evaluation of skill based child health trainings under rch-ii

Evaluation Of Skill Based Child Health Trainings Under RCH-II

2nd National Child Health Workshop–cum–Review

October 2012

Contents

Introduction 3

Approach & Methodology 4

Key Findings & Issues

- Overall Issues 7

- Child Health Training

FBNC 10

F-IMNCI 14

NSSK 18

Conclusion 22

- 3 - MOHFW - DFID - Evaluation Of Skill Based Health Trainings

Introduction

• The MoHFW, under the DFID supported RCH II TMSA engagement, has commissioned Deloitte

to carry out an evaluation of the skill based maternal and child health trainings under NRHM.

• The following trainings in Child Health are being evaluated:

• Overall objective – to review the effectiveness and impact of the trainings, relating to:

Institutional Capacity and

Training Management

Systems

Suitability of trainers and

appropriateness of training

sites

Suitability of Deployment

site and trainee

knowledge and confidence

• Facility Based Newborn Care (FBNC)

• Facility based Integrated Management of Neonatal and Childhood Illness

(F-IMNCI)

• Navjaat Shishu Suraksha Karyakram (NSSK)

Child Health Trainings


Approach & Methodology

Evaluation Team &

Advisory Group

Development of

Assessment Tools

Sample Plan for field

Visits

An Evaluation Team and an Advisory Group have been constituted for the purpose of this

evaluation

• Medical Doctors & Public Health Experts

• Management Professionals

• Paediatricians from LHMC and Safdarjung

Team Members

Members of the Evaluation Team

Development of study tools

Field visits

Analysis

Report writing

• MOHFW

• Development partners – DFID, UNICEF, WHO,

• Professional/Technical Bodies – IAP, NNF

• Educational/Research Institutes – MAMC, LHMC

Child Health

Members of the Advisory Group

Provide overall guidance

Provide suggestions and

recommendations


Evaluation Team &

Advisory Group

Development of

Assessment Tools

Sample Plan for field

Visits

CH Trainings Status of field visits#

FBNC, F-IMNCI,

NSSK Karnataka

Madhya

Pradesh Maharashtra Rajasthan Bihar

Uttar

Pradesh

# Field visits have been completed in the states highlighted in deep blue.

• Criteria for Selection of states for field visits based on:

• Mix of high and low performing states

• States with reasonably high number of trained personnel across trainings

• States selected for the visits:

• Sample Plan

• Interviews with various stakeholders at the state and district level

• 2 Training sites and 4 deployment sites to be evaluated per training in each state except

for FBNC where 2 deployment sites (1 per district) were visited

• For FBNC, F-IMNCI, and NSSK, a pair of trained MO and nursing staff was interviewed

at each deployment site

Approach & Methodology

Key Findings, Issues & Recommendations


Overall Issues

Approach and

planning

• Limited institutional structure, focus and vision to plan and manage

trainings

• Inadequate staff capacity, and communication mechanisms at the

state level

• Lack of a comprehensive and updated human resource database to

drive training, planning and monitoring efforts

Trainee Selection

• Choice of trainees is often sub optimal (from facilities with low or no

case load) or those assigned field duties resulting in limited impact

of training

Training

• Training sites selected at times without having adequate training

infrastructure – mannequins, classrooms, AV aids, etc.

• Often do no follow appropriate infection control and waste

management practices

Deployment

• Lack of enabling environment at deployment site

• Lack of adequate manpower means facility based services can’t be

provided round the clock

• Trainees unable to practice skills learnt leading to erosion of

knowledge, skills, and confidence over time

Monitoring and

Supervision

• Lack of a robust system at state level to monitor training, post

training performance and initiate corrective action

• No provision for hand holding, supportive supervision, or refresher

training for trainees

Child Health Training

Issues & Recommendations

Facility Based Newborn Care


Snapshot of FBNC Training

Karnataka(‘10) Madhya

Pradesh(‘09) Maharashtra(‘12) Rajasthan

Duration of

Training

3 months (till

2011-12)

4 days +

2 weeks (observership)

Training Site

(Theory) State & Private

Medical Colleges

(both at same site)

