Operational Guidelines for Sustainability of Family Planning Training Units in Punjab and Sindh
January 2019
Table of Contents List of Contributors ...... 3 Introduction ...... 5 Background ...... 5 Definition of Operational Guidelines ...... 6 Family Planning Training Units ...... 6 Table 1: Location of FPTUs in Punjab and Sindh ...... 7 Composition of FPTU ...... 7 Organizational Structure (Organogram) ...... 8 Standard Operating Procedures ...... 8 1: Facility level ...... 8 Availability of Materials/Models and Equipment...... 9 Enabling Work Environment ...... 11 2: Provincial level ...... 11 Strengthening procurement process of FP commodities and supplies ...... 11 Budget Allocation for maintenance and procurement ...... 11 Budget allocation for Trainings ...... 12 Improving Monitoring, Evaluation and Accountability ...... 12 Work plans: ...... 12 Accreditation ...... 12 Selection Criteria for Trainers, Trainees and Facility...... 12 Terms of Reference for Selection Criteria: ...... 13 Regular Meetings ...... 14 Annex 1: Standard List of Items Required to Establish FPTU ...... 15
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List of Contributors No. Name Designation Organization/Department 1. Dr. Fauzia Assad Country Director Jhpiego
2. Dr. Sadaf Gull Training Coordinator Jhpiego 3. Dr. Afshan Ameen Provincial Program Manager Jhpiego
4. Dr. Ashfaque Memon Provincial Program Manager Jhpiego
5. Mr. Saadat Hussain M & E and FP Compliance Jhpiego Khokhar Manager 6. Dr. Bushra Amjad POC Jhpiego
7. Dr. Afshan Tahir POC Jhpiego 8. Ms. Misri Bano Senior POC Jhpiego 9. Ms. Kiran Munawar POC Jhpiego 10. Mr. Haider Safdar M & E Officer Jhpiego Abbasi 11. Dr Bushra Khan Senior Registrar Holy Family Hospital, RWP 12. Dr Anila Nosheen Senior MO Lady Willingdon Lahore 13. Dr Raana Mazhar Chief Consultant Gynecologist Lady Aitchison Lahore 14. Dr Noreen Asghar Director PME PWD
15. Dr Abdul Rehman FC HQ SHCMED Department of Health 16. Dr Ayesha Qureshi Deputy Secretary (Tech) PWD 17. Dr Sara Nawaz DMS Administration 18. Shazia Nadeem Dy DPWO (C&T) PWD 19. Dr Atiqa Imran CMO PWD
20. Dr Fauzia Syed MS Lady Aitchison Lahore
21. Dr Sidra Munir WMO/DMS Lady Aitchison Lahore
22. Dr Asma Ehsan AMS Holy Family Hospital, RWP 23. Dr Nailah Akhtar Director (Tech), Population PWD Welfare Department. 24. Dr Fazeela Shahzad Asst Professor FJMU/GRH
25. Dr Rubina Sohail Professor of OB/GYN SIMS/SHL 26. Mr. Shahid Nusrat DPWO Lahore PWD
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No. Name Designation Organization/Department 27. Ms. Abida Javaid RA PSPU
28. Dr. Tayyaba Wasim Professor of OB/GYN SIMS/SHL
29. Dr. Amna Zia Eusaph Assistant Professor KEMU/ LWH 30. Dr. Haris Ahmad Head of SUKH Aman Foundation
31. Dr. Talib Lashari Technical Advisor CIP Cell
32. Mr. Irfan Hussain Coordinator CIP Cell 33. Dr. Shoaib-un-Nisa Assistant Professor, Ghulam Muhammad Mahar Medical College, Sukkur 34. Dr. Waqar Ahmed Additional Director Public DOH Health 35. Dr. Ghayas Sanjarani Assistant Director RCH DOH 36. Dr. Mohammad Moosa Assistant Director DOH Qazi 37. Dr. Khadija Bano HOD Ward -9 JPMC 38. Dr. Haleema Yasmeen HOD Ward-8 JPMC 39. Dr. Ishrat Saba WMO Qasimabad Hospital, Sindh 40. Dr. Shabnam Parveen Consultant Gynecologist JIMS –Jacobabad 41. Dr.Lubna Baig Professor of OB/GYN AIPH –JSMU)
42. Dr. Nighat Shah Consultant AIPH 43. Mr. Mehjabeen Consultant AIPH Musharraf 44. Dr. Muneera Junaid Consultant SGH Saudabad 45. Dr. Ashfaque Shah Director General PWD 46. Ms. Nasreen Ghouri Director ME&R PWD
47. Mr. Muzaffar Qureshi Manager Operations CIP PWD 48. Mr. Zahid Baig Assistant Director PWD
49. Dr. Shama Iftikhar Deputy Director RHS PWD
50. Dr. Amber Gaba Principal RTI PWD
51. Dr. Irshad Begum Senior Instructor PWD
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Introduction The Maternal and Child Survival Program (MCSP) is a global, USAID Cooperative Agreement to introduce and support high-impact health interventions with a focus on twenty four, high-priority countries, including Pakistan. The Program is led by Jhpiego in collaboration with a consortium of lead and partner organizations.
