Annex A: PROJECT PLAN

Project Title

In Service capacity building of maternal, newborn and child health care workers in

Sierra Leone

Implementation Period February 2017 to July 2018 – proposed start and end date

Budget Currency1 GBP Exchange rate £1 = 6673.61 Leones

Budget Amount Total £327,284

Leones: 2,184,167,381

% = 100

Direct 81% =

£265,100

Indirect: 19% =

£62,184

SLA Institutional Support Amount 1% =

£3,250

Implementing partners Lead: Liverpool School of Tropical Medicine, Centre for Maternal and Newborn Health

Geographic location/s

All 14 districts of Sierra Leone

Funding Partner/s Main: Johnson and Johnson

Problem Statement (Describe the problem that the project will solve):

Since the end of the civil war in 2002 there has been some improvements in maternal and newborn health outcomes in Sierra Leone, but despite a reduction in maternal mortality ratio (MMR) it still remained high at 1100/100,000 in 2014. Since the 2014/2015 Ebola virus disease (EVD) epidemic the MMR ratio has increased further to 1360/100,000 in 2015.

The EVD epidemic saw the loss of 221 health care providers and cessation of regular health care worker training programmes which has impacted on the quality of care being provided. The President of Sierra Leone’s post Ebola Recovery and Transition plan has the aim of saving 600 women’s lives in the next 18 months. To achieve this, health care providers need to be trained to deliver appropriate antenatal, delivery and postnatal care

The CMNH/LSTM has been working in partnership with the Ministry of Health and Sanitation (MoHS) in Sierra Leone since 2009 to improve maternal and newborn health through capacity building of health care providers.

1 Budget currency should either be in USD, British Pounds or Euros. When budget is in another currency, please convert to USD and indicate exchange rate

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Since 2013 the CMNH/LSTM has been providing technical assistance to MoHS for in-service capacity building of health care providers. This innovative approach to continuous clinical education for frontline health care providers was designed to increase the capacity of the system for in-service training, and supportive supervision.

Most of the frontline health care providers deliver reproductive and maternal health services in peripheral health units located in rural areas. These health care providers have limited training opportunities. Under the initial phase of the in-service capacity building programme, MoHS and CMNH/LSTM designed a decentralized in-service training programme in 7 modules (antenatal care, normal labour/delivery, emergency obstetric care, post-natal care, family planning, adolescent reproductive health and basic nutrition) based on the Basic Package of Essential Health Services for Sierra Leone (BPEHS). These 2 day modules were delivered in a flexible manner at 200 training sites set up and located in all districts of Sierra Leone under the programme. Resources to implement quality trainings were also developed (training manuals, supervision tools, master trainers and supervisors).

From 2013-2015, CMNH/LSTM trained 53% (1948) of 3656 health care providers based at facility level identified for training, 73 supervisors and 386 master trainers. Additional training is needed because of new guidelines from the World Health Organisation that have been produced as well as the fact that several master trainers and supervisors were lost during the Ebola disease outbreak.

Project Goal (Impact Statement):

To increase the capacity of 500 health care providers within peripheral health units, where the majority of care takes place, to be able to provide good quality maternal, newborn, child and adolescent health care. Also, the programme will permit to update the existing resources (training sites, equipment, trainers and supervisors), and to develop and evaluate a mentoring system to sustain the gains of the intervention.

Project Objectives:

a) Update resources required to sustain the in-service capacity building training approach in Sierra Leone (updating of training materials, training of trainers, capacity building of supervisors)

b) To provide and evaluate training for 500 health care providers in 7 modules based on the BPEHS to improve maternal and newborn outcomes at the primary care level.

c) To provide support for trainers and provide quality assurance of trainings.d) To develop and introduce a system of district level mentorship by health care workers at facility level

which will continue to support health care providers practice in high quality reproductive, maternal, newborn and child health following the completion of this programme.

Expected Outcomes:

a) 80% of the 500 trained health care providers will improve in knowledge/skills immediately after the training.

b) % of service users who report being satisfied with the care that they have received at ANC, PNC, family planning clinic and newborn care.

