Contributions to Capacity Building..

1. Contributions to Capacity Building.. From NHSRC…..

2. NHSRC Areas of Contribution • District Planning & Management. • Hospital Management • HMIS. • Community Processes • Human Resource Development Proposed Areas: • Epidemiology. • Clinical Skills & CME programme Capacity Building is more that Training. It is also institutional capacity… and induction of human resource.. and building up of systems – by which the capacity to deliver increases…

3. 5 general principles of approach.. • Should be done in state along with a state partner organisation. • Should reach at least to district level resource persons- to reduce one or two steps in the training cascade.. • Should help develop and be based on state-specific material • Should be participatory but also based on defnite systematised training material with in-built evaluation- • Should have an intensive post training follow up and mentoring to ensure that training outcomes translate into programme improvements.

4. District Planning for RCH: 1. Partner Organisations: • Chhattisgarh: State Health Resource Center. • North Eastern States: NE-Regional Resource Center and SPMUs, • Jharkhand: PHRN, CINI • Orissa & Bihar: PHRN 2. Course Structure: • 6 days contact programme • Followed by four months mentored work in districts. • Then Repeat 6 days contact programme. • Followed by four months montored work in districts. • And then another 6 days training and four months mentoring. 3. Certification: Of Participation, of completion and .. If they pass exams could become eligible for diploma in public health.

5. Examples of mentored assignments: • Assess district plan in child health(1); write instructions for a 30 cluster sample survey and select the clusters(2), devise a questionnaire(3) and a dummy table(4), do survey(5) and then based on findings revise the plan(6). • Modify the district malaria plan after reading the GIS(1); devise a qualitative study to understand why some villages are high focus(2), develop a BCC campaign for these villages(3). • Devise a focal group discussion(1) to understand the problems of the ASHA programme (2). Devise a monitoring plan- that includes choosing indicators, and schedule of meetings and processes. (3). Implement this for a month and revise guidelines based on experience of appraisal(4) Another principle: To train a team – not just individuals – and team should bring together contractual and the regular employee. Each assignment builds skills – in a measurable manner.

6. Coverage to date: • Eight States of North East: Two rounds of training completed and second round of mentoring. Ongoing: Approximately 390 medical officers from about 80 districts. • Chhattisgarh: Two rounds of training completed for 21 persons and one round of training for 60 persons from 16 districts. • Orissa: One round of training completed for 8 districts: 45 persons. Other programmes postponed due to floods/tensions. • Jharkhand: 12 districts – 70 persons trained two rounds( second round ongoing)- • Bihar , Haryana , J &K, Uttar Pradesh : wanting to start up. • Kerala: with modifications with AMCPH:

7. Improve Quality in Hospital Services.. • There are four steps: • The Mapping of Existing Processes.(As-Is Document) • Deciding on What Processes are desired (To-Be Document). • Capacity Building at every level: Skills, Knowledge of Processes, Motivation, • Documentation to guide and check and ensure that each agreed upon process is followed- in a measurable manner. (Choice is between ISO and NABH: ISO is process centered- and will build up maximal quality for any level of inputs. NABH is hospital specific, but is very input based).

8. Specific Management Processes that require capacity building: • Patient satisfaction scores improve as measured by exit interviews. • Decreased patient time and crowding at outpatient department. • Promptness of care. • Sturdy admission and improved discharge processes • Institution of system for medical and death audits leading to improved professional levels of clinical care. • Timely reporting of investigations. • Calibration of all instruments • Verification of investigation results to ensure accuracy and standards. • Improved bio-medical waste management- achieving well defined standards. • Sterilisation and infection control measures.

9. Specific Management Processes( cont.) • Improved management of hospital sanitation especially of cleanliness. • Improved management of laundry services ensuring that all beds have clean laundry. • Improved cleanliness and aesthetics of surroundings. • Improved indoor illumination levels( measured regularly) • Complaint resolution time- leading to not only a measure of grievances. • Compliance with all laws and regulations especially AERB, PNDT. • Stores and inventory management functions. • Maintenance of records and documents.

