strengthening family planning and pre-service...
TRANSCRIPT
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Strengthening Family Planning and Pre-Service Nursing and Midwifery
Education in India
Dr Bulbul Sood September 18, 2012
Courtesy: HIP
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Revitalizing PPFP/PPIUCD services
Presentation Outline India need and
opportunity How PPFP/PPIUCD
services were initiated and scaled up
Lessons learned
2
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Source: World Population Prospects: 2008 Revision Population Database UN Population Division
10 Most Populous Countries in the World Population (Millions)
Year 2008 Year 2030
Japan (127.7)
Russia (141.9)
Bangladesh (147.3)
Nigeria (148.1)
Pakistan (172.8)
Brazil (195.1)
Indonesia (239.9)
USA (304.5)
India (1149.3)
China (1324.7)
Philippines (124.4)
Russia (128.9)
Bangladesh (203.2)
Brazil (217.2)
Nigeria (226.7)
Pakistan (265.7)
Indonesia (271.5)
USA (370.0)
China (1462.5)
India (1484.6)
…In next 20 years, India will be the most populous nation in the world
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Half the population growth will be in seven northern states
Source: Registrar General of India, 2006 (Population Projections for India and
Projected population of India: 2001-2026 Share of additional 371 million
Uttar Pradesh 22%
Uttarakhand 1%
Bihar 8%
Jharkhand 3%
Madhya Pradesh
7% Chhattisgarh
2%
Rajasthan 7%
Orissa 2%
Four Southern States 13%
Rest of the Country
35%
Southern states will contribute only 13% of growth
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High unmet need…..
11%
16%
34%
19%
21%
7-17
18-23
24-35
36-47
48+
In months (NFHS 3: 2005-06) N =39,215 births
5
Birth-to-birth Intervals for past five years
Unmet Need across Postpartum Period and FP use among Sexually Active Women
0%
10%
20%
30%
40%
50%
60%
70%
80%
0-3 4-6 7-9 10-12
Modern Traditional Unmet need to space Unmet need to limit Total unmet need
Source: NFHS 3: 2005-06
N=1305 N=2374 N=2168 N=2661
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Source: DLHS-3 (2007-08), IIPS Mumbai
Current use of Family Planning Methods
Gap in service delivery…..
Female Sterilization
34%
Male Sterilization
1%
Pill 4%
IUD 2%
Condom 6%
Any Traditional method
7%
Non user 46%
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Resurgence of Interest in the PPFP/PPIUCD GoI policy to reposition FP as
MNCH initiative JSY was bringing women to
facility-Immediate postpartum insertion is convenient for women
New advances and new understanding about PPIUCD
IUCD as spacing and long term reversible method-alternative to sterilization for many couples
0.743.16
7.33 9.08
10
42%
57%
84%88% 90%
0.00
2.00
4.00
6.00
8.00
10.00
12.00
2005-06 2006-07 2007-08 2008-09 2009-10(prov.)
No.
of B
enef
icia
ries
(mill
ion)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage Against Total D
eliveries
7
JSY PERFORMANCE: 2005-10
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PPIUD: Quick Facts Insertion times: Post placental:
• 10 minutes after delivery of placenta
Immediate post partum • within 48 hours after delivery
Intracesarean • During cesarean section
Interval / Delayed post partum • 6 or more weeks after delivery
Insertion Techniques: Instrumental
8
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Review of safety of PPIUD Cochrane database review, updated 2010
Safe and effective Advantages: Mother: high motivation and convenience Provider: assurance woman not pregnant
No differences between manual and instrumental insertion
Few contraindications Expulsion rates higher than with interval Feasible: PPIUD insertion popular in
diverse countries; China, Mexico, Egypt Early follow-up important in identifying
spontaneous IUD expulsions
9 Grimes D, Schulz K, van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices. The Cochrane Database of Systematic Reviews 2010, Issue 1
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PPIUCD Program Requirements
10
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Service Delivery Tools Training material, including
an insertion animation video Kelly’s Forceps & Job Aids
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Client Education Material & Data Collection Registers Posters & Films Leaflet and Follow Up Card
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Strengthening Counseling and giving Choices to women………..