Potential beneficiaries: the interventions will be implemented in all 14 districts of Sierra Leone and will involve peripheral health units, these units provide primary health care to the population. All main referral hospitals in each district will also benefit from the interventions. The 2013 Sierra Leone Demographic and Health Survey (DHS) 2

2 Sierra Leone Demographic and Health Survey Report 2013. Accessed online 15/12/2016. Available at http://dhsprogram.com/pubs/pdf/FR297/FR297.pdf

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reported that there are approximately 187,264 births annually, 55% of these were delivered in a health care facility and that there are 1.5 million women of reproductive age group (15-49 years) in Sierra Leone 3. Therefore, the estimated beneficiaries under the proposed programme are presented in the table below.

Key Strategies (Provide a description):

The LMST/CMNH will work directly with RCHD to deliver the training through national facilitators. Coordination and planning of the OJT programme is done by designated staff from MoHS with technical support from CMNH/LSTM to ensure ownership of the programme by MoHS. The OJT delivers training to health care workers within districts close to their place of work using local facilitators and master trainers. This strategy for delivery ensures that 1) participants are away from their place of work for a shorter time, limiting the impact of the training on service delivery. 2) Training is based on current research and can be directly related to participant’s place of work. 3) Participants are trained with and by their local peers which increases team working, sharing of good practice and provides an opportunity to discuss and possibly resolve local issues related to care provision.

The previous phase of OJT has demonstrated the effectiveness of using national facilitators to deliver training to enhance understanding of participants and ensure relevance to local practice. The CMNH will continue to employ this strategy in this next phase of the OJT which will also further enhance the skills of facilitators to deliver good training and provide sustainability of the programme through continued availability of experienced facilitators.

The CMNH is a member of the MoHS working group which is harmonising reproductive, maternal and newborn health training in Sierra Leone. The CMNH will continue with this strategy of harmonization with OJT module content, through review and updating of facilitator and participant manuals to ensure that the content adheres to national and international standards.

Main Activities List them): Targeted Outputs Specific Locations

District(s) Chiefdom(s) Village(s) GPS

3 World Health Organisation: Sierra Leone. Maternal Child Health, Adolescent profile. Accessed online 15/12/2016. Available at http://www.who.int/maternal_child_adolescent/epidemiology/profiles/maternal/sle.pdf

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Type of Beneficiary NumberHealthcare Provider 886DHMT members 30RCHD MOHS technical team 10Women of reproductive age 15-49 825, 000Newborns (first 48 hours of life) 102, 995

Coordinates

(if available)

Revision and updating of training materials.

Distribution of updated training manuals to training sites, facilitators and participants.

Review of equipment available in training sites.

Replacement of worn out training equipment in 200 training sites. Updating of 256 facilitators/master trainers.

7 training modules updated including facilitator and participant manuals.

200 training sites and 500 participants and approximately 386 facilitators trained in phase I of the OJT. Updating of all facilitators at this stage, even if they are not needed currently needed, will ensure that any future scale up can happen rapidly.

200 sites reviewed to ensure that all training sites meet minimum standards for quality training.

Based on CMNH/LSTM extensive experience with competency based training, we anticipate that 20% or less of the equipment will need replacement.

All 14 districts in Sierra Leone

All 14 districts in Sierra Leone

All 14 districts in Sierra Leone

All 14 districts in Sierra Leone

See annex 1

See annex 1

See annex 1

See annex 1

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Updating of facilitators/master trainers who will receive update training: approximately 256.

Training of new facilitators/master trainers trained.

Approximately 256 facilitators/master trainers trained during phase I of the OJT receive updated training on revised training manuals, and teaching sessions.

Approximately 128 new facilitators/master trainers trained.

