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 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

Roles and Responsibilities

Training on IUCD and PPIUCD/PAIUCD: Steps to be taken by CMO, CMS, SQAC, DQAC

1. Identify doctors and nursing personnel from each facility to travel to the divisional training site for a five-day theoretical and practical training.
2. Each trainee is provided theoretical knowledge, has the opportunity to observe procedures and to conduct a minimum of one procedure (1 Interval IUCD insertion, 1 PPIUCD insertion on client under supervision and 1 PAIUCD insertion on client (if available) independently under the supervision prior to certification.
3. Ensure that the training is followed by on-site mentoring of trainees by the divisional level trainers as per the standard training plan.
4. CMO and CMS to review IUCD/PPIUCD/PAIUCD performance of trained providers at the facility level, sharing experiences and planning for consistent quality of care.
5. CMO and NUHM team to ensure availability of IUCD insertion kits and supplies.
6. DQAC team to periodically visit facilities to ensure trained service provider are following service provision standards.

Training on Injectable Contraceptive: Steps to be taken by CMO, CMS, SQAC, DQAC

1. CMO should conduct follow up within two to three months of completion of training.
2. CMO and NUHM team to ensure availability of Antara supplies where trained service providers are available.
3. DQAC team to periodically visit facilities to ensure trained service provider are following service provision standards.

Training on Centchroman Oral Contraceptive Pill: Steps to be taken by CMO, CMS, SQAC, DQAC

1. CMO should conduct follow up within two to three months of completion of training.
2. CMO and NUHM team to ensure availability of Chhaya pills supplies at facilities with trained service providers.

Facility Whole Site Orientation: Steps to be taken by Additional Director and CMO

1. Additional Director should leverage the support of WSO master trainers in orienting and sensitizing tertiary, secondary and primary facility staff of other districts/cities of the division.
2. CMO to ensure periodically client exit interview is conducted to assess behaviour change in facility staff through client satisfaction level.

Infection Prevention (IP) Training: Steps to be taken by CMO

1. Identify a qualified and experienced trainer, either from within or outside the district hospital/ medical college.
2. The trainer should first assess the existing IP practices and do a training needs assessment of the facility staff (Refer to: UHI’s Infection Prevention checklist).
3. The trainer can utilize the UHI training package to conduct half-a-day training, using PowerPoint presentations, group exercises, pre and post knowledge assessment tools, posters and other necessary materials.
4. For any large facility, government or private, an IP committee should be formed which identifies the gaps, develops an action plan and regularly reviews for closure of gaps. For a small facility, a provider can take the responsibility of this function.
5. The IP committee, where ever existing, should meet on a monthly basis after the training to assess the progress in improving IP practices according to the action plan, using the assessment checklist. The committee should then decide and implement the necessary corrective actions.
6. Learnings on IP should be reinforced from time to time.
7. In addition to a classroom training, facility visits by trainers are helpful in observing gaps and encourages practical hands-on-learning.
8. To ensure availability of infection prevention equipment and supplies at the facility.

Training of Surgeons on No-Scalpel Vasectomy (NSV): Steps to be taken by CMO

1. At district level sufficient number of doctors to be trained to meet the NSV need of the community.
2. A follow up post training should be conducted within one to three months.
3. To ensure availability of NSV instruments, supplies, job-aids and documents at the NSV service delivery points.

Training of Providers on Minilap and Laparoscopic Female Sterilization (FST): Steps to be taken by CMO

1. At district level sufficient number of doctors to be trained to meet the female sterilization need of the community.
2. A follow up post training should be conducted within two to three months.
3. To ensure availability of FST instruments, supplies, job-aids and documents at the FST service delivery points.

Refresher Training: Steps to be taken by CMO/ACMO

1. Identify the number of doctors/staff nurses previously trained on any FP method and assess their performance, so as to identify the need for further refresher training, guidance and support.
2. Together with NGO partner, help in identifying empanelled private providers requiring further refresher training, guidance and support
3. Nominate such doctors/empanelled private providers and staff nurses for a refresher training

Monitoring and Evaluation of Training Activities

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.

IUCD/PPIUCD/PAIUCD Insertion Training

1. Number of providers trained- segregated list of doctors and nursing personnel
2. Increase in the number of IUCD/PPIUCD/PAIUCD insertions performed in facilities over a given time
3. Number and percentage of deliveries and abortions followed by PPIUCD and PAIUCD insertion respectively
4. Percentage of facilities with at least one provider trained in IUCD/PPIUCD/PAIUCD insertion

Training on Injectable Contraceptive

1. Numbers of providers trained in dispensing injectable contraceptive (Antara)
2. Percentage of facilities having at least one provider trained in dispensing injectable contraceptive (Antara)
3. Increase in the number of injectable cases (dosage wise) at facilities over a given time

Training on Centchroman Oral Contraceptive Pill

1. Numbers of providers trained in providing Chhaya services
2. Percentage of facilities having at least one provider trained on Chhaya services
3. Increase in the number of Chhaya users at facilities over a given time

IP Training

1. Number of participants in IP training- segregated list to look for support staff participation
2. Percentage knowledge gain post training
3. Number of facilities implementing IP training
4. Percentage of all facilities conducting IP training
5. Number and percentage of facilities having functional IP committees 

Facility Whole Site Orientation (WSO)

1. Number of orientations planned and organized
2. Number of participants of WSO in each facility- segregated list to look for clinical and non-clinical staff participation
3. Evidence of increased FP acceptors, post-abortion FP acceptors and post-partum FP acceptors.
4. Evidence of increased participation of adolescent and youth in facility adolescent health day at the facilities.

Training of Surgeons for NSV

1. Number of surgeons trained in NSV
2. Percentage of facilities having at least one provider trained in NSV
3. Increase in numbers of NSVs performed at facilities over a given time

Training on Minilap and Laparoscopy (FST)

1. Numbers of providers trained in FST (both in Minilap & Laparoscopy)
2. Percentage of facilities having at least one provider trained in FST
3. Increase in the number of FSTs performed at facilities over a given time

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 below 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.

* 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.