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