Strengthening the Capacity of Providers and Staff to Offer Quality Family Planning Services 

Purpose: To provide guidance on implementing training for providers and staff towards improving the quality of family planning (FP) services.

Audience:

  • Chief Medical and Health Officers(CMHO/CDMO/CMO)
  • Persons In-charge of Private Health Facilities
  • Nodal Officers- Urban Health and Family Planning
  • Senior State Health Officials
  • The Federation of Obstetrics and Gynaecological Societies of India (FOGSI)
  • District Ob/Gyn Societies
  • Indian Medical Association office bearers

Background: Training is an opportunity for providers to learn the latest information on family planning and to clarify their concerns and doubts regarding particular types of contraceptive methods. It enables providers to seek solutions to day-to-day problems and to improve the quality of services in general. Training of providers is also critical in the light of the Indian Supreme Court’s mandate of 2016 that mandates quality FP services to be provided without coercion.

The following seven types of training provided under the Urban Health Initiative (UHI) were found to be effective in strengthening the capacity of the providers and the health facility staff. The CMHO/CDMO/CMO can add value to the FP services by facilitating training on these aspects. The providers referred here include the medical officers and the paramedic staff in both government and accredited private facilities.

Evidence of the Impact of Strengthening the Capacity of FP Service Providers and Staff

  • Contraceptive Technology Updates (CTUs) led to a decrease in the number of rejections for family planning services, particularly for female sterilization, Intra Uterine Contraceptive Device (IUCD) and injectable in the private sector, in the UHI project areas. They also led to an increase in the rate of post-abortion contraceptive use.
  • In 11 cities in Uttar Pradesh (UP), 298 doctors were trained in Post-partum IUCD (PPIUCD) insertion by the UHI resulting in an increased number of PPIUCD acceptors from 1180 in 2011 to 11462 in 2013.
  • Under the Women’s Health Program of Population Services International (PSI) in 30 districts in the three states of UP, Rajasthan and Delhi, 198 private providers were trained for PPIUCD services that resulted in 13364 insertions from October 2011 to December 2015.
  • Under the UHI, infection prevention training was implemented in 35 high volume public and private facilities in 11 districts. Infection prevention practices and utilization of inexpensive and locally available supplies were observed to improve across all sites.
  • Eleven No-Scalpel Vasectomy (NSV) surgeons were trained under UHI, increasing the number of NSVs provided from 3723 in 2011 to 4869 in 2013, representing nearly 77% of all vasectomies in the state.
  • In 10 project cities under PSI’s Expanded Access to Quality (EAQ) program, 2272 NSVs were performed by private providers from 2015 to 2016, representing almost 31% of the total NSVs performed in the state.

All the combined efforts under the UHI interventions to strengthen the technical and inter-personal capacity of the FP service providers contributed to an increase in provider motivation, which resulted in an increased contraceptive prevalence in the project cities.

Guidance on Implementing the Trainings

The details of the seven UHI trainings that were effective in strengthening the capacity of providers and staff are mentioned below.

Contraceptive Technology Updates
Contraceptive Technology Updates (Refer to Global Handbook for Providers) are a type of Continued Medical Education (CME) intended to provide technical updates and review of best practices in provision of contraception for providers at a facility as well as address prevailing biases or myths regarding contraception.


Purpose: To build an enabling environment for family planning among health personnel, including the support staff working at the facility
Duration: 2-3 hours, with subsequent refresher trainings as per need
Content: Sensitization of staff towards the quality of FP services
Audience: Paramedical and support staff
Frequency: Annually and refresher as needed


Steps to be taken by CMHO/CDMO/CMO/CMO for conducting CTUs:

  • Ensure sufficient budget in the district Program Implementation Plan (PIP) for CTUs on a bi-annual basis.
  • Based on the existing district FP data and trends, match the need for specific CTUs vis-à-vis the knowledge and the skill sets of the doctors.
  • Conduct CTUs on a regular basis, prioritizing topics based on identified needs and gaps. For example, if providers refuse to insert IUCD in post-abortion clients then there is a need for a CTU on post abortion contraception.
  • Identify credible experts from a local medical college, the local FOGSI chapter, technical agencies or NGOs, as well as the State Institute for Health and Family Welfare (SIHFW) and request them to provide an update on specific topics in an interactive manner, providing new knowledge and promoting exchange of views among participants.
  • Ensure 100% participation in the CTUs from public as well as private sector providers. For example, explore with FOGSI/IMA office bearers on the best ways to seek 100% participation of accredited and empanelled private sector providers.
  • Involve the District Quality Assurance Committee (DQAC) (Refer to Operational Guidelines on Quality Assurance in Public Health Facilities_2013, Section B, Page 13) in the regular review and update of CTU training materials.
  • Review and follow-up on the CTU with doctors in monthly review meetings.

Refer to the ‘Family Planning: a Global Handbook for Providers for method-specific training and guidance

Facility Whole Site Orientation
WSOs are short sensitization/orientation sessions for paramedic and support staff at a facility, and are intended to build a supportive environment w.r.t the quality of FP service provision, specifically addressing the prevalent myths and misconceptions among clients and staff related to contraceptive methods. For example, PPIUCD decisions are often influenced by cleaners, ward aayas/boys etc. and their sensitization can help support favorable FP decisions.


