Strengthening Provider Capacity

Strengthening the Capacity of Health Service Providers and Health Staff to Deliver Quality Family Planning and AYSRH Services

Purpose: This tool provides guidance on essential trainings for health service providers and staff of both public and private sector towards improving the quality of family planning (FP) and adolescent and youth sexual and reproductive health services (AYSRH).

Audience:

Additional Director/Joint Director
General Manager-FP and Urban (National Health Mission (NHM)
General Manager Rashtriya Kishore Swasthya Karyakram (RKSK)
Chief Medical Officers (CMO)/Additional Chief Medical Officers (ACMO)
Chief Medical Superintendent (CMS)
Nodal Officers- Urban Health and Family Planning
Divisional Urban Health Consultant (UHC)
District Program Manager (DPM)/Urban Health Coordinator (UHC)
State Quality Assurance Committee (SQAC)/District Quality Assurance Committee (DQAC)
Medical Officer In-charge (MOIC)/Staff Nurse The Federation of Obstetrics and Gynecological (Ob/Gyn) Societies/of India (FOGSI)/District Ob/Gyn Societies/Person In-charge of Private Health Facilities

Background: Training is an opportunity for health care providers to update themselves with techniques and information on contraception. It enables health care providers to seek solutions to day-to-day problems and to improve the quality of services in general. Overall, improving the competencies of health care providers strengthens their skills and knowledge, which has a profound effect on the uptake of contraceptive services and increasing client satisfaction. The competency-based training are effective in strengthening the capacity of the health care providers. The health care providers referred here include the medical and non-medical staff in both government and private facilities.

Evidence of the Impact

The Challenge Initiative (TCI) India technically supported the government in the capacity building of health care providers. The evidence from various initiatives taken under the TCI project for strengthening the technical and inter-personal capacities of the health care providers contributed to an increase in provider motivation, which resulted in the uptake of FP services and adolescent-friendly services in the project geographies.

In 2017, the Government of India (GoI) expanded the method mix by including two new contraceptive methods—the injectable Antara and non-hormonal weekly pills, Chhaya. The GOI's guidelines called for a phased rollout of new methods, with the focus in year one being on providing services only to district hospitals. TCI India's advocacy efforts in the Madhya Pradesh (MP) on increasing access to new contraceptive, resulted in the state government moving an order towards provisioning of the new methods in urban primary health center (UPHCs) by training medical officers and paramedical staff on the new contraceptives. By January 2018, 12 medical officers, 21 staff nurses, and 20 Auxiliary Nurse Midwife (ANMs) were trained in Indore, an intervention city in MP. This increased the uptake of the second dose of Antara to 70% in Indore while the dropout rate at the state level was around 60%. Inspired by the Indore example, other TCI India supported cities gradually increased the uptake of Antara by facilitating training of service providers. (Refer to Most Significant story - Madhya Pradesh’s Expanded Method Mix Brings Injectables to Urban Primary Health Centers).

Similarly, TCI India advocacy efforts in Firozabad, Uttar Pradesh (UP), for leveraging the services of a government contracted agency—the Hindustan Latex Family Planning Promotion Gender Intentional Trust (HLFPPT) to train providers in IUCD insertion resulted in the expansion of fixed-day static (FDS) services with IUCDs across all nine UPHCs of the city. Following in the footsteps of Firozabad, the other 17 intervention cities in UP trained 608 providers on IUCD insertion through HLFPPT. (Refer to Most Significant story - TCIHC Advocacy Leads to IUCD Provider Training in Uttar Pradesh UPHCs).

To strengthen AYSRH services in urban, TCI India technically assisted Rashtriya Kishore Swath Karyikram (RKSK) in organizing a WSO for 1260 clinical and non-clinical staff from 96 UPHCs across five intervention cities in UP. The orientation focused on developing health care providers' competencies in communicating with adolescents and youth about sexual and reproductive health (SRH) issues in a friendly manner. The WSO of facility staff marked improvement in the adolescent health services data uploaded from the 96 UPHCs into the HMIS. A total of 6,369 boys and 10,059 girls were registered for adolescent-friendly health services (AFHS) in the first year of implementation, i.e., from April 2019 to March 2020. In the second year of implementation, from April 2020 to March 2021, this increased by 7% (6,788 boys) and 19% (11,970 girls). Later, TCI India supported government in scaling AFHS to 238 UPHCs in 10 additional cities of UP.

Guidance on Implementing the Trainings

1. On board service providers and assess training needs

Ensure all urban health facilities meet GoI standards for trained service providers in IUCD, injectable contraceptives, and Centchroman Oral Contraceptive Pill services. Provide infection prevention training for all staff levels and conduct sensitization sessions, particularly for male service providers, to prioritize and promote family planning. Assess healthcare providers' training status and needs during facility assessments, gap analyses, and rapid assessments. Coordinate with partners like TCI India for hands-on training in collaboration with the CMO and district hospital. Conduct an annual training needs assessment for ongoing improvement.

