TASK SHIFTING INTERVENTION: ADVOCACY FOR IMPLANTS TAUSEEF AHMED PhD December 14, 2016
CONTENTS Introduction Rationale / Aim Intervention and Pilot test Results Discussion and Future Strategy Recommendations
INTRODUCTION/BACKGROUND Unmet need for contraception in Pakistan continues to be high 20% (2012-13) Modern CPR continues to be low and tilted towards inefficient and traditional methods Desire to stop pregnancies emerges to be quite high beyond fourth birth Young mothers continue to express high need for birth spacing but not fulfilled Access to family planning remains as one of the major barriers to progress in family planning in Pakistan Health Infrastructure is seriously underutilized for FP services, while FP2020 goal set for Pakistan to achieve 55 percent CPR by 2020 requires serious steps
RATIONALE, AIM, OBJECTIVES Access to services, according to public sector plans, include expansion of facilities, esp in uncovered areas, improving monitoring and demand creation Bureaucratic approach leads to highly restrictive policies that shuns innovativeness Innovative pilots are conducted in Pakistan but public sector managers do not carry forward the fruits of innovative measures Health sector strategy makes it mandatory availability of FP services from all health outlets but no concrete measures are taken Task-Shifting piloted in several countries scaled up for regular service provision changed their contraceptive method mix positive effect on birth spacing and growth rates Task Shifting improves Choice and of course health status of women in Pakistan
WHY TASK SHIFTING Task shifting is the name given to a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers. Reorganizing the workforce in this way, task shifting can make more efficient use of the human resources currently available to dispense much needed family planning services Provision of injectables by community based workers has revealed good results and made access to this method relatively easy
TRAINING OF MASTER TRAINERS IN IMPLANTS INSERTION AND REMOVAL IN PAKISTAN JUNE 2012 Population planning wing Government of Pakistan and OBS (organon Bio Services) Health Care trained 57 doctors as Master Trainers from the Reproductive Health Services Centers of the Department in two batches: CONSUMPTION OF IMPLANON DURING MARCH 2013 TO JULY 2014 Sindh consumed 8,710 Implanon whereas Punjab consumed 1,765. The reason of low consumption of Implanon in Punjab is low priority, lack of information and lack of interest. Moreover no involvement of paramedic staff in inserting Implants at community level because the policy i.e. RHS Centers staffed by appropriately trained doctors will be designated to provide these contraceptives.
INTERVENTION AND RESULTS
LEARNING FOR RAWALPINDI DISTRICT Selection of District: Rawalpindi Trainings provided: Training Venue: Holy Family Hospital Rawalpindi Centre of Excellence Trainers engaged: Dr. Farhat Arshad and Dr Rizwana Ch. Gynecologist Training Batches: 04 Trainer Cader Trained: WMOs : 08 ( insertion and removal and to supervise LHV s at facilities) LHVs : 26 ( Implanon insertion and removal) Training duration: 02 days No of insertions in trainings: 1-2 insertion by each participant No of removals in training: observed one client only Oriented 350 LHWs for Referral Mechanism
Dr. Hina Dr. Hifza Dr. Madiha Dr. Mamoona Dr. Robina Dr. Samina Dr. Tahira Ms. Farah Naz Umm e Habiba Haleema Saadia Ms. Mehmooda Ms. Mussarat Ms. Nayyar Awan Ms. Rahila Ms. Sania Ms. Shabana Ms. Shaheen Ms. Tanveer Ms. Tayyaba Ms. Anila Ms. Asma Irfan IMPLANON INSERTED INDEPENDENTLY BY WMOS AND LHVS APRIL-MAY 2016 18 16 15 18 18 14 12 10 8 6 4 2 0 6 8 4 5 8 1 10 5 2 8 8 8 4 3 0 6 6 4
Dr. Hina Dr. Hifza Dr. Madiha Dr. Mamoona Dr. Robina Dr. Samina Dr. Tahira Ms. Farah Naz Umm e Habiba Haleema Saadia Ms. Mehmooda Ms. Mussarat Ms. Nayyar Awan Ms. Rahila Ms. Sania Ms. Shabana Ms. Shaheen Ms. Tanveer Ms. Tayyaba Ms. Anila Ms. Asma Irfan Ms. Yasmine COMPARISON OF COMPETENCY (WMO VS. LHV) Aggregate Scores in Post Test for insertion of Implant 30 25 20 15 21 22 20 21 20 26 18 23 16 27 19 21 13 25 23 25 26 16 23 22 25 14 10 5 0 Av Score 21.1 Av Score 21.2
DISCUSSION
