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Strengthening PSE for Nursing & Midwifery Cadre and Strengthening PPFP & Introduction of PPIUCD Services in India
Dr. Bulbul Sood
Inter-linkages between different interventions at various stages of the life cycle
Linking child survival to other inventions such as reproductive health, family planning , maternal health
Sharper focus on adolescents
Recognizing nurses as ‘pivots’ for service delivery
Expanding focus on child development and quality of life
INDIA’S CALL TO ACTION SUMMIT FOR CHILD SURVIVAL AND DEVELOPMENT AT MAHABALIPURUM
2
STRATEGIC APPROACH TO RMNCH+A
To strengthen the foundation of ANM/GNM education resulting in:
better prepared service providers,
higher functioning educational institutions and
ANMs/GNMs who are competent, confident and ready to work upon graduation.
Goal of strengthening PSE Program in India
3
Program Components
Improved Quality of PSE
Improved Educational Processes
(at the institutions)
Improved Clinical Practices
(at the clinical practice sites)
Strengthened Capacity of the
Faculty
(both teaching and clinical skills)
Strengthened training
infrastructure
(Class rooms, skill labs, IT)
Introduction of internship for
ANMs
4
Programmatic Approach
Strengthening of ANM/GNM
schools
MCHIP’s
TA since 2010
NNC/SNC
5
• Establishing a center of
excellence for PSE
• Strengthened to provide
training backstop and
mentoring of faculty of
ANM/GNM schools
• Direct strengthening of
ANM/GNM schools
• Establishing linkages with
NNC/SNC for sustained
performance
Strategic support for
improved planning and
management
Implementation of Educational Standards at the
NNC/SNC/ANMTCs/GNM schools
Share • Share educational
standards with the faculty
Orient • Orient faculty on educational standards
Implement • Provide technical assistance in
the implementation of standards
Strengthen • Educational processes
such as preparation of session plan etc.
6
Establishing Skill Labs
- Anatomic models
- AV aids
Strengthening of IT infrastructure
Development of quality libraries
State’s initiative for strengthening of basic infrastructure such as class rooms etc.
Strengthening Training Infrastructure
Catalytic TA to facilitate the above with NRHM and state funds
7
Strengthening Skills Lab Stations
8
Labour corner
Infection Prevention corner
Special skills corner
ANC and PNC corners
Family Planning Corner
3 Days Clinical Skills Standardization Training of Labor room staff
All health care providers of MCH area including nursing tutors are trained on • AMTSL • ENBC • NB resuscitation • Partograph • Infection prevention practices • Managing Complications like
Eclampsia and PPH
IPP Before and After Training
9
National Nodal Centre at NRS college of Nursing-Kolkata established in November 2012
Capacity Building of the Faculty: 6 weeks training at NNC Kolkata
Course Description and Evaluation methods
Knowledge: A score of at least 85% on the knowledge assessment.
Skills: Satisfactory performance of clinical skills evaluated by Objective Structured
Clinical Examination (OSCE).
Practice: Demonstrated ability to provide quality services in the clinical setting and
demonstrated good facilitation skills.
Clinical
training
• 101 tutors trained from several states since Nov 12
• 17 tutors from UK
• 23 tutors from Jharkhand
11
Clinical Skills Evaluation using OSCE N=101
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMTSL
AN Comp
ENBC
NB-R
Parto
IP Comp
PN Comp
IP
Pre Test Post test
College of Nursing developed as State Nodal Center (SNC) for improving PSE in Uttarakhand
Courses available:
• M.Sc Nursing
• B.Sc Nursing
• Post Basic Nursing
• GNM/ANM Nursing
State College of Nursing, Dehradun
• SNC certified by the INC.
• 6 weeks training of ANM/GNM faculty will be initiated soon.
13
Strengthening of State Nodal Center Quality improvement at the SNC using Performance Standards
College of nursing certified by INC as a State Nodal
20%
59%
31%
56%
38% 41%
60%
76% 77%
100%
47%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Classroom AndPractical Instruction
Clinical InstructionAnd Practice
SchoolInfrastructure AndTraining Materials
SchoolManagement
Clinical AreasWhere Student
MidwivesundertakeClinical Experience
Overall
% S
tandard
Ach
ieve
d
Area
Baseline 1st Internal A
14
Strengthening of ANMTCs in Uttarakhand
38% 45%
50% 44%
37%
84% 84%
62% 62% 63%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rani Pokhri Gaddarpur Almora Khirsu, Pauri Pithoragarh
Baseline Current Score
15
Quality improvement using the performance standards
Strengthening of State Nodal Center - Jharkhand
Quality improvement at the SNC using Performance Standards
27%
53%
31%
75% 76%
52% 60%
76%
38%
100%
47%
64%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Classroom AndPractical Instruction
Clinical InstructionAnd Practice
School InfrastructureAnd Training
