STRENGTHENING TRAINING AND CAPACITY BUILDING …

STRENGTHENING TRAINING AND CAPACITY BUILDING Experiences from USAID’s LuzonHealth Project OCTOBER 2017

Photo credit: LuzonHealth, RTI International. RTI International. (2017). Strengthening Training and Capacity Building: Experiences from USAID’s LuzonHealth Project

Disclaimer: This publication was made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents of this publication are the sole responsibility of RTI International and do not necessarily reflect the views of USAID or the United States Government. RTI International is a registered trademark and a trade name of Research Triangle Institute. The RTI logo is a registered trademark of Research Triangle Institute.

CONTENTS LIST OF ACRONYMS II

BACKGROUND AND CONTEXT 1

LUZONHEALTH’S EFFORTS IN TRAINING AND CAPACITY BUILDING 3RESULTS 5

RECOMMENDATIONS AND NEXT STEPS 5

REFERENCES 6

LIST OF ACRONYMS

BEmONC Basic Emergency Obstetric and Newborn Care

BTL bilateral tubal ligation

CHO City Health Office

DOH Department of Health

DOHRO Department of Health Regional Office

FP family planning

FPCBT Family Planning Competency-Based Training

HC health center

IRR Implementing Rules and Regulations

IUD intrauterine device

LGU local government unit

LMT Lactation Management Training

MLLA minilaparotomy under local anesthesia

MNCHN maternal, neonatal, child health and nutrition

NSV no scalpel vasectomy

OSCE objective structured clinical examination

PHO Provincial Health Office

PTE post-training evaluation

RHU rural health unit

TA technical assistance

USAID US Agency for International Development

USAID.GOV Strengthening Training and Capacity Building: Experiences from USAID’s LuzonHealth Project | 1

BACKGROUND AND CONTEXT The decline in maternal and neonatal mortality in the Philippines is slow, resulting from gaps and inequities in the delivery and utilization of health services and deficiencies in trained providers in the health systems [1]. Although studies have shown that maternal deaths can be averted by investing in the four pillars of safe motherhood programs (i.e., modern contraceptive use, antenatal care, safe delivery, and post-natal care) [2], the contraceptive prevalence rate in the Philippines remains low at 37.6 percent [3]. This is likely attributable to the lack of trained family planning (FP) service providers, as shown by the 2013 service delivery capacity baseline study conducted by LuzonHealth: 54 percent of frontline health workers were not trained in FP and maternal, neonatal, child health and nutrition (MNCHN) programs [4].

On June 27, 2012, the Department of Health (DOH) issued an administrative order, National Strategy Towards Reducing Unmet Need for Modern Family Planning [5], as a means to Achieving Sustainable Development Goals on maternal health [6]. In response to this order, the LuzonHealth Project provided technical assistance (TA) to partner organizations, DOH Regional Offices (DOHROs) and local government units (LGUs) to increase clients’ access to a wide range of FP services by enhancing the training continuum and strengthening the DOH’s training system. The training continuum aims to develop competent, effective, self-reliant service providers who are compliant with DOH standards, principles, policies, and guidelines through a functional and institutionalized training system.

Additionally, the Responsible Parenthood and Reproductive Health Act of 2012 and its Implementing Rules and Regulations (IRR) stipulate that all hospitals shall provide a full range of modern FP methods [7]. To support the implementation of the IRR, the DOH issued Department Memorandum 2014-0312 establishing guidelines for setting up FP services in hospitals. Pursuant to this, LuzonHealth, in coordination with DOHRO III and City/Provincial Health Offices (C/PHOs) assisted hospitals in assessing their capacities and needs in providing/revitalizing and installing a hospital-based FP and MNCHN program. Consultative workshops were conducted with these hospitals in February 2016. One of the needs identified was the lack of training in Family Planning Competency-Based Training Level 1 (FPCBT 1) and FPCBT 2: post-partum intrauterine device (PPIUD) insertion, bilateral tubal ligation by minilaparotomy under local anesthesia (BTL-MLLA), and no scalpel vasectomy (NSV).