INTERVENTION RESULTS Excellent response was shown by the WMOs and LHVs and that clients were fully satisfied by the services available at RHCs regarding insertion of implanon. LHVs are able to insert implanon independently No women come with infection or sepsis No women come for removal Post competency test was taken by trainer after 2 months Women/clients were satisfied with insertion of implanon Women/clients able to get long acting family planning methods of their choice Health department Rawalpindi developed requisition mechanism for Implanon
INTERVENTION: CHALLENGES & SUCCESS Challenges: Availability of implanon Referral at some centers Equipment and other items ( Piodine, gauze, bandages etc) at some centers Supportive Supervision ( No trained WMO was available with the system) Success: Regular supervision and monitoring. Cluster meeting of LHWs with the facility staff. Able to communicate health department that task shifting is a best tool to provide LAFP contraceptive methods through LHVs
SERVICES PROVISION BY PWD AND DOH SERVICE PROVIDERS Methods Population Welfare Dept. Department of Health Provider FWW WMO MO LHV WMO MO IUD Yes Yes NA Yes Yes NA Implants No Yes No No No No NOTES: Yes trained and can provide; No means service not being given but potential exists NA service not applicable
JADELLE
IMPLANON
DEVISE FUTURE TASK SHIFTING STRATEGY Should focus on: Competency based training for 6 days More and more health care providers (i.e. LHVs) may be trained Close supportive supervision till six months Availability of implants in stock for at least six months (CWH) Availability of equipment and other items required for implants insertion and removal A strong mechanism for demand generation ( involve all stakeholder) Ownership and monitoring mechanism A strong referral mechanism Assessment of client s satisfaction
STRATEGY FOR TASK SHIFTING FOR PROMOTION AND USE OF IMPLANTS For community based provision of Implants at district level there is a need for shifting of task. The following steps should be taken : 1. Advocacy for policy change 2. Demand Generation at community level 3. Competency based Training of Lady Health Visitors and Family Welfare Workers 4. Ensure availability of Implanon at health facilities 5. Supportive supervision mechanism
COMPETENCY BASED TRAINING OF LHVS AND FAMILY WELFARE WORKERS IN IMPLANON INSERTION AND REMOVAL Competency based training conducted in two phases: 1. Training of Trainers 2. Step-Down Training Training of Trainers (TOT) Duration: 6 days (2 days theoretical, 4 days clinical practicum including 5-8 independent insertions. ) Participants: Doctors and LHVs from Rural Health Centers Curriculum: Developed by Pathfinder International (or use already developed by Jhpiego) Venue: Reproductive Health Service Centre (District Level)
ENSURE AVAILABILITY OF IMPLANTS AT HEALTH FACILITIES/ RHSC Ensure availability of Implants at health facilities Population Welfare Department and Dept of Health to ensure the availability of Implants at all levels. A vital role in building of coordination and linkages in between health and population department is noted. The Depts need to revive and facilitate District Technical Committees to ensure commodity and other challenges for further actions. A strong referral mechanism
SUPPORTIVE SUPERVISION MECHANISM Developing supportive supervision mechanism. Master trainers will monitor to assess the following: Knowledge Proficiency in inserting implants Follow infection prevention protocols Pre and post counseling techniques Removal techniques through pre and post feedback checklist. This mechanism will help the providers to enhance their knowledge and skills. REPORTING TOOLS Reporting tools will be developed for decision making for further action and feedback. Important indicators (process and output) will be covered in these tools
CHALLENGES & SUCCESS Regular supply of Implants. Periodic refresher/meeting to enhance their skill. Regular supervision and monitoring. Neighbourhood meeting of LHWs for demand creation and with the facility staff for referral mechanism
RECOMMENDATIONS Stage 1: All MOs and LHVs of District to have competency based training Stage 2: Health care providers (i.e. LHVs) to be trained in other districts Stage 3: Expand scope to cover Jadelle insertion and removal Stage 4: Comprehensive Supply Chain and Referral mechanism to be evolved Stage 5: LHV In-service curriculum to add in implant insertion and removal modules Stage 6: Review implant assessment in the light of CIP estimates and incorporate the same in procurement plans
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