Capacity Building

Introduction

Building capacity of health care providers is very important for efficient diagnosis and treatment to deliver high-quality Preventive, promotive, curative & rehabilitative services. Which not only decrease morbidity but also address irrational use of medicines. The newly recruited and existing MOs, FMOs, LHVs, staff Nurses, Midwives Dispenser & health technicians are the main manpower to address MNCH & general diseases in the community, the training strategy will cater the all MNCH/FP and 18 DHIS disease being collected by DHIS system on monthly basis

Training Strategy
  • There are following salient features of this training strategy for PPHI:

     Initiate early and prolonged skin to skin contact (1). Provincial-level trainings on topics such as MNCH, FP, DHIS , IMNCI, Communicable , Non Communicable diseases and community mobilization
     Regional level trainers/ monitors who will support provincial and district level trainings where applicable and will do monitoring of the cascade trainings
     Regional level Orientation for the regional management staff including RDs, PHSs, RMMs etc.
     District based trainers and trainings would be carried out by selected MOHQs, Health facility in charges etc.
     District based trainings including on-the-job training modules based on the high frequency, low dose approach) and supported by MNCH coordinators & MOHQs
     Trainings Orientation of different trainings for District management staff including DMs, Ex M&E , SOs etc.
     Training through other key stake holders like PWD on Family Planning & DHIS ToTs by DoH, DG office, UNICEF & WHO etc.
     Province wide trainings would be done by the generated pool of trainers from all levels including, HO, Regional & District level
     Trainings could be outsourced based on available robust training institution at ground level, the contract will be signed with such selected entities following PEPRA rules once they are selected they would be give standardization of trainings & material selected and finalized for the training they will do trickle down trainings as per scope & need of the regions or districts. Currently BLS trainings are outsourced to Dow Medical University hospital for Health care providers & trainers. But for pre-service training of midwives we get services from different institutions like Abu Zafar institute of Medical sciences Koohi Goth, Ziauddin Hospital & Isra University Hyderabad

    PPHI will train master trainers in different areas including;

     Trainings on MNCH, IMNCI which will cover Pnemonia, Diorhhea, PSBI 0-5 years
     EPI
     Other communicable diseases like TB, Malaria, Pneumonia, Typhoid etc
     Non-communicable diseases
     Training on community mobilization
     Trainings on MNCH (PCPNC, MCPC, KMC, HBB, STDs FP (PPFP, IUCDs, PPIUCDs, Implants, FP counselling)
     Nutrition
     Provincial training on clinical skills course TS training for only master trainers
     Community Case management
     Trainings for service providers (CMWs, LHVs ,WMOs and Gynaecologists) by MNCH coordinators , MOHQs or hiring any training institution
     Staff: The trainers either MOHQs or MNCH coordinators MNCH services will support all these trainings by providing one technical person at HO & Regional level

    Group trainings would be covered as follow at provincial level;

     Clinical Training Skills course (CTS) (Consultant from any recognized institutions are needed to carry out this training at least one in year one)
     Clinical update training for trainers when any new material comes
     Helping Baby breathe
     Helping mothers survive "bleeding after birth"
     Family Planning
     Kangaroo mother care
     IMNCI
     EPI
     Infection prevention
     TB
     Nutrition
     Refresher trainings for newly graduated midwives before putting them in assigned health facilities

    Trainings Types;

     Workshop Trainings
    i. Clinical update training for Obstetric care trainings of ( FMOs, LHVs & Midwives ) 2-3 trainings per districts
    ii. Clinical attachments of midwives at the training site supervised by incharge FMO and other clinical staff like LHV & Midwives in all three shifts followed by on the job coaching and mentoring by MNCH coordinators
     Pre-Induction
    Pre induction training for newly hired staff of all cadre
     On the job trainings
    These would be done for the all kind of medics and para medics already posted at the health facility. Who are trained in group based trainings or through on the job trainings using OJTs

    Following on the job modules for MNCH will be implemented over the course of one year training plan;