2 | Strengthening Training and Capacity Building: Experiences from USAID’s LuzonHealth Project USAID.GOV

In 2013, LuzonHealth conducted a service delivery baseline assessment of health facilities in its 21 project sites to determine the capacity of its partners to provide quality FP and MNCHN services. The assessment showed that of the 856 rural health units/health centers (RHUs/HCs), 97 percent were providing pills, 84 percent were providing depot medroxyprogesterone acetate, and 74 percent were providing condoms as FP methods. However, only 46 percent of the frontline health workers from these facilities were trained to provide FP counseling and commodity-based FP methods. Within the RHUs/HCs, only 25 percent of providers were trained in interval IUD insertion and 12 percent in PPIUD insertion. Among the 178 public hospitals in the project sites, 34 percent were providing interval BTL-MLLA, 12 percent were providing NSV, and 43 percent were providing interval IUD insertion.

The following specific challenges were identified in the baseline assessment:

(1) The DOH’s FP training courses are implemented regardless of whether poor health provider performance is attributable to gaps in knowledge, competence in performing specific skills in the delivery of health services, or unfavorable work environment.

(2) The pool of trainers and training institutions is lacking, particularly in skills-based clinical FP courses, such as interval IUD and PPIUD insertion and BTL-MLLA.

(3) Although the various DOH-approved FP/MNCHN training courses require a post-training evaluation (PTE) to be conducted three to six months after training, this evaluation is often not performed due to a lack of trainers.

(4) After receiving interval/PPIUD insertion training, providers’ confidence was low because of the lack of supportive supervision.


LUZONHEALTH’S EFFORTS IN TRAINING AND CAPACITY BUILDING Considering the huge numbers of health service providers needing training, LuzonHealth worked in close collaboration with the DOHROs to build the capacity of its city and provincial sites by providing training courses for service providers in the public and private sectors. This capacity strengthening was conducted by improving the training continuum and strengthening the training system in accordance with the DOH Training Policy for priority FP/MNCHN programs.

The LuzonHealth Project designed a diagnostic workshop that includes environmental and knowledge assessments and the objective structured clinical examination (OSCE) as the initial step in the continuum. The environmental assessment describes the work setting and policy/systems environment in which clinical skills are performed, whereas the knowledge assessment determines the level of retention and understanding of course content. The OSCE assesses the competence of service providers in performing specific skills and determines their ability to integrate knowledge and clinical and communication skills in the delivery of health services. The results of the diagnostic workshop help stakeholders identify the focus of clinical interventions, supply evidence to fine tune or harmonize training activities, and provide an opportunity for DOHROs and C/PHOs to address quality needs for the entire range of FP/MNCHN service provision.

Partner DOHROs and C/PHOs were trained in conducting the diagnostic workshop, including training FP/MNCHN assessors for OSCE. A diagnostic workshop facilitators’ guide was developed and used during the training.

To ensure an adequate number of OSCE assessors, the project worked with DOHROs and C/PHOs to identify service providers at the LGU level with the potential to be trained as OSCE assessors. These


individuals became the pool of FP/MNCHN assessors for the region and were tapped to conduct OSCE across provinces within the region.

LuzonHealth assisted the DOHROs and C/PHOs in building the pool of training providers by conducting a training of trainers for required courses to address identified training gaps. Prospective trainers were selected from public and private sector organizations, institutions, and academe to increase the cadre of DOH-accredited/certified training providers.

The project trained competent PPIUD service providers from DOH-retained hospitals, LGU provincial hospitals, and City Health Departments with birthing facilities with high volumes of deliveries as PPIUD trainers and tapped them as local TA providers to conduct simultaneous PPIUD training courses.

The lack of BTL-MLLA training providers and institutions prompted the project to establish training centers across regions in Luzon. The project trained service providers in selected retained hospitals in BTL-MLLA. Once certified as competent BTL-MLLA service providers, they were trained as BTL-MLLA trainers to increase access to this training.

One integral component of an effective and efficient training system is the PTE of recently trained health service providers by trainers. Therefore, the project worked to ensure that training models were provided, PTE checklists developed, and trained trainers capacitated in PTE and the use of the appropriate checklist. PTE ensures that the knowledge and skills acquired during training are integrated and implemented by the health service providers in their respective work settings.

To reduce the number of PTE visits per trainee, the trainers bring Mama Natalie and/or ZOE pelvic models during facility visits and observe the trainees perform the procedures on the appropriate models. If competence is observed in the various procedures, the trainee is then recommended for certification. Trainees who have not gained competence, as observed during PTE, are referred to supervisors for supportive supervision. Supervisors then inform the trainers when the trainee is ready for repeat PTE for certification of competency.

To ensure an efficient training system, the training programs were institutionalized with standardized training content and processes, and with clear and defined quality standards for course implementation. Additionally, to ensure quality, the training system included a process for evaluating training needs and determining the types of training courses required.