All 14 districts in Sierra Leone

All 14 districts in Sierra Leone

See annex 1

See annex 1

Project Inputs (List and quantify):

1. Two-day workshop with 20 stakeholders (MoHS, DHMTs) to agree updating of training materials and implementation plan.

2. Review of 200 OJT training sites including audit of teaching equipment provided during phase 1 of the OJT project. Four teams of 2 people to visit 50 sites over a 7 day period to review numbers of facility staff who have attended phase I OJT, number of master trainers/facilitators in each site and availability /condition of training equipment

3. Procurement and replacement of training equipment to 200 training sites. Available training equipment within each site (estimate 20% of initial set up cost for possible replacement of equipment).

4. Printing, packing and shipping of training materials for 500 participants and 360 facilitators/master trainers to all districts in Sierra Leone, including:

5.i. Training manuals

ii. Participant manual, supervision toolsiii. M&E tools

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iv. Mentorship tools v. Log books for trainee, trainer and supervisor

6. Update training in all modules or approximately 256 facilitators/master trainers across all 4 provinces of Sierra Leone (total 8 courses):

i. 64 facilitators/master trainers in Eastern province in x2 back to back 2.5 day course.ii. 64 facilitators/master trainers in Western province in x2 back to back 2.5 day course.

iii. 64 facilitators/master trainers in Northern province in x2 back to back 2.5 day course.iv. 64 facilitators/master trainers in Southern province in x2 back to back 2.5 day course.

7. Training in all modules for approximately 128 new master/trainers facilitators (total of 4 courses):i. 32 facilitators/master trainers in Eastern province in 3.5 day course.

ii. 32 facilitators/master trainers in Western province in 3.5 day course.iii. 32 facilitators/master trainers in Northern province in 3.5 day course.iv. 32 facilitators/master trainers in Southern province in 3.5 day course

8. Cascade training of 125 facility based staff and supervision by district in modules 1 and 2 (ANC, normal labour and delivery) all districts:

i. Supervision team visits to all training sites within Eastern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

ii. Supervision team visits to all training sites within Western province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

iii. Supervision team visits to all training sites within Northern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

iv. Supervision team visits to all training sites within Southern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

9. Roll out of cascade training 125 facility based staff and supervision-Modules 3 and 4 (EmONC, PNC,HBB).

i. Supervision team visits to all training sites within Eastern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

ii. Supervision team visits to all training sites within Western province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

iii. Supervision team visits to all training sites within Northern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

iv. Supervision team visits to all training sites within Southern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

10. Roll out of cascade training 125 facility based staff and supervision modules 5 and 6 (FP, ARSH & Nutrition)

i. Supervision team visits to all training sites within Eastern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

ii. Supervision team visits to all training sites within Western province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

iii. Supervision team visits to all training sites within Northern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each.

11. Supervision team visits to all training sites within Southern province (approximately 50 sites) over 7 day period; 4 teams of 2 people to cover approximately 12 sites each

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12. Monitoring and evaluation of impact of training in all provinces, one week visits to training sites by district to determine impact of training on health care workers practice:

i. Eastern Area: Approximately 25 sitesii. Western Area: Approximately 25 sites

iii. Northern Area: Approximately 25 sitesiv. Southern Area: Approximately 25 sites

13. Quarterly mentorship of health care workers in 25% of health care facilities in all provinces One week visits to training sites by district to determine impact of training on health care workers practice:

i. Eastern Area: Approximately 25 sitesii. Western Area: Approximately 25 sites

iii. Northern Area: Approximately 25 sitesiv. Southern Area: Approximately 25 sites

14. Quarterly mentorship of health care workers in 25% of health care facilities in all provinces

i. Eastern Area: Approximately 50 sitesii. Western Area: Approximately 50 sites

iii. Northern Area: Approximately 50 sitesiv. Southern Area: Approximately 50 sites

15. Dissemination of findings at national level and at regional and international conferences and through publications Half day dissemination meeting in Freetown for 30 participants including representatives of:

MoHS Stakeholders CMNH/LSTM Johnson and Johnson

Specific equipment required by the project:

- Teaching equipment will be procured for the training sites. The specific type and amount of equipment will be determined after the review of all sites. This equipment will remain with the facilities after the duration of the project. The equipment will belong to and be the responsibility of the MoHS. It will not be LSTM equipment.

