of Additional Staff Required to Meet the Gap
Proportion of workers available for MCH care
Health
Workers(M)
Lab Staff
LHVs
ANMs
Staff Nurses
100%
80%
60%
40%
20%
0%
-20%
Doctors
Percent of Health
Workers
Staffing Requirement for MCH at Ganjam
Staff Requirement at Block Level Facilities
100%
80%
60%
40%
20%
Jagannathprasad
Block PHC
Kodala CHC
Buguda Block
PHC
Polasara Block
UGPHC
Badagada Block
UGPHC
0%
Patrapur Block
PHC
Percent of Health Workers
Staffing Requirement at Block Levels for ANMs
Health Facilities
Proportion of Additional Staff Required to Meet the Gap
Proportion of workers available for MCH care
Staff Requirement at PHC New Level
Health Facility
Proportion of Additional Staff Required to Meet the Gap
Proportion of workers available for MCH care
Baragaon
PHC New
Rahada PHC
New
Beguniapada
PHC New
Karchuli
PHC New
Goudagotha
PHC New
100%
80%
60%
40%
20%
0%
Baranga
PHC New
Percent of Health
Workers
Staffing Requirement at PHC (New) Level for ANMs
Staff Requirement at Sub Centre Level
Khamarpali
SC
Kodala-II
Buguda-II
SC
Biranchipur
SC
Konkorada
SC
100%
80%
60%
40%
20%
0%
Goudagotha
SC
Percent of ANMs
Staffing Requirement at Sub Centre Level
Health Facility
Proportion of Additional Staff Required to Meet the Gap
Proportion of workers available for MCH care
Conclusion
 To meet the requirements of the NRHM service guarantees,
the 18 health facilities would need to supply an additional
342,128 hours, translating to about 181 additional FTE
workers.
 Additional staff required to the extent 80 ANMs, 37 male
HW, 43 physicians, 15 staff nurses and 9 lab staff.
 However the supply of LHV is 16, which is about 2.4 more
than required to meet the demand.
 In case of ANMs Badagada Block UGPHC has the largest
shortfall of staff, requiring an additional 13 FTEs to meet the
SG in the NRHM.
 The WISN ratio for that center is 0.52, indicating the supply
of hours of care is only slightly better than half of that
required.
Recommendations
 In the presence of government promises to deliver a minimum
package of services, the WISN method should be used as a
methodology to calculate the expected demand as well as supply
and the gap.
 Government health planners should use WISN data to consider
the magnitude of staffing increases that would be needed to
meet service guarantees.
 Our study generated time standards in minutes for each MCH
activity promised by the NRHM. These standards could now be
applied to other districts in India with slight modification if
required.
 WISN, then, can provide a useful tool for civil society advocates
who seek to hold governments accountable for their health
service guarantees.
THANK YOU