Counseling done on ALL methods including LAM, FABM, Injectables, PPIUCD etc. ANC During early stages of labor (PPIUCD) In the postpartum period while in the
hospital Pre-discharge counseling
Choice is verified before IUCD
is inserted Counseled on return visit
13
•Counselors hired/being hired •Several sites are using PMTC counselors
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Rapid expansion of PPFP/PPIUCD services in India Start of PPFP/PPIUCD program in U.P. in 2009 Queen Mary Hospital,
Lucknow 7 Faculty trained as trainers
– 1 from each unit ALL Ob/Gyns and residents
(59) oriented Providers from District
Women’s Hospitals - Allahabad and Jhansi trained
Now scaled up to 19 states UP Uttarakhand Jharkhand Delhi Haryana Punjab Rajasthan Bihar Madhya Pradesh Assam
14
Meghalaya Chattisgarh Orissa West Bengal Gujarat Maharashtra Tamil Nadu Karnataka Andhra
Pradesh >55,000 PPIUCD inserted
Donor support from USAID, Gates, Packard, NIPI, UNFPA
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Number of PPIUCD Insertion Reported (Feb-10 to May-12)
15249
8004
6368
4273
2796 2387 2184 1537 1376 1361 1145 874 714 688 631 582 413 34 33
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Num
ber o
f PPI
UC
D in
sert
ions
State
15
N=50,649
As on 04/07/2012 PPIUCD insertion data received from other facilities of Delhi included
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State wise PPIUCD Acceptors by Type (Feb 10 – May 12)
15249
6368
4273 3583
2796 2387 2184 1537 1376 1361 1145 874 714 688 631 582 413 34 33
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Post Placental Intra cesarean Post partum N=46,228
Post Placental
43%
Intra cesarean
36%
Post partum 21%
As on 04/07/2012
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PPIUCD Insertion by Type Top 20 facilities Jan-2011 to May-2012
4699
2718 2335 2253 2211
1790 1707 1323
1080 1075 1040 850 848 842 782 710 680 673 579 574
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Post Placental Intra cesarean Post partum N=28,769
As on 04/07/2012
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Proportion of PPIUCD Acceptors among institutional deliveries Jan-2011 to May-2012
23% 19%
11% 10% 8% 8% 7%
5% 5% 4% 4% 4% 3% 3% 3% 2% 2% 2% 1% 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Total Deliveries -6,20,722 Total Insertion-41,259
As on 04/07/2012
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PPIUCD Follow-up Rates by State (Jan 11 to May 12)
100%
79%
65% 64% 62% 60% 57% 57% 55% 53% 48%
44% 43% 39% 38%
28% 25% 21% 21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%N- 41,259
As on 04/07/2012
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% PPIUCD acceptors by type of delivery (Jun 11 to May 12)
0%
5%
10%
15%
20%
25%
30%
35%
State
% Intra-cesarean PPIUCD % Post-vaginal PPIUCD (Post-placental + Post-partum)
20
Intra-cesarean PPIUCD: 8% of cesarean deliveries (n= 1,64,550) Vaginal PPIUCD: 6% of vaginal deliveries (n=376219)
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Follow-up findings (Jan-2011 to May-2012)
No Complaint 89%
Missing String 4%
Expulsion 2%
Infection 1%
Other Complaint 4%
N=19,956
N=Total number of Follow-up As on 04/07/2012
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Lesson learnt in Use of PPIUCD
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Advocacy at National and Regional level for PPFP/PPIUCD
23
Contraceptives and Beyond, Jaipur, May 26-27, 2010
AICC-FOGSI conf, Kolkata, Feb 26-27, 2010
10th World Congress on RCH, Nagpur, Sept 2010
Annual Bihar Ob/Gyn Society’s Conference, Patna, Dec 4-5, 2010
FOGSI-FIGO International Congress on Recent Advances in Ob/Gyn. Mumbai, April 8-10, 2011
International Congress on Contraception, Kolkata, May 6-8, 2011
Addressing concerns around safety of Postpartum IUCD critical to the success…
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PPIUCD Side Effects/Complications
Perforation: Entire world literature does not report ANY
perforations when inserted at correct time Uterine wall very thick, and PP uterus
responsive to oxytocin Infection: Large series (more than 1000 patients) show
infection rates of less than 1% No need for prophylactic antibiotics
Increased cramping and bleeding: Masked by normal postpartum symptoms
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Expulsion Rates Are Related to Provider
To reduce expulsion: Use correct technique
• place all the way at fundus • sweep instrument to the side • take care that IUCD does NOT
