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:

• 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.”

CONSUMPTION OF IMPLANON DURING MARCH 2013 TO JULY 2014

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

IMPLANON INSERTED INDEPENDENTLY BY WMOS AND LHVS APRIL-MAY 2016

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Aggregate Scores in Post Test for insertion of Implant

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

THANK YOU