- A camera will be purchased so that the training, workshops, meetings and monitoring/evaluation can be captured

- The project will benefit from an existing vehicle bought from funds from a previous project – fuel and maintenance costs are the only inputs to this project

- The project will also benefit from existing laptops bought from funds from a previous project that the assigned staff will use during the lifetime of the project.

Specific personnel needed to implement the project:

- A senior technical officer technical officer, M&E and Logistics officer and driver, based in Sierra Leone, are required to implement this project. These are full-time staff.

- A senior research associate based in the UK will implement project activities directly with the team in Sierra Leone. This position will work part-time (5%) on this project.

- A research assistant, programme manager and admin and logistics officer, based in UK will provide expertise, support and advice to the team in Sierra Leone. These are part-time staff (5%, 10% and 5% respectively).

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Sustainability Plan (Description of what happens when the project comes to an end):

The proposed programme involves using facilitators/master trainers who are based at the district level in Sierra Leone and who will continue to provide care with the colleagues that they train. This means that they can also continue to provide support to colleagues to help them develop their knowledge and skills further as well as continuing to develop their own training skills. A level of sustainability has already been achieved by continuing:

Ensuring the programme is planned and implemented through the RCH Directorate Involving those facilitators/master trainers involved in phase I of the in-service capacity building

programme. Ensuring the district level trainers and supervisors are from within the DHMT.

Training equipment is provided to all 200 training sites and will remain at these sites during and at the end of the training for future use by the DHMT. The inclusion of members of MoHS from the national and district level means that they fully understand the training programme and support sending their staff to the trainings.

Introducing mentorship which is led by the DHMTs means that continued development and support for health care providers at the primary care level can be sustained beyond the life span of the programme.

The MOHS have observed the positive impact of the In-Service Capacity Building programme both on health care providers practice and on the development of senior staff to deliver large scale, high quality training programmes, hence their specific request to CMNH/LSTM to support scale up of the programme. Ownership of the programme by MoHS with a focal person from MoHS involved in the planning and management of the programme means that it becomes embedded in the training plans of MoHS. The CMNH/LSTM has developed training materials in partnership with MoHS based on the BPEHS which means they take account of current research and also the local context and national health needs.

Exit Strategy (Include elements of transfer of skills and propose transition plan):

Transfer of skillsThe OJT training is coordinated and managed by MoHS with technical support from the CMNH. This has enabled transfer of knowledge and skills to designated staff with MoHS on the planning, management, monitoring and evaluation of a large scale training programme.

In phase I of the OJT the CMNH worked with MoHS to identify health care providers to train as master trainers by CMNH. This has allowed transfer of clinical knowledge and skills to 386 key frontline staff in maternal, newborn and child health care. These master trainers are a permanent resource within Sierra Leone who; 1) act as facilitators for future training programmes, 2) share their newly acquired knowledge with colleagues and peers in day to day practice, 3) update their own practice based on what they have learnt as master trainers, 4) have been trained to teach and deliver skills and drills training, 5) have developed understanding of how to plan, implement, monitor and evaluate training programmes.

The CMNH worked with MoHS to identify supervisors for the OJT for each of the training sites. CMNH provided technical support for training of supervisors, planning and implementation of supportive supervision in partnership with DHMTS.

Transition planThe ethos of the OJT is to deliver district based training, at lower level health facilities to health care providers through locally based master trainers who are supervised by DHMTs and MoHS. Training packages are based on

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the BPEHS to ensure relevance to Sierra Leone health needs. The CMNH will work with MoHS:1. To ensure that ownership of the OJT remains with MoHS including planning, management and

implementation of the programme.2. Conduct a risk assessment and risk mitigation plan to assist with transition.3. Work with MoHS to ensure at the end of the programme that all databases of master trainers are up to

date.