Purpose: To build an enabling environment for family planning among health personnel, including the support staff working at the facility
Duration: Two to three hours with subsequent refresher trainings as needed
Content: Sensitization of staff towards the quality of FP services
Audience: Paramedical and support staff
Frequency: Annually and refresher as needed


Steps to be taken by CMHO/CDMO/CMO/CMO for conducting WSO:

  • WSO is organized on the basis of the type of facility. In a large public or private facility (tertiary and secondary), WSO can be conducted by senior level staff within the facility. In smaller public and private facilities, the doctor-in-charge and the nurses can arrange similar training for their staff during regular meetings (Refer to UHIs Whole Site Training Guideline with links).
  • CMHO/CDMO/CMO/CMS should include the number of facilities and the percentage of staff that underwent WSO as indicators in the monthly review meeting in order to monitor the implementation of this particular training.
Training on Infection Prevention
IP is an essential component in the delivery of quality FP services. Training on IP is provided to doctors, nurses, paramedics and other relevant staff such as sweepers, ayahs etc. to increase their knowledge and skills with respect to IP practices at the facility.


Purpose:  Improving quality of care in family planning services contributes to the assurance of patient and provider safety, reduction of maternal and newborn morbidity as well as hospital acquired infections in general. Cleanliness and good infection prevention practices are an important element in clients’ satisfaction and their willingness to utilize services.
Duration: Half-a-day
Content: Infection Prevention Reference Booklet for Health Care Providers (EngenderHealth, 2011) and Standards and Quality Assurance in Sterilization Services, Chapter 06, Page No. 53 (Government of India, 2014) 
Audience: Providers, nursing and other relevant staff in both government and private sector facilities.
Frequency: Based on needs assessment but especially recommended at the time of staff turnover.


Steps to be taken by CMHO/CDMO/CMOs to roll out training on infection prevention practices:

  • Identify a qualified and experienced trainer, either from within or outside the district / medical college.
  • The trainer should first assess the existing IP practices and the training needs of the facility (Refer to UHI Infection Prevention Checklist).
  • The trainer can utilize the UHI training package to conduct half-a-day training, utilizing power-point presentations, group exercises, pre and post knowledge assessment tools, posters and other necessary materials.
  • For any large facility, government or private, an IP committee should be formed which develops an action plan. For a small facility, a provider can take the responsibility for this function.
  • The IP committee, where present, should meet on a monthly basis following the training to assess the progress in improving IP practices according to the action plan, using the assessment checklist. The committee should then decide on and implement the necessary corrective actions.
  • Learnings on IP should be reinforced from time to time.
  • In addition to a classroom training, facility visits by trainers are helpful in observing any gaps and encouraging hands-on learning.
Training of Surgeons on No-Scalpel Vasectomy
Many districts lack sufficient number of NSV surgeons to meet the increase in demand for NSV arising from the awareness building activities among men. Training of surgeons on NSV can be organized in government identified training centers. Potential providers can be identified as per GOI guidelines and their names can be recommended through district CMOs, program managers and NGOs for training. This should be supported with client mobilization by community volunteers at the time of training to ensure that participants are able to get adequate hands-on-practice (Refer to the TCIHC FDS tool for additional guidance).


 
Purpose: Increases the pool of trained surgeons available to provide NSV services so as to meet the increasing demand being generated for this method
Duration: Five days
Content: To follow GOI reference manual for male sterilization (Refer Standards & Quality Assurance in Sterilization Services (GOI, Nov. 2014)
Audience: Doctors (MBBS and above)
Frequency: One time training, ongoing post training support/mentoring


Training on Female Sterilization
Increasing the pool of providers trained in laparoscopy and minilap sterilization can help fulfill the increasing demand for these services. The CMHO/CDMO/CMO can coordinate with the training centers in their cities, acquire their training calendars and facilitate the participation of trainees for FST (Refer to the GoI manual on female sterilization).The same approach can be taken up by NGOs, initiating and coordinating with the CMOs and other stakeholders to facilitate FST training (Refer to the TCIHC FDS tool for additional guidance).


 
Purpose: Increases the pool of trained doctors available to provide female sterilization so as to meet the increasing demand being generated for this method
Content: Follow GOI reference manual for female sterilization (Refer Standards & Quality Assurance in Sterilization Services; GOI, Nov. 2014)
Audience: Doctors (For Minilap – MBBS and above, Specialists in other surgical fields; For Laproscopy – MBBS performing minilap sterilization, Post Graduate diploma or degree in Obstetrics/Gynecology, Specialists in other surgical fields)
Frequency: One time training, Post training support/mentoring


Training on Immediate Post-Partum Intra Uterine Contraceptive Device Insertion
The Janani Suraksha Yojana (JSY) scheme has resulted in an increased number of institutional deliveries at facilities across India. This has provided the opportunity to provide Long Acting Reversible Contraceptives (LARC) such as PPIUCD to women who desire to use these methods.  However, many of these opportunities are missed because providers in the facilities lack the necessary skills to provide immediate post-partum IUCD insertion. Training a core group of providers at the district women’s hospital and in medical colleges can create the necessary technical capacity among nurses and other doctors to provide this service. Funding is available through the Program Implementation Plan (PIP) to train doctors and nurses from each public facility conducting deliveries.