come out during withdrawal Use correct instrument
• Kelly placental forceps (curved, longer) may be better than ring forceps
Insert at the correct time • postplacental is better 25
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What should be done while scaling up the PPFP/PPIUCD Program ? Institunalize the PPIUCD services Scale up training of all providers within the facility to provide services
competently, according to established standards Place emphasis on ensuring quality of services including IP practices Build up good client caseload Ensure training management and monitoring is in place
Strengthen Systemic Counseling Counseling training on PPFP/PPIUCD of all providers especially nurses Equip facilities with counseling job aides and support use of IEC Materials Promote use of AV material in outdoor waiting area Involve CBWs (AWW, ASHA) to create awareness about PPFP/PPIUCD
Strengthen follow-up system Establish a follow-up mechanism and regular monitoring of ALL CLIENTS Regular systemic review of service data to further strengthen the services
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Future Plans….
GOI to scale up PPIUCD services in all 150 districts in high focus states of Bihar, UP, Jharkhand, Rajasthan, MP and Chattisgarh
Orientation and clinical trainings of providers (Doctors and Nurses) and other stakeholders
Hiring and training of FP Counselors at the facilities
Supportive Supervision for the provision of Quality services and follow-up 27
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Introduction of PPFP/PPIUCD services among the Sathiya Network of Private Providers
Strategy: To develop 5 Clinical training sites for the 7 cities
UP- Lucknow, Barabanki, Agra, Allahabad & Varanasi UK- Dehradun & Haridwar
To support master trainers for the clinical trainings of Sathiya providers for PPIUCD services
In collaboration with MBPH, provide TA to introduce PPFP/PPIUCD services among the identified Saathiya providers
29
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Saathiya Programmatic Approach for Trainings
30
Existing Public Sector Training Sites (Uttarakhand)
Training Site 1 Lucknow
Private Providers of Lucknow &
Barabanki (83)
Training Site 2 Allahabad
Private Providers of Allahabad (31)
Training Site 3 Varanasi
Private Providers of Varanasi (24)
Training Site 4 Agra
Private Providers of Agra (61)
Training Site 5 Dehradun
Private Providers of Dehradun & Haridwar (34)
Training of trainers from the private
sector at this training site
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Developed BCC materials, in association with the MBPH team, for use by the Saathiya Network
Included PPFP/PPIUCD counseling in Saathiya Helpline (a toll free call center)
Provider’s Leaflet Poster Flipbook for Counselors
Demand Generation:
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Developed Client Card for recording PPIUCD services, including follow-up visits
Integrated reporting of PPIUCD Services into the existing online Saathiya reporting mechanism
32
Online Service Reporting Format Client Card
www.hamjoli.net/ppiucd/net
Establishment of Recording/Reporting System
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Total No of Doctors Trained
Insertions Jan 12
Insertions Feb 12
Providers Initiated Services (Based on till March Report)
234 149 135 51
33
Established 5 PPFP/PPIUCD Training Sites
3 Sites established by August and 2 Sites by Dec 11
3 Sites initiated training in Sept. 11 and 2 in Jan. 12
Developed 11 trainers
Note: None of the private providers were providing PPIUCD Services before intervention
Collaborated with DKT India, IUCD manufacturer to provide CuT-380A at concessional rate
Outcome:
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Jharkhand: Strengthening FP services at targeted facilities in 3 focus districts
Target facilities: 3 District Hospital and 9 CHCs Building Capacities
1093 Drs/nurses/ANMs trained on CTU 267 participants trained in FP Commodity Storage & Management Infection Prevention & FP Counseling Training for Interval IUCD
Implementation of standards by SBM –R approach and onsite support Strengthen Counseling & IP practices Reorganization of MCH Centre for privacy for Counseling and IUCD
Insertion Supported development of FP clinical training strategy for the state of
Jharkhand
(Focus Districts: Chaibasa, Simdega and Giridih)