The agenda of MCSP in Pakistan is to engage Federal Ministry of Health, Regulations and Coordination, Provincial Departments of Health, Population Welfare Department, Planning & Development, Provincial Integrated and Vertical Health Programs, research institutions, health facilities, healthcare providers and community health workers in adopting and accelerating evidence based approaches to accelerate uptake of family planning services in Pakistan. The Program has been implementing multi-faceted activities, which are designed to increase access to family planning services in three provinces of Pakistan namely Punjab, Sindh and Baluchistan, especially concerning Long Acting Reversible Contraceptives (LARCs). The Program has been supporting the Provincial Departments of Health and Population Welfare to achieve FP2020 goals.
The Maternal and Child Survival Program is:
• Developing collaborative partnerships to create environment for enhanced family planning service delivery by engaging Population Welfare and Health Departments at Provincial and District Levels • Raising standards of quality in family planning service provision by building service providers’ learning and performance in service provision • Ensuring adherence to family planning compliance regulations, especially informed choice and voluntary choice Background Making family planning services financially sustainable over a long term is an increasing challenge, given the growing number of users and competition for scarce resources by other health and development programs. One route to sustainability is increasing the cost-efficiency of services. Managers can learn to use cost-revenue analysis tools to understand how staffing patterns, the service mix, service practices, and procurement contribute to the cost of delivering services. LARCs can contribute to cost efficiency by minimizing resupply and number of visits. When making such changes, however managers must be careful not to erode the quality of care or reduce access to services. Unless staff are given adequate resources, training, and supportive supervision, the quality of care may suffer. High quality of care can encourage potential family planning clients to seek out, adopt, and/or continue using contraception Quality of care depends on offering clients a full range of methods, giving them accurate and complete information, choice of method, technical competence of providers and client focused or individualized services
Empirical evidence generated from Pakistan reveals that more than 47% of clients (Khan and Khan 2012) go to private practitioners for seeking family planning services. The time is right to take private sector onboard for enhancing access, effectiveness and quality in provision of family planning services. The private sector needs to be acknowledged for the important role that they are playing in the health delivery system and family planning program of the country and to emphasize how their role is contributing to the to the
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Currently, Population Welfare and Health departments work as two independent units with very little if any integration between them. One of the major challenges for the provincial government is to find a way to integrate these departments to ensure an effective and sustainable family planning program.
According to WHO, there should be a minimum of twenty three doctors, nurses and midwives for a catchment population of 10,000 in order to deliver essential maternal and child health services. Pakistan is reported to have 9.6 doctors and 4.9 nurses and midwives (14.5 providers cumulatively) for a catchment population of 10,000. According to WHO (2016), currently, there is a deficit of about 7.2 million skilled health professionals worldwide. A projection model driven by population growth would lead to a global deficit of about 12.9 million by 2035. This is crucially alarming and suggests that in order to meet this deficit, Pakistan must focus to increase recruitment and trainings of health providers. In the Pakistan context, more mid-level providers such as LHWs, LHVs, CMWs, FWCs, and Nurses need to be recruited and trained with special emphasis on competency based training and quality of service delivery. These providers may provide primary healthcare services, including family planning; thereby bridging the gap identified by WHO for the catchment population.
Jhpiego in its endeavor to bridge the gap setup Family Planning Training Units in various hospitals to help as resource centers to provide quality based training. The operational guidelines will help in the setting up, appropriate utilization and smooth functioning of the family planning training units. Definition of Operational Guidelines Operational guidelines describe the processes and procedures that staff in the Department follow when carrying out their work. These guidelines will act as an umbrella over service delivery guidelines and also assess the impact and quality of the whole process. When an organization/department implements operational guidance, the organization/department sets standards for operating procedures within the organization. These standards will depend on the goals and operational tasks of the department. Family Planning Training Units Family Planning Training Units (FPTUs) are resource centers at the facilities of Health Department. These training units are expected to deliver high quality, competency-based comprehensive family planning trainings that meets international standards.