Annex 1: Targeted districts and health facilities

District Training siteWestern AreaTotal = 25

Kuntolor CHCApproved School CHCGeorge Brook CHCKroobay CHCGreybush CHCLakka Ogoo Farm CHCWellington CHCKoya Town CHCAllen Town CHCCalaba Town CHCWiberforce CHCNewton CHCWaterloo CHCHastings CHCHeart and Hand Care CHCGrafton CHCGoderich CHCSongo CHCTombo CHCYork CHCGinger Hall CHCMoyiba CHCJener Wright CHCRegent CHCMurray Town CHC

Port LokoTotal = 15

PortLoko Government HospitalLunsar CHCMasiaka CHC Sumbuya MCHPKonta Line CHP

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Mange CHC Sendugu CHCGbinti CHCMalekuray CHCKamasondo CHCPetifu Junction CHCMana II CHPGbaneh Lol MCHPTagrin CHCRogbere Junction

KambiaTotal = 11

Kambia DHRokpur CHCMambolo CHCBamoi Munu MCHPGbalamuya CHCMadina CHCKamassasa MCHPKychom CHCKassirie CHCMafufuneh CHCKukuna CHC

KailahunTotal = 13

Kailahun Government HospitalGballahun CHPNgiehun Luawa CHPKoindu CHCPendembu CHCMabai CHCJojoima CHCDaru CHCShegbwema CHCBunumbu CHPManowa CHCSandaru CHCBandajuma CHC

KenemaTotal = 19

Kenema Regional hospitalBlama CHCMondema CHCBaoma Koya CHCLargo CHCNekebo CHCGbo-Lambayama CHCMCH StaticHangha CHCDodo CHCGeima CHPGeigbwema CHCWeima CHC

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Levuma CHCBaama CHCJoru CHCSendumei CHPTongo CHCPanguma Hospital

BoTotal = 20

Bo Government HospitalNjala CHCDambala CHCMCH StaticYimoh Town CHCNPBKs CHCNeedy CHCGbanja TownMongeri CHCSumbuya CHCJimmi CHCJembe CHCYamandu CHCBumpe CHCSerabu CHCNgalu CHCGondama CHCTikonko CHCGboyama CHCKoribando CHC

PujehunTotal = 13

Pujehun Government HospitalSumbuya Bess. CHPBumpeh CHCPotoru CHCFuta Peje CHCSahn Malen CHCBlama CHCBandajuma CHCZimmi CHCGbondapi CHCBandasuma CHCJendema CHCFairo CHC

BontheTotal = 11

Bonthe District HospitalMattru Jong HospitalTihun CHCMattru CHPGbap CHPMadina CHCMotuo CHPStatic underfive Bonthe Tei CHP

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Yorni CHCGbangbama CHC

MoyambaTotal = 14

Sembehun CHCShenge CHCNjama CHCSenehun CHCTaiama CHCMano CHCGbangbatok CHCMokanji CHCMoyamba Junction CHCStatic 1 CHCMoyamba Govt HospitalBauya CHCBradford CHCRotifunk CHC

BombaliTotal = 15

Makeni Regiona HospitalMasuba ClinicMakump CHPMasongbo CHC (2 sites)Batkanu CHCMapaki CHCBinkolo CHCKamabai CHCGbendembu CHCMabunduka CHPKamaranka CHCKamalo CHCKamakweiWesleyan Hospital Fritonia CHCKegbere CHC

KoinaduguTotal = 11

Musaia CHCFadugu CHCKondembaia CHCSinkunia CHC BEMONCBendugu CHCBandaperie MCHPYiffin CHCKoinadugu CHCFalaha CHPKabala Government HospitalBafodea CHP

TonkoliliTotal = 14

Magburaka Govrnment HospitalMCHP Magbass

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CHC MabontorCHC BumbunaCHC BenduguCHC MatotokaCHC MakaliCHC MasingbiCHC YeleCHC MabangCHC MaraCHC Hinistas Mile 91MCHP BonkababayCHC Mathoir

KonoTotal = 14

Koidu Government HospitalKoidu MCHPKimbadu CHCGandorhun CHCKangama CHCMotema CHCYengema CHCJaiama Sewafeh CHCManjama CHPNjagbwema CHCKoardu MCHPKombayendeh CHCKayima CHCTombodu CHP

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