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28% 28%
96%
34% 49%
35%
90%
60%
83%
36% 28%
38%
0%10%20%30%40%50%60%70%80%90%
100%
Bag
odar
, CH
C
Dum
ri, C
HC
Dis
trict
Hos
pita
l
Raj
dhan
war
, CH
C
Ban
o, C
HC
Kol
ebira
, CH
C
Dis
trict
Hos
pita
l
Thet
haita
ngar
, Ref
eral
Hos
pita
l
Dis
trict
Hos
pita
l
Cha
kada
rpur
,S
ubdi
visi
onal
Hos
pita
l
Maj
hgao
n, R
efer
alH
ospi
tal
Man
ohar
pur,
CH
C
Giridih (April 2012) Simdega (Jan 2012) Singhbhum West ( April2012)
Jharkhand: % achievement in the FP services performance standards
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Jharkhand: Use of contraceptive methods in 3 selected district hospitals
Permanent methods Spacing methods
0
547
126 236
483
1978
255
586
PPIUCDInsertion
IntervalIUCD
OP Cycle ClientsdistributesCondoms
2010 2011
36
5512 1742
31057
8411
FemaleSterilization
Male Sterilization
2010 2011
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Target facilities: 8 facilities (2-Ranchi and 6 facilities in the 3 focus districts) Capacity Building
> 70 providers trained on PPFP/PPIUCD Training including Counseling and IP
Training Site: RIMS & Sadar Hospital Ranchi developed as training sites
Successfully introduced PPFP/PPIUCD services at all the target facilities
Strengthened supportive supervision and follow-up of clients Supported use of IEC/BCC material Supporting scale-up of PPFP-PPIUCD services throughout State (6
facilities in each District)
Jharkhand: Introduction of PPFP/PPIUCD Services
(Focus Districts: Chaibasa, Simdega and Giridih)
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Jharkhand: Total number of PPIUCD insertion Oct 10 to May 12
0
20
40
60
80
100
120
140
160
180N=1497
*Data from facilities- Ranchi-2, Focus districts-11
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Jharkhand: FP integrated activities
To introduce PPFP/PPIUCD services in target facilities in Dist. Jamtara and Deoghar Successfully introduced PPFP/PPIUCD services in District Hospital Jamtara
and Deoghar Strengthened the PPFP counseling Recording reporting system IEC/BCC
Strengthened the FP service delivery at six facilities (Deoghar-3; Jamtara-3) Conducted CTU, Infection prevention practices, PPFP counseling
training for the providers Initiated pilot study on introduction of Postpartum FP screening
tool in Kolibira block in Dist. Simdega Completed baseline data collection and implementation of tool under
progress
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Jharkhand: Scale up activities
FP quality improvement process has been scaled up to additional 21 District Hospitals Disseminated the FPSD performance standards and
SBM-R process Providing strategic support to scale-up PPFP/PPIUCD in
all 21 District Supported training of providers from Dist. Hospital on
PPFP/PPIUCD clinical training Supported PPIUCD insertion forceps and data
recording registers
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Uttarakahnd: Strengthening FP services at UHCs in Dehradun and Haridwar
Adaptation of FP Performance Standards Building Capacities
60 Drs/ANMs trained on CTU, Interval IUCD insertion & Infection Prevention 73 Drs/ANMs/Community Mobilizers trained on FP Counseling
Reorganization of UHC for privacy for Counseling and IUCD Insertion Strengthening Counseling & IP practices Scaled-up the strengthening in 3 additional UHCs in Haldwani District
0%10%20%30%40%50%60%70%80%90%
100%
Kanw
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Baseline Assessment-3
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Uttarakhand: Family Planning Service Delivery Status UHCs
Family Planning services
PRE INTERVENTION -2010
POST INTERVENTION-2011
Oct Nov Dec Total Oct Nov Dec Total
Female Sterilizations - Referrals 0 0 9 9 0 25 35 60
Male Sterilizations- Referrals 0 0 2 2 0 2 20 22
OP cycles distributed 93 92 206 391 566 591 838 1995
CCs distributed 6570 10340 8910 25820 18380 16063 18087 52530
Interval IUCDs Inserted 11 2 6 19 47 74 141 262
Others- EC Pills 0 0 0 0 87 113 100 300
Women counseled for FP (ANC/FP clinics) 0 0 0 0 987 777 1350 3114
* 980 IUCDs inserted from May 2011- May 2012
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Women’s Hospital DDN ,Haldwani and SMIH developed as service delivery & training sites
Providers from 11 additional sites trained for PPIUCD services and 10 established as service delivery sites
Total 105 Providers trained till date (54 Doctors and 51 Nurses). 50 doctors have initiated the services.