Jhpiego established Family Planning Training Units (FPTUs), prior to initiation of MCSP, under various projects to build a more resilient infrastructure for family planning trainings in Sindh and Punjab. These Units, 12 in Punjab and 10 in Sindh, were fully equipped and established to facilitate the routine training courses on family planning provided by Provincial department of health and population welfare department. The FPTU utilizes the infrastructure and platform of the facility to link training to service delivery. The linkage allows learners to practice on model and also in a live setting thus linking on site simulation and actual clinical practice.
FPTUs were assessed to determine strengths and weaknesses, with a special focus on critically assessing the sustainability of these units without any donor-dependent financial and/or technical support. A consultative meeting was held in both Punjab and Sindh to share the findings with the key stakeholders, Page | 6 to find a way forward for sustaining and utilizing these FPTUs, and to develop operational guidelines for smooth functioning of FPTUs.
Table 1: Location of FPTUs in Punjab and Sindh S.no FPTUs in Punjab S.no FPTUs in Sindh
1 Holy Family Hospital , Rawalpindi 1 Lady Dufferin Hospital (LDH), Karachi
2 Lady Aitchison Hospital, Lahore 2 MCH Korangi # 5, Karachi
CMW School , DHQ Hospital, Mandi Liaquat University of Medical & Health 3 3 Bahauddin Sciences (LUMHS) Hyderabad
APPNA Institute of Public Health (AIPH), 4 Lady Willingdon Hospital , Lahore 4 Karachi
5 Nishtar Hospital, Multan 5 MCH Saudabad, Karachi
6 DHQ Hospital, DG Khan 6 MCH Landhi SESSSI, Karachi
7 Services Hospital, Lahore 7 Regional Training Institute, PWD, Karachi
Ghulam Mohammad Mahar Medical College 8 CMW School , Sargodha 8 (GMMMC) Hospital, Sukkur
Bahawalpur Victoria Hospital, Rai Bahadur Udhawdas Tarachand (RBUT) 9 9 Bahawalpur Civil Hospital, Shikarpur
Jacobabad Institute of Medical Sciences 10 DHQ Hospital, Sahiwal 10 (JIMS), Jacobabad
11 Allied Hospital , Faisalabad
12 DHQ Hospital, Gujranwala
Composition of FPTU Each FPTU is comprised of a well-equipped classroom, family planning clinical skills lab and labour room. It serves as a capacity development site to foster the skills and competency of in-service and pre-service providers in provision of family planning services. This may include gynecologists, doctors, paramedical staff, nurses, community midwives, LHWs and students of medical universities.
Classroom Skills Lab Labor Room
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Organizational Structure (Organogram)
Health Department Population Welfare Department
Medical Head of Gynecology FHC In-charge Superintendent Roles and Obstetrics Roles Roles
FPTU In-charge
Healthcare Professionals
Medical Superintendent Role Collaboration with PWD, FHC, Govt Budget allocation & maintenance and Audit meetings Head of Gynecology and Obstetrics Role Collaboration and Accreditation FPTU In-charge Run FHC; Collaborate PWD and HOD FPTU In-charge Management: • Availability and maintenance of resources • Regular meetings arrangement
Standard Operating Procedures 1: Facility level Availability of Infrastructure for setting up of skills lab, availability of area for classroom teaching, along with the availability of Labor room, counseling area and FHC located within the premises of health facility is an essential requirement for functioning of FPTU.
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Availability of Materials/Models and Equipment -Classroom, skills lab, labor room and FHC should be fully equipped to provide FP trainings and FP services
-Commodity supply should be regularized to these units in order to ensure service delivery as stock outs of commodities results in non-utilization of skills.
-In Sindh PWD will provide FP commodities to DOH, LHW Program, PPHI and private sector.
-Classroom: A class room with proper seating arrangement, lights and teaching aids including white board, markers and multimedia.
-Skills lab: Fully equipped with different demonstration stations including the following:
• Interval IUCD Station o Demo trolley with long polka chair & light source o Zoe model o IUCD insertion Kit o CU-T o Surgical Gloves • PPIUCD Station o Demo trolley with long polka chair & light source o Mama U model o PPIUCD insertion Kit o Cu-T o Surgical Gloves • Implant Station o Demo trolley with long polka chair & light source o Rita Arm model o Implant insertion and removal kit o Implanon o Jadelle o Surgical gloves o Lidocaine o Distilled water o 5 cc syringes o Saniplas o Bandage o Adhesive plaster and antiseptic • Infection prevention Station o Cap Mask o Apron o Stand holding 02 Buckets with lids o Tub o Brush Page | 9
o Goggles o Utility gloves o 0.5% Chlorine solution
• Counseling Demonstration area o Table o Chair o Revolving Chair o Counseling Tray o Counseling Desk Reference
Note: Regular maintenance of Models and statistics available in the skills lab to be ensured by FPTU In-charge.
