Central Training Plan PROF. DEOKI NANDAN, MD, FAMS, FIAPSM, FIPHA, FISCD Director

Need for a National Training Plan HRD is critical for improving performance, efficiency and effectiveness of health systems and delivery of health services It has become all the more important as new health programs are introduced. All the health care personnel need updating of both knowledge and skills. Focus on in-service training/on-the-job training is necessary to improve content and quality of services to cater to emerging needs for training. In-service training is necessary for all category of personnel – service providers, programme managers, bio-statisticians, etc.

Core Strategies 1.Needs assessment- Review state training plans – PIPs and RoPs, to assess training needs and loads. 2.Develop a Central training plan and strategy to meet the gaps and needs 3.Quality improvement and management of training through standardizing curriculum, resource material and standards (including proficiency certification) 4.Strengthen capacity for training through trainers’ training and infrastructure support 5.Coordinate implementation of trainings in the states with optimal utilization of all available health facilities and human resource. 6.Establish training information management systems, monitoring, supervision and support

Review of Training NIHFW reviewed the State PIPs and ROPs for  Progress in of in-service training indicated by the states.  Training programmes planned by states for

Four Thematic Areas ◦ Maternal Health ◦ Child Health ◦ Family Planning ◦ Disease Control Review was conducted on the following four thematic areas and in the context of NIHFW has done in the last seven years in conducting training of trainers since beginning of NRHM

Abstract of Training Load ( ) Trainings/Activities covered Category of staff to be trained Number to be trained in Duration of Training Place of training Status of TOT Availability of training modules and teaching aids Availability of monitoring formats

Maternal Health (9 High focus states + 3 NE States)

Child Health (9 High focus states + 3 NE States)

Family Planning (9 High focus states + 3 NE States)

Disease Control (9 High focus states + 3 NE States)

Other Programmes (9 High focus states + 3 NE States)

COLOURS -- denotes GREEN - Data has been taken from the information received from the state (it is present in the state ROP as batch size) RED - Data has been taken from the information received from the state (Information is not given in state ROP). ORANGE - Data has not been provided but the budget is reflected in ROP YELLOWISH GREEN - Actual training Load will be higher as some states have mentioned only batches for few of the trainings.

S.No. Name of State District Hospital Blood Bank FRUsCHCsPHCsSub- Center 1 Assam # Bihar Chhattisgarh NA 13 NA Jharkhand # Madhya Pradesh 4628 NA Orissa #3214 NA Rajasthan Uttarakhand # Uttar Pradesh 71#48 NA Arunachal Pradesh 13NA Meghalaya 62 NA Nagaland TOTAL State wise Total Number of Health Facilities Source: Rural Health Statistics 2008 #Information taken from MOHFW website

Number of Health Facilities of other Departments S.No.Name of StateRailway s Hospital ESI Hospitals/ Dispensaries Armed ForcesCentral Police ForcesP & T Hospitals Hospital s Dispensarie s ArmyAir Force NavyITBPCRPFBSFCISFAssam Rifles 1 Assam Dispensary + 41 Hospital 4 2 Bihar 6 NA Chhattisgarh Jharkhand Madhya Pradesh Orissa Rajasthan Uttarakhand Uttar Pradesh Arunachal Pradesh NA Meghalaya NA Dispensary + 1 Clinics 1 12 Nagaland NA Hospital0

S.No. Name of StateMedical College SIHF W RHFWTCANM Schoo l GNM School Nursing CollegeCGHS B.Sc.M.Sc.P.B.B.Sc. Dispensarie s Empanelle d Hospital 1Assam Bihar6(G)+3(P) Chhattisgarh2(G)+1 (P) NA 4Jharkhand Madhya Pradesh5 (G)+3(P) Orissa3(G)+1(P) NA4 7Rajasthan# 6 (G)+2(P) Uttarakhand# 2(G)+1(P) Uttar Pradesh9(G) + 9(P) Arunachal Pradesh NA 11Meghalaya NA 12Nagaland NA TOTAL State wise Teaching/Training Institutions including CGHS Source: Rural Health Statistics 2008 #Information taken from MOHFW website