     Antenatal care
     Normal Labor & Delivery
     Partograph
     PPH
     Postpartum care
     Breast feeding
     Newborn care
     HBB
     Rapid initial assessment
     Pre eclampsia/Elampsia
     Purpural sepsis
     Manual removal of placenta
     Birth planning
     Vacum extraction
     Vaginal Bleeding in pregnancy
     Staff : staff required for the implementation of these trainimg is either new hiring for HO level or tacking some of existing staff in training pool like for MNCH trainig at HO level Master training is requird to plan, execute and track all the trainings through two regional master trainers, 1 master trainer for two regions. Similarly for execution of other General diseases one master trainer is required to plan, implement, execute, monitor and track all provincial level trainings this could be new hiring or existing PHS vacancy could be filled for such a person who can take this role

    Staffing requirements to implement training plans;

     Provincial training teams
    Two Master trainers at provincial level to manage the team of regional master trainers/ PHSs to implement training plan at regional level & district level.these two master trainers at HO level would be supported by Program assisstant (Total 4) to support provincial level training implementation as well as supportive supervision during clinical trainings at regional & district level including attachments of midwives and other staff when required
     District trainings teams
    District based teams would be MOHQs, MNCH coordinators & Selected MOs and FMOs in the pool of trainers or where needed regional offices and HO can also provide support to district level trainings as well. The identified MOHQs would be given first priority as a trainers if these do not have capacity then new hirings would be done for them as having capacity to impart training
Quality of Care
  • The analysis on quality of care at PPHI health facilities was conducted by MCHIP/Jhpiego. The findings showed poor quality of services at health facilities. Therefore, there is a team of technical plus management team available at district level to improve quality of care services through health care providers.

    These team streamline interventions to improve quality of services i.e. facility quality audit, which an identified person (most likely facility in charge) will be responsible to conduct periodically (quarterly). This will help each facility identify gaps and improve those gaps by regularly updating facility action plans based on the quality audit. The process of audit will utilize a standard checklist to be used for every MNCH services and scoring is done in each area and subsequently, rewards would be given to those who are good performers. From last year pay for performance and contract renewal would be linked with the performance criteria which would further improve the individual performance and thus quality of care.

    PPHI Sindh's long-term goal is to make these centers ISO certified. Therefore, PPHI needs support with regards to training of team in QI and implementing QoC strategies at HFs for aiming to achieve the ISO certification which would be first ever for PHC facilities in Pakistan.

    PPHI more than 600 Health facilities are registered with the Sindh Health care commission and will soon adopt quality of care process to get quality certification from SHCC.
Evidence based Practices in MNCH
  • In order to contribute towards the reduction of maternal, newborn and child health mortality, PPHI Sindh introduced many evidence-based practices and trained health care providers of the health facilities. Most of these evidence-based practices were introduced for the first time in province of Sindh includes:

     For reducing the burden of post-partum haemorrhage (PPH): Advance antenatal distribution of misoprostol was introduced.
     For decreasing puerperal sepsis: Implementation of infection prevention protocols was instituted in every facility.
     For increasing facility-based delivery: 24/7 BHU Plus provide MNCH services.
     For managing eclampsia: Availability of magnesium sulphate was ensured at all health facilities.
     For strengthening referrals: Ambulances were placed at all 189 BHU Plus for timely referrals.
     For identifying obstructed labour: Availability and utilization of partograph was ensured in all labour rooms.
     For decreasing pre-term birth: All BHU Plus were equipped with ultrasound facilities particularly dating scan, therefore, pregnant mothers identified with such conditions are counselled during the ANC and referred to tertiary care hospitals timely to manage premature labours. Recently, PPHI also introduced facility-based Kangaroo Mother Care (KMC) for saving the lives of premature babies. This intervention is scaled up to all BHU Plus.
     For decreasing birth asphyxia: Helping baby breathe corners are established where trained staff and necessary equipment are available for newborn resuscitation within one golden minute.
     For reducing neonatal sepsis: Free of cost supply of Chlorhexidine to BHU Plus for application on umbilical card just after cutting the cord post-delivery.
     For curbing Pneumonia and diarrhoea in under 5: Availability of Amoxicillin, Oral Rehydration Salt (ORS) and Zinc
Skills of Health Care Providers
  • Skills of health care professionals in making accurate diagnosis and providing proper treatment is still a major issue. PPHI’s experience shows that one-time training of the health care providers is not enough. In order to sustain their skills refresher trainings, follow up after training, clinical mentoring need to be implemented on regular basis. In order to tackle this challenge, PPHI have created a dedicated position of MNCH coordinator whose responsibility is to regularly visit health facilities to provide on the job coaching and training to the health care providers to polish their technical skills. The regular mentoring will not only improve their technical skills but also improve their attitude towards quality of care.