LuzonHealth’s training and capacity building method is unique because of the mix of trainers from the public and private sectors, the training needs assessment (diagnostic workshop), and the utilization of proven performance improvement approaches to identify provider and other gaps.


RESULTS LuzonHealth’s emphasis on designing and implementing diagnostic workshops improved the training continuum in five of the eight partner DOHROs. A total of 109 FP and 55 MNCHN assessors have been trained, and 606 FP and 391 MNCHN trained health service providers have been assessed.

LuzonHealth, in collaboration with the DOHROs and C/PHOs, conducted training of trainers courses in FPCBT 1, Interval IUD Insertion, PPIUD Insertion, and BTL-MLLA. A total of 36 FPCBT 1, 4 Interval IUD Insertion, 49 PPIUD Insertion, and 27 BTL-MLLA trainers have been trained and certified. Additionally, the project was able to establish eight DOH-retained hospitals, two provincial hospitals, and a City Health Department as training providers/institutions for PPIUD insertion and/or BTL-MLLA. Therefore, there is now a training institution in all eight regions in Luzon. These training institutions are in the process of becoming accredited by the Philippine Health Insurance Corporation as FP providers to enable them to claim reimbursement for services rendered. These training institutions are also being tapped as local training providers in their respective areas of jurisdiction. As training providers, these institutions are actively conducting PTEs and providing coaching and mentoring to trainees.

The trainers and health service providers trained by LuzonHealth as of June 2017 are summarized in the table below.

RECOMMENDATIONS AND NEXT STEPS To ensure an efficient FP/MNCHN training system, it is imperative that the FP/MNCHN training programs regulated and approved by the DOH are institutionalized with standardized content and processes and clear and defined quality standards.

Ensuring the provision of quality services by making training available, consistent, and sustainable is equally important. Thus, the training continuum should include a process of evaluating training needs and determining the types of training courses required through conducting diagnostic workshops, institutionalizing their use nationwide, and expanding the use of OSCE as a tool for PTE. Also, OSCE can be used during supportive supervisory visits for coaching and mentoring.

Additionally, it is imperative that the training system be strengthened through (1) the creation and maintenance of an efficient training database management information system, (2) the installation of processes and guidelines for accrediting training institutions and facilities for clinical practice (i.e.,

2017 TRAINING DATA FOR LUZONHEALTH-SUPPORTED AREAS, BY TYPE OF COURSE

TRAINEE FPCBT 1 INTERVAL IUD PPIUD BTL-MLLA BEMONC* LMT**

Trained Trainers 36 4 49 27 – 54

Health Service Providers

2,536 242 484 68 526 1,436

*Basic Emergency Obstetric and Newborn Care

**Lactation Management Training


hospitals, midwife clinics, and RHUs), (3) the development and certification of trained trainers and trained service providers, and (4) the development of mechanisms for financing training courses.

REFERENCES 1. Romualdez, A. G., Jr., dela Rosa, J. F. E., Flavier, J. D. A., Quimbo, S. L. A., Hartigan-Go, K. Y.,

Lagrada, L. P., & David, L. C. (2011). The Philippine health system review. Health systems in transition, 1(2). Retrieved from 2011;1(2).http://www.wpro.who.int/asia_pacific_observatory/Philippines_Health_System_Review.pdf

2. Ahmed, S., Li, Q., Liu, L., & Tsui, A. O. (2012). Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet, 380(9837), 111–125. doi: 10.1016/S0140-6736(12)60478-4.

3. Philippine Statistics Authority & ICF International. (2014). Philippines National Demographic and Health Survey 2013. Manila, Philippines, and Rockville, MD, USA: Philippine Statistics Authority and ICF International.

4. LuzonHealth FP/MNCHN Service Delivery Capacity Baseline Survey. 2013.

5. DOH. (2012). Administrative Order No. 2012-0009: National strategy toward reducing unmet need for modern family planning as a means to achieving MDGs on maternal health. Retrieved from http://alfi.org.ph/wp-content/uploads/2012/07/Natl-Strategy-Toward-Reducing-Unmet-Need-DOH-AO-2012-0009-posted.pdf

6. United Nations. (2013). The Millennium Development Goals Report 2013. Retrieved from http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf.

7. Congress of the Philippines. (2012). Republic Act No. 10354: The Responsible Parenthood and Reproductive Health Act of 2012. Retrieved from http://www.lawphil.net/statutes/repacts/ra2012/ra_10354_2012.html

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