10. Key aspects of capacity building • All employees involved- including sweepers, class IV etc. • Much of capacity building is team based and again largely mixed groups. • Based on training material prepared locally – but usually by adaptation of core material. • All trainings are on-site through hired agencies, backed up by NHSRC. • Post training follow up by one person posted in the hospital , using key documents and documentation as tools. • The training programmes are only one day at a time- but is recurrent, uses adapted material and very good on the job support- measures itself by programme outcomes and not training outcomes. All in service hospital adminstration should move in this direction.

11. Health Management Information Systems.. • We believe 90% of the investment should be on capacity building. Hardware and software costs should be less than 10%. • Focus of capacity building should be on • Analysis of data – converting data elements into indicators • Using information(analysed data) for programme improvement. • Data validation. • Better quality of data entry. • All states receive capacity building in 3 phases of 6 months : • Phase I: systems up & running : Quality data on flow • Phase II: Information for Use- at all local levels • Phase III: Ownership shift- capacity building for programming:

12. Progress… in HMIS capacity building… • Assam: trained for state and 23 districts, server established, district applications customized and functioning with block level data entry. • Haryana: trained for state and 20 districts, server established, district applications customized, functioning with district level data entry. • Madhya Pradesh: trained for state and 48 districts server established, district applications customized and functioning with borrowed server space. • Orissa: trained for state and 48 districts; server established, district applications customized and functioning with borrowed server space. • J&K: trained for all districts of Ladakh division in Leh- 4 districts, • Uttaranchal – training ongoing. • Other than this- Tamilnadu, Himachal, Punjab, Chandigarh, Uttarakhand and 6 NE states are waiting with requests for start up

13. Key aspects of capacity building • Training is provided at the state capital- with district teams coming to the state. • Detailed HMIS tool kit used for training: • Data Dictionary. • Indicator Guidelines. • Use of Computers. • Use of software for analysis of data at all levels – PHC, CHC, District. • Tools are adapted for state level – before training begins. • Follow up e-group for support; performance of system would be ensured. • Partnership with HISP at national level and at state level, state HMIS unit.

14. ASHA programme & VHSCs • Main focus is on supporting states in ASHA programme. Put in place ASHA support structures and systems – especially on training. • Have put in place 8 state facilitators for 8 EAG states( two need to be filled up again) and through NE-RRC for all NE states. • Building up ASHA resource centers/state training teams at state level, community mobiliser at district level and block level facilitators. Induction of those selected. • Fifth round of training – state teams being trained by CHETNA-NHSRC joint teams. • Development of further training materal where needed.

15. Nursing Education Capacities • Ongoing studies plus technical support programme in four states- Rajasthan, Bihar, Orissa and Chattisgarh. • Study of current situation within government and in open market. Also the plans and roll out of nursing education. • Build a road map for increasing nursing education and also better nursing workforce management. • Support faculty development for new schools. • Support opening of new schools within public sector and through PPPs.

16. In service skill development and certification- the plan for epidemiologists.. • Over 690 epidemiologists being recrutied • Over 50 medical entomologists being recruited. • Most would not have epidemiologists qualification and may be used to only ensure flow of information. • But ideally they should analyze information flowing through and be able to provide district epidemiological profile which is critical for district plan and for IDSP. • Even existing courses are poorly adapated for this role. • Except for VCRC’s programme- general entomology courses are not enough

17. The Proposal… • AchuthaMenon Center for Public Health, Trivandrum is willing to give a diploma in epidemiology. • A distance education program with a ten day induction and two 6 day trainings 4 months apart would lead upto the diploma. • The assignments given would improve program outcomes along with building skills. Only those who complete could continue: • London School of Hygiene and Tropical Medicine has a globally recognised distance education program which they would licence it to us. • This would help retain the recruits for 18 months- as well as give us truly qualified epidemiologists. • Also builds systems for the future also- if the contact program and mentoring are done in coordination with nine leading zonal public health institutions.. In Chandigarh, in Delhi, in Guwahati, in Kolkata etc. • Could be initiated and handed over, or fully organised by NHSRC.

18. This general approach could be also used for… • Continuing medical education combining with Diplomas and Degree in Family Medicine • Continuing Nursing Education. ……. and so on..

19. Thank You.