State Medical

Colleges State & Private

Medical Colleges

State Medical

Colleges

Training Site

(Observership) PGI Chandigarh KEM Mumbai

Kalawati Saran

Backlog of

observership No Yes No Yes

Trainees Mainly Contractual

MOs and SNs

Paediatricians &

SNs largely. Mix of

regular &

contractual

Permanent MOs,

Paediatricians and

SNs

Permanent

Paediatricians and

SNs

Trained

manpower

dedicated to

SNCU

Yes Yes No No

Strengthening of

SNCU Yes Yes Partial Partial

Monitoring and

Supervision Very limited Yes Very limited Very limited


FBNC Training – Issues

• Approach, Planning, and Trainee Selection

• Trainee selection and training roll out not in sync with setting up of / strengthening of SNCUs

• High attrition rates of trained personnel in states where contractual staff has been trained

• Training

• States that lack sites for conducting the observership phase of the training face huge backlog in

observership of trained personnel, especially staff nurses

• Knowledge of trained personnel was generally found to be poor when they had not completed the

observership phase

• Pediatricians are trained together along with staff nurses in the same class room sessions despite the

large gap in relative understanding between the two which makes the training less effective

• Deployment

• In some states, the trained staff was not dedicated to the SNCUs and this impacts the functioning of

the SNCUs

• Lack of AMC/CMCs at the SNCU coupled with frequent breakdown of equipment impact the capacity

to handle cases

• Poor condition of labour rooms at the site of SNCU increases the work load

• Poor diagnostic services at the District Hospital limit the ability to identify and treat diseases

• Most of the SNCUs have seen a rapid increase in case load and were admitting far more number of

sick newborn than their capacity which reduces quality

• Lack of attached ward for mothers of the new born causes problems in managing attendants

• Monitoring & Supervision

• States collect data from SNCU, but it is hardly analyzed to identify trends, draw insights, and take

corrective action

Good impact but major issues with retention of trained contractual personnel, completion of the

observership phase of the training, site strengthening and dedicated staff


FBNC Training – Recommendations


• States should plan for setting and scaling up of the infrastructure of the SNCU along with

the training

• Provide a framework for career progression to address the attrition rate of contractual staff

• Training

• Create separate batches of MOs and nursing staff for the theoretical training sessions

• States with medical colleges should plan for creating sites within the state to conduct the

observership phase of the training

• Emphasize on infection control practices at the training sites

• Deployment

• Ensure that the trained staff members are exclusively posted at the SNCUs and are not

assigned to undertake other duties

• Set up feeding rooms and step down units at all SNCUs

• Ensure that AMC/CMCs are put in place for the equipment

• Improve the condition of labour room in the hospital with SNCUs and train some staff there

to treat birth asphyxia (through SBA and NSSK training)

• Strengthen the diagnostic services in the hospital where SNCU is located

F-IMNCI


Snapshot of F-IMNCI Training

Karnataka Madhya


Uttar

Pradesh

Duration of

Training 11 days/5 days 5 days

11 days/5

days 5 days

Training Site

(Classroom)

RHFWTC,

DTC &

SIHFW

RHFWTC HFWTC

Medical

Colleges

Medical

Colleges

Medical

Colleges Training Site

(Clinical

Session)

DH &

Medical

Colleges

Medical

Colleges

District

Hospital

Trainees MOs &

SNs MOs & SNs

MOs(incl.

Ayush)&SNs

MOs, SNs,

and LHVs MOs only

MOs

only

Priority Sites

for selection of

trainees

24x7

PHCs None

RH and 24x7

PHCs None None None

Strengthening

of deployment

sites

No No No No No No

Monitoring and

Supervision No No No No No No


F-IMNCI Training – Issues


• Non-adherence to guidelines requiring prioritizing of FRUs/CHCs followed by 24x7 PHCs for

selecting of trainees

• Ineligible staff members also trained, such as Ayush doctors and ANMs/LHVs

• Training

• Pre-training meeting of trainers largely not being conducted at the training site

• Combined classroom session for MOs and SNs an issue due to wide gap in their knowledge level

and grasping abilities

• Training content is too complex for SNs

• Large batch size impacts the quality of trainer-trainee interaction

• Lack of training package in local languages makes it difficult for SNs to understand

• Lack of harmonization of content, technical terminology, and treatment guidelines across similar

trainings causes confusion

• Number of SOPs have been revised and need to be updated in the training package

• Very few training sites had clinical facilitators impacting quality of clinical sessions

• Deployment and Monitoring

• Lack of enabling environment and low case load at posting site reduces practice of skills and

impact of training

• Most trained staff fared poorly on knowledge and skill assessment

• Tracking of performance through data review and on-site monitoring is missing

The training has had very limited impact on ground due to inappropriate selection of trainees

and absence of supplementary efforts towards strengthening the facilities where they are

posted. The knowledge levels of most MO’s and staff nurses have been found to be poor.