    The first task that was given to MNCH coordinators was to do a need assessment of health care providers where they lack skills and need immediate refreshers. During this exercise it was realized that there are only 30 health care providers trained in IMCI. PPHI Sindh needs urgent assistance in training all the health care providers in IMCI in order to contribute towards reduction of U5MR in Sindh.

    These MNCH coordinators provide continuous on the job training & coaching of in-service health care providers. Apart from that PPPHI also invest on the pre service education of female health care providers from far flung rural areas of Sindh where hiring female providers for MNCH is issue, PPHI identified and selected matriculate girls from those areas and sent them for two year midwifery course in private midwifery institutes like Ziauddin University hospital, Isra University hospital and Abuzafar Institute of Medical sciences Koohi Goth Karachi, so far 250 girls are graduated and serving as midwives in far flung areas of Sindh province.

    BHU Plus 24/7 round the clock services for Management of deliveries through provision of skilled birth attendants.

    PPHI Sindh has recently established 304 BHU Plus which are round the clock maternal and child health facilities. Each of these facilities have a female medical officer in morning shift while midwives in evening and night shift. All BHU plus are equipped with necessary supplies, equipment and medicines. Additionally, most of these facilities have ultrasound and ambulance facility available. A number of mobilization activities are done in order to increase deliveries at these health facilities such as community support group meetings with both male and female by PPHI Sindh’s community support groups, awareness sessions conducted in the villages by female and male medical officers, announcements on radio etc.
Referal Mechanism
  • Improving referral through strengthening linkages with the community through LHWs:

    Pakistan introduced National Programme for Family Planning and Primary Health Care (FP&PHC) in the year 1994, widely known as "Lady Health Workers Programme" (LHWP). The goal of this programme is to create a comprehensive basic level effective system for providing primary health care by increasing community participation and behaviour change regarding basic health issues and family planning.

    These LHWs have access to households, strong interaction with local women and proven high-level acceptability have rendered them appropriate and reliable MNCH service providers at the community level. Despite all this there is poor district health system referral support.

    The referral mechanism is made more robust by putting in place the meetings with LHWS on regular basis when they come to the health facility for monthly meeting to keep them updated with latest evidence based practices, the minutes of these meetings would be recorded regularly and based on information the community data would be collected based on health session delivered and referrals made by LHWs to health facility. After end of each quarter LHWs performance is reviewed and based on that a reward system (form of small gifts) is built that would keep them motivated to do a good job.

    Prompt referral to higher level facilities by providing ambulance service when needed:

    PPHI Sindh has procured 189 number of ambulances. These ambulances are available at majority of 24/7 MCHCs. Currently, these ambulances are used free of cost pick & drop for the women during facility-based delivery provided they have paid all fur scheduled ANC visit to the health facility, this is also utilized for transporting females with complications during pregnancy or newborn requiring urgent care, to nearby hospitals. These ambulances will be used for other emergency services such as referring sick young infants with PSBI. For this awareness regarding this service need to be generated providing community with a toll-free number to contact ambulance service at PPHI in case of emergency.
Midwifery Training
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