2. Select the type of training to conduct and develop training plan

Select the type of competency-based training to be provided based on the training need assessment findings for strengthening health care providers' capacity and activating health facilities to provide method-mix services. Create an annual training calendar or as per requirement, and prior to training arrange following resources: master trainers, a training center, contraceptive commodities and equipment/instruments, consumables, a sufficient number of eligible clients for hands-on practice, training modules of the GoI, educational material, power point presentations, projector, stationary and logistics.

3. Conduct the training activities

Ensure that the health care providers and facility staff are trained to provide informed choice to eligible FP clients. The following are the specifics of competency-based trainings that are effective in building the capacity of health care providers.

Training on IUCD and PPIUCD/PAIUCD

Training all service providers at the district women's hospitals, medical colleges, community health center and UPHCs can create the necessary technical capacity to provide these services.

Duration: Comprehensive 5-days theoretical and practical training at the clinical training site on interval IUCD, PPIUCD and PAIUCD

Content: IUCD, PPIUCD and PAIUCD reference manual (Refer to: IUCD manual for medical officers and nursing personnel; and GoI’s PPIUCD training video)

Audience: Government and private sector doctors and nursing personnel

Frequency: One-time training; with post-training supportive supervision/ mentoring and refresher as needed

Note: Community volunteers should ensure availability of eligible clients in the training so that the trainee participants could get the opportunity for comprehensive practice.

Training on Injectable Contraceptive

The availability of Antara services at the UPHCs gave additional choice to women for maintaining space between births.

Duration: One day

Content: Injectable contraceptive reference manual (Refer to: Reference Manual for Injectable Contraceptive March 2016)

Audience: Government and private sector doctors and nursing personnel

Frequency: One-time training; with post-training supportive supervision/ mentoring and refresher as needed

Note: The trainer can be service providers (MBBS and above, AYUSH, Staff Nurses) with prior training experience. And can be designated by Director Family Welfare/State Quality Assurance Committee at state level and by CMO/DQAC at district level. It is mandatory that the first shot of injection be administered under the guidance of a trained MBBS doctor after proper screening. Subsequent shots may be administered by trained AYUSH doctor/staff nurse/LHV/ANM.

Training on Centchroman Oral Contraceptive Pill

Chhaya / Centchroman (Ormeloxifene) is a non-steroidal, non- hormonal weekly oral contraceptive pill added to National Family Planning Program to provide method-mix choices to the community.

Duration: One day

Content: Oral contraceptive pills reference manual (Refer to: Reference Manual for Oral Contraceptive Pills March 2016)

Audience: Government and private sector doctors and nursing personnel

Frequency: One-time training; and refresher as needed

Note: The SQAC/Director Family Welfare at State level and DQAC/CMO at District level can designate trained service providers (MBBS and above, AYUSH, staff nurses) for training Medical Officer (MBBS/AYUSH), staff nurse, LHV and ANM on Chhaya pills.

Infection Prevention (IP) Training for Facility Staff

Cleanliness and good IP practices are an important element in clients' satisfaction and their willingness to obtain services.

Duration: Half day

Content: Infection Prevention Reference Booklet for Health Care Providers, 2nd Edition, 2011 (Engender Health) and Standards and Quality Assurance in Sterilization Services, Chapter 6, Page no. 53

Audience: Counsellors, medical, paramedical and other support staff in both government and private sector facilities

Frequency: Three monthly or six monthly - Based on assessment, but necessary at the time of staff turnover

Facility Whole Site Orientation (WSO) on FP & Adolescent-Friendly SRH Services

WSO are brief sensitization/orientation sessions to build a FP supportive and gender inclusive environment.

Family Planning

Duration: 2-3 hours, with follow-up refresher trainings as required

Content:

Family Planning: TCI India document: Whole-site Family Planning Orientation of High Volume Facility Staff and value clarification on gender and contraceptive use

Adolescent-Friendly SRH Services: TTCI India document: Whole-site Orientation for Adolescent Friendly Health Services and value clarification on gender and contraceptive use

Audience: Staff nurse, ANM, Counsellors, LHV, paramedical staff, pharmacist, lab technician, ward boy/girl, data entry operator, Accredited Social Health Activist (ASHA), janitor and security staff. Clinical and non-clinical staff of private facilities.

Frequency: Annually; and refresher as needed

Note: The CMO can create a pool of master coaches from the health system to facilitate WSO of clinical and non-clinical staff. These master coaches can be CMS, HODs of medical college, and MOICs.

Training of Surgeons On No-Scalpel Vasectomy (NSV)

NSV method has a strong gender perspective as it encourages males to take responsibility for FP and reducing the additional liability of women.

Duration: 5 days

Content: GoI reference manual for male sterilization (Refer to: Standards & quality assurance in sterilization services, GoI, Nov. 2014)

Audience: Doctors (MBBS and above) of public and private sector

Frequency: One-time training, with concurrent post-training support/ mentoring and refresher as needed

Note: Community volunteers should ensure availability of eligible clients in the training so that the trainee participants could get the opportunity for comprehensive practice.