1508 PPIUCD insertions from April 2011 till May 2012
993 women (66%) followed up till date. 5% expulsion rate.
Supported scaleup of PPFP/PPIUCD services in additional 10 facilities of Uttarakhand (2 Medical College, 2 district hospital and 6 combined hospital)
Uttarakhand : Introduction of PPFP/PPIUCD Services
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Uttarakhand: Introduction of PPFP/PPIUCD services
Month wise Follow up
14 25 26 26
33
53
76 75 81
51
91
114 115
153
Follow up Finding N=993
No Problem
83%
Missing String
3%
Other Complain
ts 8%
Expulsion
5%
Infection 1%
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Uttarakhand: Strengthening of SBA Training Sites
Supported strengthening of 10 existing SBA training Sites and development of 7 new sites Conducted 3 day refresher training for the SBA trainers
from existing sites Conducted SBA ToT for developing SBA trainers at 7
new sites Conducted Clinical Skills Standardization training to
strengthen SBA training site linked clinical practice site Supported development of SBA training plan
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Uttarakhand: Strengthening of SBA Training Sites
90.5% 95.9%
87.8% 85.1%
78.4% 91.9% 91.9%
70.3% 70.3%
58.1% 83.8%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Female Hospital DehradunDistrict Hospital, Rudrapur
Combined Hospital RishikeshFemale Hospital Almora
District Hospital UttarkashiFemale Hospital Haldwani
District Female Hospital PauriCombined Hospital Ranikhet
Female Hospital, HaridwarBase Hospital, Almora
WH, Pithoragarh
83.8%
87.8%
89.2%
83.8%
83.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Combined HospitalKotdwar
CHC Karanprayag
CHC Agustyamuni
DH Bageshwar
CHC Lohaghat
Baseline 1st Internal Assessment
New
Site
s Ex
istin
g Si
tes
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UP- Strengthening of Divisional Clinical Training Centers
Development of Performance Standards
Capacity Building Clinical Training Skills training for
identified Master Trainers of DCTCs
Facilitated Roll out of Clinical Training Skills course for all the teaching staff at the 10 DCTCs
Continued supportive supervision for implementation of standards
Strengthened system of proper record keeping and feedback mechanism
0%10%20%30%40%50%60%70%80%90%
100%
DCTC Standards Assessment Baseline Assessment Percentage1st Quarterly Assessment Percentage2nd Quarterly Assessment Percentage
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Developed Postpartum Family Planning (PPFP) Counseling LRP
Capacity Building > 50 providers trained on PPFP/PPIUCD
Training including Counseling and IP Use of IEC/BCC material Supported compilation of PPFP/PPIUCD
videos with other FP TV spots to be used for demand generation for FP services
Over 1500 PPIUCD insertions done Strengthen supportive supervision
and follow-up of clients
UP: PPFP/PPIUCD Services introduced at 4 facilities (2-Lucknow, 1- DWH Jhansi and Allahabad)
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Services scaled up to 13 new sites 53 Service providers from the new
sites trained, sservice provision started in 11 sites
Monitoring visits made by MCHIP to all except 1 site (Gorakhpur) for strengthening of services.