Materials
School Management Clinical Areas WhereStudent
MidwivesundertakeClinical Experience
Overall
% S
tandard
Ach
ieve
d
Area
Baseline Current Score
16
Strengthening of ANMTCs in Jharkhand
26% 24%
9%
49%
31% 30%
62%
43%
53%
44%
79%
40%
88%
61%
39% 41%
49%
69%
40%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Simdega Giridih Chaibasa Hazaribagh Dumka Deoghar Dhanbad Ranchi Jamsedpur Palamu
Focus Sites Scale-up sites
Baseline Current Score
17
Quality improvement using the performance standards
High Unmet Need For Family Planning
11%
16%
34%
19%
21%
7-17 18-23 24-35 36-47 48+
In months (NFHS 3: 2005–06) N =39,215 births
18
Birth-to-Birth Intervals for Past Five Years
Unmet Need across Postpartum Period and FP Use among Sexually Active Women
Source: NFHS 3: 2005–06
N=1305 N=2374 N=2168 N=2661
0%
20%
40%
60%
80%
0-3 4-6 7-9 10-12
Modern Traditional
Unmet need to space Unmet need to limit
Total unmet need
Resurgence of Interest in Postpartum Family Planning
Government of India policy – to reposition FP as MNCH initiative
Shifting focus from terminal methods to spacing methods
JSY was bringing women to facilities for deliveries – postpartum family planning is convenient to women
19
Experience in India
Renewed effort of the GOI to focus on spacing by revitalizing use of IUD both PPIUCD and interval IUCD
MCHIP provided TA to support both demand & supply side of the equation
Developed a range of training, counseling, BCC & service support materials for the scale up of PPFP/PPIUD in the country
Staff Nurses allowed to insert PPIUCD
Rapid Expansion of PPFP Services in India
Start of PPFP/PPIUCD program in U.P. in 2009
Queen Mary Hospital, Lucknow
District Women’s Hospitals, Allahabad and Jhansi
Services Scaled Up in 19 States
UP
Uttarakhand
Jharkhand
Delhi
Haryana
Punjab
Rajasthan
Bihar
Madhya Pradesh
Assam
21
Meghalaya
Chhattisgarh
Orissa
West Bengal
Gujarat
Maharashtra
Tamil Nadu
Karnataka
Andhra Pradesh
> 200,000 PPIUCDs inserted
Donor support from USAID, Gates, Packard, NIPI
Support from national as well
as state governments during
the expansion
MCHIP Support to PPFP Program In Jharkhand
• Services initiated at all 24 district level facilities
• 5 training sites for PPFP/PPIUCD established
311 doctors and 422 staff nurses trained. Training on
– Counselling of clients
– Insertion Technique (use of Humanistic Zoe Models)
– Infection Prevention
• Post training follow-up and support by MCHIP staff
PPIUCD Experience In India Total Reported PPIUCD Insertions since Feb-2010
25252
22652 21723
13651
11586 10231
9017 7731
7042
3223 3100 2633 2091 1904 1104 1018 870 717 348
0
5000
10000
15000
20000
25000
30000
Post-placental (within 10
min) 47%
Post-partum
(within 48 hrs) 22%
Intra-cesarean
31%
N=145,893
Source: PPIUCD Monthly reports Data as on 30/10/2013
INDIA : Trend of PPIUCD acceptors
3.9% 4.2%
5.0%
5.6%
6.3%
7.7% 7.6%
6.9%
5.7% 5.7%
6.7%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
0
50
100
150
200
250
Qtr-4 Qtr-1 Qtr-2 Qtr-3 Qtr-4 Qtr-1 Qtr-2 Qtr-3 Qtr-4 Qtr-1 Qtr-2
2010 2011 2012 2013
% A
ccepto
rs
Ave
rage F
aci
litie
s
Quarter
Average facilities reported data % Acceptors
% of PPIUCD acceptors is sustained
at 6-7% even after rapid scale up of
services to many new sites
State-wise Follow-up Rates at 6 Weeks (%) (Based on
Jan 11- Sep 13 Data)
122%
103%
70% 68% 64%
57% 56% 49% 48%
41% 35% 34% 34% 32% 32%
27% 27% 27% 25% 24%
N=140,924
Source: PPIUCD Monthly reports Data as on 30/10/2013
Follow-up Findings (Based on Jan-11 to Sep-13 Data)
2.75%
1.51%
4.41%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
Expulsion Infection Removal
N=57,339
Source: PPIUCD Monthly reports Data as on 30/09/2013
Trend of PPIUCD Insertion - Jharkhand Training sites-6 and Service Delivery sites -36
(Mar-10 to Sep-13)
Method Mix of long acting methods: Jharkhand
Innermost to Outermost Ring 1: Oct 12-Dec 12 Ring 2: Jan 13- Mar 13 Ring 3: Apr 13- June 13 Ring 4: Jul 13- Sep 13
(Oct-12 to Sep-13)
Trend of PPIUCD Insertion - Uttarakhand Training sites-2 and Service Delivery sites -44
0
5
10
15
20
25
30
35
40
45
50
Oct
Nov
Dec
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
2010 2011 2012 2013
0
200
400
600
800
1000
1200
Month
Num
ber
of fa
cilit
ies
Num
ber
of PPIU
CD
Number of facilities Number of PPIUCD insertions
(Mar-10 to Nov-13)
Method Mix of long acting methods: Uttarakhand
32% 25%
48% 44%
39%
Male Sterilization
Female Sterilization
Interval IUCD
PPIUCD
Innermost to Outermost Ring 1: Oct 12-Dec 12 Ring 2: Jan 13- Mar 13 Ring 3: Apr 13- June 13 Ring 4: Jul 13- Sep 13 Ring 5: Oct 13 – Nov 13
(Oct-12 to Nov-13)
81%
11%
8%
2010-11 $ 3,316,300
45%
22%
3% 4%
26%
2011-12 $ 4,406.291
25%
14%
1% 5%
55%
2012-13
USAID BMGF Norway (II) Packard Foundation Govt of India
$ 7,971,837
LEVERAGING RESOURCES: Involvement of multiple donors, increased funding from GoI
Thank you