F1000Research 2024, 13:125 Last updated: 19 FEB 2024

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]
Rutuja Garghate 1, Dr. Sonali Choudhari2
1school of epidemiology and public health, Datta Meghe Institute of Higher Education & Research, Wardha, Maharashtra, 442001,

India
2Department of community medicine and Public Health, Datta Meghe Institute of Higher Education and Research, Wardha,

Maharashtra, 442001, India

v1 First published: 19 Feb 2024, 13:125 Open Peer Review

https://doi.org/10.12688/f1000research.143421.1
Latest published: 19 Feb 2024, 13:125
https://doi.org/10.12688/f1000research.143421.1 Approval Status AWAITING PEER REVIEW

Any reports and responses or comments on the

Abstract article can be found at the end of the article.

Background

One of the six elements that constitute the framework of the World
Health Organization System is the delivery of health care. To tracks
the development of healthcare service delivery, it is vital to focus on
its dimensions. The objective of the current learning is to evaluate the
quality of healthcare provided at the lowest level in the Wardha
District.

Methods

A community-based cross-sectional study will be conducted in the

rural area around all the sub-centers of Wardha District. A semi-
structured questionnaire will be used to assess the sociodemographic
profile and associated factors, namely, service delivery, service
provision, and facility assessment.

Study implications

This study will help formulate policies that will inculcate grass-root-
level health care services to gain insight into how much 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

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research should concentrate on identifying localized deficiencies and

developing console indicators to estimate healthcare delivery systems
objectively.

Keywords
Healthcare delivery system, Primary health care, Sub-centers,
Healthcare service delivery, Grassroot level work in healthcare,
Grassroot level.

This article is included in the Datta Meghe

Institute of Higher Education and Research
collection.

Corresponding author: Rutuja Garghate ([email protected])

Author roles: Garghate R: Conceptualization, Formal Analysis, Validation, Writing – Original Draft Preparation; Choudhari DS:
Supervision, Visualization
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 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
First published: 19 Feb 2024, 13:125 https://doi.org/10.12688/f1000research.143421.1

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List of acronyms and abbreviations

ANC: Antenatal Care
ANMs: Auxiliary Nurse Midwives
ASHA: Accredited Social Health Activists
AWCs: Anganwadi centres
AWW: Anganwadi workers
BMW: Bio-Medical Waste
CHVs: Community Health Workers/Volunteers
CHWs: Community Health Workers
FGDs: Focus Group Discussions
FHWs: Female Health worker
FLHWs: Front Line Health Worker
HRH: Human Resource for Health
ICDS: Integrated Child Development Services
ICT: information and communications technology
IDI: in in-depth interviews
IEC: Information, Education and Communication
IPHS: Indian Public Health Standards
IUCD: Intrauterine Contraceptive Device
LBW: Low-birth Weight
MDG: Millenium Development Goals
MHM: Master in Hospital Management
MO: Medical Officers
MPHWs: Multi-purpose Health Worker
MTP: Medical Termination of Pregnancy
NHDs: Nutrition and Health Days
NMR: Nuclear Magnetic Resonance
NRHM: National Rural Health Mission
PHCs: primary health centres
POM: Personal Outcome Measures
SDGs: Sustainable Development Goals
TINI: The India Nutrition Initiative
UHC: Urban Health Centre
WHO: World Health Organization

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,

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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.

Secondary objective
To evaluate the benefits, utilization, and workflow of different levels of community health workers.

Methods
Study design
A mixed method study will be conducted through a combination of free-listing, time motion study, and in-depth
interviews.

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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.

Study population
All the community health workers which include:

1. The Accredited Social Health Activists (ASHA)

2. Anganwadi workers (AWW)

3. Auxiliary Nurse Midwives (ANMs) from the study villages.

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.

Variables
Socio-demographic profile of ASHA, AWW and ANM

1. Age criteria

2. Educational status of ASHA, AWW and ANM

3. Type of family

4. Economic status

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

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▪ 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 Kolmogo-
rov–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.

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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

Confidence Level (%) Sample Size

95% 226
80% 127
90% 181
97% 253
99% 299
99.9% 362
99.99% 400

Equation
h
i
Sample size n ¼ ½DEFF  Npð1  pÞ d2 =z2 l«zðN1Þ þ pðlpÞ :

Results from OpenEp., Version 3. open-source calculator--§SPropor.

Expected outcomes/results
The expected outcomes of this study will display the workflow, service delivery, frequency of work, and factors
influencing work among healthcare personnel.

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

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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.

Dissemination
Study will be published in index journal.

Study status
Yet to start.

Data availability
Underlying data
No data are associated with this article.

Extended data
Zenodo: Assessment of grassroot level health care service delivery system in Wardha District: A cross sectional study,
https://doi.org/10.5281/zenodo.10439958.9

Acknowledgements
I would like to express my gratitude to Mr. Laxmikant Umate for his support with the sample size calculation and
statistical work in this study. He is a statistician and a member of the DMIHER research and development unit.

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References

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OF THE FUTURE SELF. JMR J. Mark. Res. 2011 Nov; 48: S23–S37. Monitoring of Under-Five Children Among Anganwadi Workers
PubMed Abstract|Publisher Full Text|Free Full Text in the Rural Area of Wardha District. Int. J. Curr. Res. Rev. 2020;
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5. Health care delivery: [cited 2022 Dec 20]. Assessment of grassroot level health care service delivery
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study of community mental health workers in rural India.

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