PPIUCD Coordinators/nurses trained on PPFP/PPIUCD counselling; kits provided to all sites
Appropriate display of IEC material ensured in each facility
UP: Scale-up of PPFP/PPIUCD Services at 13 facilities (5-Medical College, 8 - DWH)
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Strengthening Pre-Service Nursing and Midwifery
Education
Courtesy: HIP
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Goal and Objectives: Pre-Service Education
Goal: Strengthening PSE for the Nursing and Midwifery cadre by supporting the national initiative of the Indian Nursing Council
Objectives: At national level - Establishment of National Nodal Centers At state level: Strengthening select ANMTCs in Jharkhand & Uttarakhand Facilitating up-gradation of School of Nursing, Agra to College of
Nursing Training of ANMTC tutors in clinical and teaching skills at the nodal
centers
51
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National level activities: Pre-Service Education
Five Colleges of Nursing have been identified as the National Nodal Centers (NNCs) of excellence for Pre-Service Education (PSE)
(Christian medical college, Vellore, St.Stephens, Delhi, Nil Ratan Sarkar Medical College, Kolkata, Christian Medical College, Ludhiana and Government College of Nursing, Vadodara)
A national technical advisory group for strengthening of PSE formed and performance standards for use by the NNCs developed.
Sections Areas Number of
Standards
1. Class room and practical instruction 15 2. Clinical instruction and practice 17 3. School infrastructure and training
materials 13
4. School management 16 5. Clinical site practices 20
TOTAL 81
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Achievement: Implementation of Educational and Clinical performance standards
National level activities: Pre-Service Education
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Operationalization of NNC-Kolkata Developed a learning Resource
package for 6 weeks ANMTC faculty training .
Strengthened NNC –Kolkata (Skills Lab, Computer lab and Library )
Conducted 3 days CSS workshop for clinical practice site strengthening
Developed 15 master trainers in all NNCs (10 days ToT for 6 weeks ANMTC faculty training)
3 batches of 6 weeks ANMTC faculty was done
Inculcated mentorship visit to trained ANMTC faculty from NNC
National level activities: Pre-Service Education
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TA to GoI/INC-Successes
Supported the development of roadmap for the strengthening PSE for nursing midwifery cadre in the country, using the program model initiated by MCHIP.
GoI is setting up 10 state nodal centers in 10 high focus states
Leveraged resources from GoI/Other donors.
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Development of Educational and Clinical standards
ANMTC faculty trained on Teaching skills Skills lab & Library strengthened students record keeping, evaluation
modalities firmed-up Development of resources/tools in Hindi
for strengthening of ANMTCs: Cumulative record for ANMs Learning guides / Checklist for MNCH
procedures and lesson plan Practical record book Teacher evaluation formats for ANM
faculty
Jharkhand: Strengthening Pre-Service Nursing and Midwifery Education at ANMTCs
(Focus Districts: Chaibasa, Simdega and Giridih)
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ANMTC at Work
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Jharkhand: Quality improvement at the ANMTCs of 3 focus districts
58
Performance Improvement in ANMTC Standards
0%10%20%30%40%50%60%70%80%90%
100%
Simdega Gridih SinghbhumWest
Simdega Gridih SinghbhumWest
Clinical Educational
Baseline 1st IA 2nd IA 3rd IA 4th IA 5th IA 6th IA 7th IA
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Adapted Educational and Clinical standards ANMTC faculty trained on Effective Teaching skills Workshop on Clinical Practice Update for ANMTC Tutors and
participants from ANMTC linked clinical practice On site/Whole site training on Counseling and IP conducted for
Clinical Practice Site Skills lab & Library strengthened Scaled-up the intervention to additional 3 ANMTCs
Uttarakhand: Strengthening Pre-Service Nursing and Midwifery Education at ANMTCs (Ranipokhri; Gadarpur)
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Skill Labs-ANMTC
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Library-ANMTCs
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Uttar Pradesh: Up-gradation of School of Nursing at Agra
Civil Work: Work under progress. Skills Lab , Library and Computer Lab: Civil work for Skills lab under
progress. Computer lab & library started Human Resource: Provided INC guidelines, Process of sanctioning of
positions under process from DGME Budget: Facilitated saction of Rs 4.5 Crores from INC for up-gradation Stakeholders Meeting: 2 meetings conducted under chair of DGME (2nd
Meeting held on 22nd June 12) NOC from INC, SNC and GoUP: Consent letter received from SNC, Inspection
conducted by INC; disallowed the permission due to lack of adequate staff University Affiliation: Initiated
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Thanks