 
Purpose: To impart new skills to the providers for Post-Partum Intrauterine Contraceptive Device (PPIUCD) insertion
Duration: Three-day theoretical and practical training at the clinical training site
Audience: Doctors and staff nurses in govt. and private sector
Content: Follow IUCD, PPIUCD reference manual (Refer to IUCD Manual for Medical Officers and Nursing personnel and GoI PPIUCD training video)
Frequency: One-time training and post training support/mentoring


Steps to be taken by CMHO/CDMO/CMO/CMO for conducting PPIUCD insertion training:

  • Identify doctors and staff nurses from each facility to travel to the divisional training site for a three-day theoretical and practical training. Each trainee is provided with theoretical knowledge, has the opportunity to observe procedures and to conduct a minimum of one procedure independently prior to certification.
  • Ensure that this training is followed by on-site mentoring of trainees by the divisional level trainers as per the standard PPIUCD training plan
  • Providers and the facility-in-charge to review PPIUCD performance of trained providers at the facility level, sharing experiences and planning for consistent quality of care
Refresher Training
Refresher training of on clinical methods is important for providers to have updated knowledge including the contra-indications, technical provision and the management of side-effects and complications of the methods. Government training centers having necessary infrastructure and adequate client load can be used as sites for refresher training. The trainers can include professors of government medical colleges and other trained and experienced doctors.


Purpose: To enhance the skills of existing trained providers
Duration: Three days
Content: Follow GOI reference manual for female sterilization (Refer Standards & Quality Assurance in Sterilization Services; GOI, Nov. 2014)
Audience: Doctors (MBBS, PG diploma or degree in Obstetrics/Gynecology)
Frequency: One time training, post training support/mentoring


Steps to be taken by CMHO/CDMO/CMO/CMO for conducting FST refresher training:

  • Identify the number of doctors previously trained on FST and assess their performance, so as to identify the need for further refresher training, guidance and support
  • Along with the NGO partner, help in identifying empanelled private providers requiring further refresher training, guidance and support
  • Nominate such doctors/empanelled private providers for a refresher training

Refer to the TCIHC FDS tool for additional guidance

Monitoring and Evaluation of Training Activities

The CMHO/CDMO/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 District Quality Assurance (DQA) 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. It would be useful to analyze these indicators separately for public and private facilities and providers.

Contraceptive Technical Updates
  • Number of CTUs planned and conducted
  • Number of providers participating in CTU
  • Number of CTUs conducted by facilities / districts in a year
  • Listing of topics and issues addressed in CTUs
Facility Whole Site Orientation (WSO)
  • Number of orientations planned and conducted
  • Number of participants in WSO in each facility
  • Evidence of increased FP acceptors, post-abortion FP acceptors & post-partum family planning acceptors at the facility
IP Training for Staff at Facilities
  • Number of participants participating in IP training
  • Number of facilities implementing IP training
  • Percentage of all facilities conducting IP training
  • Number and percentage of facilities having functional IP committees
NSV Training
  • Number of providers trained in NSV
  • Percentage of facilities having at least one provider trained in NSV
  • Increase in numbers of NSVs performed at facilities over a given time
FST Training
  • Numbers of providers trained in FST (both in Minilap & Lap)
  • Percentage of facilities having at least one provider trained in FST
  • Increase in the number of FSTs performed at facilities over a given time
PPIUCD Insertion Training
  • Number of providers trained
  • Increase in the number of PPIUCD insertions performed in facilities over a given time
  • Number and percentage of deliveries followed by PPIUCD insertion
  • Percentage of facilities with at least one provider trained in PPIUCD

Cost Elements

Trainings need to be planned and budgeted separately in the PIP. This includes number of activities planned, the number of participants per training and the number of days of training in each activity.

Refer to the Financial Management Report (FMR) codes of PIP of 2016-17, NHM-UP

Cost Element
FMR Code
Source
Training of NSV providers A.9.6.3 ROP 2016-17, NHM-UP
Training on Laparoscopic FST for providers A.9.6.1 ROP 2016-17, NHM-UP
Training on mini-lap FST for providers A.9.6.2 ROP 2016-17, NHM-UP
Refresher training on Laparoscopic FST for providers A.9.6.1.3 ROP 2016-17, NHM-UP
Refresher training mini-lap FST for providers A.9.6.2.3 ROP 2016-17, NHM-UP
Training on post-partum IUCD A.9.6.5 ROP 2016-17, NHM-UP

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.

This table is indicative and illustrates the manner in which cost elements are provisioned in a govt. PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as Capacity Building.

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 the monitoring of these activities in the monthly CMHO/CDMO/CMO meetings is another important step towards institutionalizing and ensuring sustainability of these capacity-strengthening activities.

Disclaimer: This document is based on the learnings collated from Urban Health Initiative (supported by BMGF), Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh (supported by BMGF). This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.