Training of Providers On Minilap and Laparoscopic Female Sterilization (FST)

Increasing the pool of providers trained in laparoscopy and minilap sterilization can help fulfill the increasing demand for these services.

Duration: 12 days for minilap and laparoscopy

Content: GoI reference manual for female sterilization (Refer to: Standards & quality assurance in sterilization services, GoI, Nov. 2014)

Audience: Doctors (for Minilap - MBBS and above, specialists in other surgical fields; for laparoscopy - MBBS performing minilap sterilization, Post Graduate Diploma or degree in Obstetrics/ Gynecology, specialists in other surgical fields)

Frequency: One-time training, post-training supportive supervision/ mentoring and refresher as needed

Note: Community volunteers should ensure availability of eligible clients in the training so that the trainee participants could get the opportunity for comprehensive practice.

Refresher Training

Refresher training on clinical methods is important for providers to have updated knowledge including the contra-indications, technical provisions and management of side-effects and complications of FP methods.

Duration: IUCD/ PPIUCD-1 day & FST-3 days

Content: GoI reference manual for female sterilization (Refer to: Standards & quality assurance in sterilization services, GoI, Nov. 2014; Reference manual for IUCD services, Family Planning Division MoHFW, GoI, March 2018)

Audience: Public and Private Sector Doctors (MBBS, PG diploma or degree in obstetrics/ gynecology), Staff nurses for IUCD/PPIUCD

Frequency: One-time training, with post-training supportive supervision/ mentoring

4. Reassess post-training knowledge and provide support

After completing classroom-based training, DQAC committee members must visit facilities to evaluate the service provider's knowledge and performance on-site. This allows the impact of the training to be assessed, as well as the need for additional mentoring, supportive supervision, and refresher training. Government officials can assess the needs of trained providers for equipment, supplies and consumables, job aids, technical materials, and other items in MOIC meetings, public-private interface meetings, and facility visits.

Roles and Responsibilities

Steps to be taken by CMO, CMS, SQAC, ACMO, DQAC

Train an adequate number of doctors at the district level to fulfil the family planning needs of the community.
Develop training plans in accordance with mandates or identified needs.
Ensure each trainee receives theoretical knowledge, opportunities to observe procedures, and the ability to independently conduct procedures as per Government of India guidelines.
Conduct a follow-up within one to three months post-training.
Ensure availability of instruments, family planning supplies, job aids, infection prevention equipment, and documents at service delivery points.
DQAC team to periodically visit facilities to ensure trained service provider are following service provision standards. DQAC team conducts periodic visits to facilities to verify compliance with service provision quality standards.
Assess the quality of service provisions and behavior change in facility staff through client exit interviews.

Monitoring and Evaluation of Training Activities

Number of trainings planned and The CMO/CMS and their team should monitor the planning, implementation and outcomes of training activities in the monthly meetings. These activities can also be reviewed in the quarterly DQAC meetings or in the District Health Society (DHS) meetings.

Implementation and outcomes can be monitored using the following indicators after setting the Expected Levels of Achievement (ELA). It would be useful to analyze these indicators separately for public and private facilities and providers.

Number of trainings planned and organized
Number of providers trained- segregated list of doctors and nursing personnel
Number of participants of WSO in each facility- segregated list to look for clinical and non-clinical staff participation
Number and percentage of increased FP acceptors, post-abortion FP acceptors and post-partum FP acceptors.
Number and percentage of boys and girls participated in facility adolescent health day at the facilities.

Cost Elements

Training needs to be planned and budgeted separately in the Program Implementation Plan (PIP). This includes the number of activities planned, the number of participants per training and the number of days of training for each activity.

In addition, training of private providers can be budgeted for in the PIP, which requires advocacy with the government at the national, state and district levels.

The table is indicative and illustrates the manner in which cost elements are provided in a government PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as capacity building.

Cost elements/ PIP Budget Head

FMR Code

Training on minilap, laparoscopic sterilization, IUCD insertion, PPIUCD insertion, injectable contraceptive for medical officers

Lap induction training &FMR-RCH.6.42.CB.1

Minilap induction training FMR-RCH.6.42.CB.2

Orientation/review of ANM/AWW (as applicable) on: New schemes, FP-LMIS, new contraceptives, post-partum and post-abortion family planning, scheme for home delivery of contraceptives (HDC), ensuring spacing at birth (ESB), wherever applicable, Pregnancy Testing Kits (PTK)

FMR-RCH.6.50.CB.1.b

* Source: NHM PIP Guideline 2022-2024

Sustainability

Linking cost of training to the PIP (PIP resource mobilization tool) is the key to making the training sustainable. The discussion of the planning and monitoring of these activities in the monthly CMO meetings is another important step towards institutionalizing and ensuring sustainability of these capacity-strengthening activities.

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