Labor room
• Well-equipped labor room should also be available as an essential part of FPTU. • Delivery tables with PV lights and neonatal care facilities should be present in the labor room along with the availability of PPIUCD kits. • Handiness of PPIUCD kits along with CU-T should also be ensured in the Operation Theatre to meet the requirement during cesarean section. • Implanon insertion area should also be fully equipped along with the supplies. • Availability of record keeping register for keeping insertion record at the insertion sites should be made. Counseling Area
• Counseling Counters to be established at OBGYN – OPDs/ labour rooms of the health facilities including primary, secondary and tertiary level. Availability of a trained clinical counselor at counseling counters should also be ensured preferably 24/7 • IEC material should be available at these counters • This will be helpful in client generation and increasing demand for Family planning services. Family Health Clinic • A family health clinic within the premises of health facility is also an essential requirement of FPTU. Counselor from FHC can play a pivotal role in client counseling at counseling counters • Besides this, liaison between Health department and Population welfare department will be developed, thus assisting in generating FP clients and FP method acceptance and responsibility lies with FPTU In-charge Trained Human Resource • Master Trainers o Trained human resource at FPTUs is needed to provide technical support and train service providers on standardized quality FP services
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o Master trainers from other health facilities can also be utilized to facilitate trainings at FPTUs (trained by RTI and PWTI and assessed by regular feedback by trainees and quality assurance steps o Focal Person /Incharge for FPTU. A focal person should be appointed for each FPTU from the OBGYN staff. This person will be responsible to take care of FPTU, including management of unit, service provision, availability of commodities and trainings schedule.
• Trained Counselor o Trained counselor from population welfare department should be appointed in Gyne/obs OPD for counseling the women coming for antenatal and post partum follow up visits o A proper record of these counseling sessions should also be maintained in counseling registers. In Sindh notification will be issued in this context after discussion.
• Trained Service Provider o Availability of trained service providers at FPTUs to provide quality FP services 24/7 is very important to provide services around the clock. Service providers should be available in all the shifts to ensure service provision.
Enabling Work Environment Smooth functioning of FPTU requires a close coordination between health and population welfare department on regular basis. FPTU Incharge and FHC Incharge should hold meetings fortnightly to ensure continuation of trainings and FPTU functioning in an organized manner. Action plan should be made on issues identified during the meetings and timelines set to resolve the issues. 2: Provincial level Collaboration between Department of Health and Population Welfare Department
• Effective partnership between DOH and PWD is required for smooth functioning of FPTUs. • One focal person to be nominated from both the DOH and PWD to organize training planning meetings quarterly. Strengthening procurement process of FP commodities and supplies • A proper mechanism for procurement of FP commodities should be chalked out to ensure availability of required commodities at service delivery points of both the health and population welfare department. • Commodity demand on CLR-6 to be sent by Gynecologists of facilities with FPTUs to MS, and further to PWD on regular basis to avoid stock outs. Budget Allocation for maintenance and procurement • Budget allocation for maintenance of FPTUs and procurement of FP commodities should be made for both the departments utilizing this budget.