Training has been reduced to an effort in achieving targets.


F-IMNCI Training – Recommendations


• Trainees from appropriate facilities to be prioritized and selected with simultaneous facility

strengthening efforts

• Training – Recommendations

• Hold the mandatory pre-training meeting among trainers as suggested in the operational

guidelines at every training site

• Depute a clinical facilitator at each training site to effective manage the clinical sessions for

each trainee

• Clinical and classroom session should preferably be held at the same facility to avoid

wastage of time and resources

• Conduct separate classroom sessions for MOs and SNs and simplify content for SNs

• Steps for resuscitation of newborn should be harmonized across all trainings in the training

content

• Teaching package should be translated in local language for better understanding of

trainees

• Training module should include sections covering malaria and update the sections on using

MUAC for malnutrition which is currently missing from the curriculum

• Equip trainees with large triage charts to be put up at their posting site for quick reference

• Monitoring

• Refresher sessions can be held during block monthly meeting; and regular performance

monitoring should be done


Snapshot of NSSK Training

Karnataka Madhya


Uttar

Pradesh

Duration of

Training 2 days in all states

Training Site

(Classroom) DTC

RHFWTC,

DH, Rented

Locations

DTCs and

HFWTCs

DH, Rented

Locations DH

Women

Hospital

(Dufferin)

Trainees MOs, SNs,

ANMs

MOs, SNs,

ANMs

MOs, SNs,

ANMs

MOs, SNs,

ANMs

MOs, SNs,

ANMs

MOs, SNs,

ANMs

Priority Sites

for selection of

trainees

None None None None Delivery

Points# None

Strengthening

of deployment

sites

No No No No No No

Monitoring and

Supervision No No

Recently

initiated a

monitoring

team

No

Recently

initiated

State NBCC

QA Cell

No

# Participants were found to be attached to delivery sites, but at times were not engaged in labour rooms and were posted in

outreach programs


NSSK Training – Issues

• Training

• Duration short for ANMs as they require more time to grasp the content

• Curriculum lacks practical component and largely based on theory

• Lacks hands-on training on usage of Radiant baby warmers (RBWs) and other equipment.

• Lack of harmonization of content, technical terminology, and treatment guidelines across

similar trainings causes confusion

• Quite a few training sites did not have mannequins needed for training. However, wherever

IAP trainers are involved they get the mannequins with them.

• Training material only available in English and Hindi and not available in other regional

languages

• Deployment

• When posted at sites with low delivery load or assigned field duties, trainee confidence

and skill gets eroded

• Essential inputs such as ambu bags and drugs found missing, and no power backup

meant low usage of RBWs

The quality of training has been reasonable in states with trainees using skills at sites with

adequate case load. However, erosion of knowledge when trained personnel are posted at sites

with low delivery load or assigned non labour room duties.


NSSK Training - Recommendations

• Trainee selection

• Prioritise SBA trained nurses for this training and encourage NSSK trained nurses to take

up SBA training

• Training

• Increase in duration for ANMs and LHVs by a day to help them grasp subject matter

• Introducing practical component (practice on live cases) for building trainee confidence

• Revising the curriculum and inclusion of section on equipment handling such as RBWs

• Translation of training material in local language apart from Hindi and English

• Harmonization of certain sections in training material which has been differently defined in

other child health trainings such as new born resuscitation algorithm, to avoid confusion

among trainees

• Monitoring

• Monitoring of performance through data review and onsite visits

• Regular refresher sessions during block meetings

Conclusion


To conclude …….

• Substantial effort and funds are involved in rolling out skill based

training programmes.

• While most of the training have been found to be useful by the

states and are giving some results, there is a need to ensure

that they achieve their maximum possible impact as envisioned

by the policy makers.

• It is important that states take a re-look at their selection, and

deployment strategies and work towards strengthening the

training systems and health facilities to realise the goals of

improved service delivery and quality through these skill based

training.

Thank You !


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