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Budget allocation for Trainings • Training budget should be included in main budget of Hospital by the medical superintendent (Logistics, running cost, cost for trainers and trainees, material to be used in trainings). It is to be ensured that each budget caters all these things. • A notification should be issued to Medical Superintendents of Tertiary care Hospitals to include FP commodities in their Pharmacy Formulary in Punjab. • DOH’s training budget to be transferred to PWD to organize all the trainings in Sindh. Improving Monitoring, Evaluation and Accountability • Feedback mechanism to be ensured for these units, hence improving monitoring, evaluation and accountability process must be in place. Trainings data to be shared regularly with provincial level. Work plans: • Quarterly training work plan for all the FPTUs to be made in consultation with HOD- OBGYN department, FPTU Incharge and Provincial stakeholders. • Facilities with FPTUs should share their work plans/training plans regularly with the provincial stakeholders by incharge Accreditation • FPTU should be accredited yearly as a training site with which institution and by HOD
Selection Criteria for Trainers, Trainees and Facility Master Trainer
• A trainer at provincial level who can transfer clinical and advanced training skills to the next level of trainers i.e. district trainers. • The master trainer should also be knowledgeable and experienced in managing, planning, conducting and evaluating the training. Selection Criteria
• Healthcare provider at the facility who provides health services including antenatal care, labor and childbirth, postpartum care including family planning • Familiar with provision of general family planning services • Willing to update family planning knowledge and acquire skills and attitudes essential to provide family planning services • Enthusiastic to learn principle of adult learning • Willing to develop course outlines • Preferably persons having experience in conducting training as facilitators, teaching skills • Committed to transfer learned skills to next level • Only medical doctors will be eligible for trainings as master trainers on implants District Trainer
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• A trained district trainer transfers standardized knowledge and skills to the service providers of the district. • They will train the service providers on family planning skills by using simulation models to build their competency. It will be followed by standardization of skills in the clinical settings Selection Criteria
• An experienced family planning provider available at district level • Willing to train service providers of all levels • Confidently conduct trainings on clinical skills • Enthusiastic to resolve technical issues of service providers • Ability to provide coaching services as a part of training follow-up Selection Criteria of Trainees:
• Providing family planning services • Willing to update knowledge and skills on family planning and to learn new techniques to expand basket of family planning choices Cadre of Trainees: • Medical Students • WMO/Senior Registrars/Post graduates • Midwifery Students • Lady Health Visitors Facility for Training
• Availability of classroom for 15 to 20 participants. • Availability of fully equipped Skill lab • A minimum of 300 deliveries at the facility site/month • At least 10% of the delivered women are provided with PPFP
Terms of Reference for Selection Criteria: • Agreement to be signed by Master Trainers and District Trainers to conduct step down trainings. • Focal person for Training Budget, Admin and logistics Support ,Training material, Clinical facilitation, Training Reports, Training Database • At least one training conducted on quarterly basis • Training plan and list of master trainer available at the training site • Maximum 15 participants for hands on trainings • Certification criteria decided according to the subject of the training
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Regular Meetings Quarterly meetings, to be organized on regular basis at provincial level for FPTUs data sharing/review and to identify prevailing issues and for future action planning. Who will arrange and participate who will decide the agenda will be defined.
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Annex 1: Standard List of Items Required to Establish FPTU
Items for Skills Lab and Labor Room Sr. Labor Items for Skills Lab Skills Lab TOTAL # Room SURGICAL & IP MATERIAL 1 Interval IUCD Kit 1 4 5 2 Postpartum IUCD Kit 1 3 4 3 Implant Insertion/Removal Kit 1 2 3 4 Dust Bins with Lid 3 2 5 6 Measuring Cup (0.5 Liter) 1 2 3 8 Goggles 2 2 4 9 P/V Light (China) 2 2 4 10 Boiler 1 1 2 11 Surgical Trolley 1 1 2 12 Bucket Stand + 2 bucket with lids + 1 Net 1 2 3 14 Brush with Handle 2 6 8 15 Disposable Gloves (Latex 100 pc box) 2 2 4 16 Surgical Gloves (50 pair box) 1 1 2 17 Utility Gloves (Long Arm Heavy duty) 2 6 8 18 Needle Cutter 1 1 2 19 Bleach ( Chlorine) (5 Litre /Gallon ) 1 5 6 20 Pyodene Bottle (Large) 1 1 2 21 Mackintoshes 1 4 5 22 Disposable Caps (Paket) 2 2 8 23 Disposable Masks (Box) 2 2 4 24 Aprons (Parachute) 3 4 7 25 Stethoscope 1 1 2 26 BP Apparatus Mercury (Table) 1 1 2 27 Green Drapes for Instruments 4 5 9 28 Plastic Spray bottle 2 2 4 29 Large Buckets with Lid for Waste Disposal 3 3 6 30 Cloth Hampers 0 2 2 31 Emergency Light (LED) 1 4 5 MODELS 32 Zoe Model 1 _ 1 33 Mama "U" Model 1 _ 1 34 Hand Held Models 2 _ 2 35 Arm Reta Model 1 _ 1 FURNITURE ITEMS 1 Demonstration Trolleys ( PPIUCD ,Interval) 2 - 2 2 Demonstration Tables ( Implant ,AN Area ) 1 1 2 3 Table for Counseling in Class Room 1 - 1 4 Revolving Chair for Counseling Class Room 1 - 1 5 Polka Chairs (High Chairs) Class Room 3 - 3 6 Patient Examination Stool (Revolving) 1 2 3 7 White board with Stand (CR) 1 - 1 8 Chairs for AN (OPD ) Counseling Area _ 2 2
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