1.Some states (Uttarakhand for some Disease Control Programme) Assam, Haryana, Madhya Pradesh etc. (for RCH) have started giving the Comprehensive Training Plan for planning training at least in some programmes. 2.States like Maharashtra and Orissa have started integration of training for a few categories - Orissa for Lab technicians across both Health & FW and Maharashtra for MO within RCH programme components in Tamil Nadu has proposed assessment of skill also in each trainee (using OSCE) at the beginning of the course and focus on training for whatever knowledge or skill the trainee lacks. 4.Haryana, J & K, Assam, Meghalaya and a few other states have proposed to integrate the trainings in Major findings of the review

4.The ROP reflects only those trainings where there is financial commitment from GOI to the state. This abstract does not include Training of master trainers, PDC etc. as these are done by institutions with funding directly from GOI and not from state PIP. 5.The abstract includes training proposed by states but perhaps not approved in ROP. There are certain trainings for which the funds have been approved but do not meet technical norms.(e.g IMNCI for MO and SBA for MO) 6.The budget has been reduced in the ROP for certain trainings but there has been no proportionate reduction in training load. 7.Many of the functional facilities are not being utilized for training at all or optimally.

1.Prepared the curricula and other details for each category for the integrated training strategy, 2.Incorporated integrated training strategy for training of all state level programme officers, SIHFW faculty, PMU personnel as well as medical college faculty. 3.Most trainees have understood the importance of such strategy as well as the advantages. 4.But the health systems in the state are yet to internalise it as is evident from the training planned in the PIPs. NIHFW over the last seven years has

ISSUES & CHALLENGES

1.After decades of vertical training, transition to integrated training is difficult and states are taking time to adapt to it. Even under the same programme eg. RCH vertical training occurs even when trainers and trainees are the same eg. Immunization Training done every year. 2.Each category of personnel has a number of training programmes for different aspects of service delivery. 3.Some people go repeatedly for training while others do not get any opportunity for training. ISSUES

Category of Participants Range of trg prog in ROP MO17 to 30 S/N4 to 11 ANM5 to 19 LHV2 to 11 MPW (M)2 to 6 MPHS (M)1 to 4 DPMU1 to 2 SPMU1 to 2 LTs.2 to 7 Specialist1 to 13 Pharmacist1 to 2 Category of participants and No. of trainings available

4.Training Plans are not based on need of the district/state for skilled human resource; Adhocism prevails. 5.Lack of prioritisation eg selection and training of personnel from those centres where facilities and case load exist so that they can become functional. 6.No clear cut plan for developing all the categories of staff for training at defined intervals. 7.Training is theory based rather than skill and programme oriented. 8.Lack of uniformity in duration, emphasis and methodology of training. Issues (contd)

9.Non functional District training Centres/Teams (DTCs), ANMTCs etc 10.Existing trainers may not be equipped with necessary skills to impart the training. 11.In EAG states, where there are large number of untrained personnel and trainers are few, the states feel they cannot complete training; backlogs keep growing and programme implementation suffers. 12.No linkage between training institutions, trainer and trainee and no follow up. Issues (contd)

9.Lack of follow up after any training regarding putting to use the new skills. 10.There is no planned supervision as an aspect of continued education. 11.State ownership of SIHFWs? 12.No appropriate linkage between NIHFW, SIHFWs and HFWTCs & other training institutions. 13.Hospitals not providing services as per norms. Issues (contd)

Challenges Human Resource Planning at the national and state level. Plan for appropriate pre service training so that we get personnel suited to the job- this requires reorientation of medical and paramedical education Proper induction training at all levels. The new incumbents to be sent for induction before placement.

Challenges (cont) A training plan which takes into account the various categories and some system of time bound training Proper utilization of the trained manpower Finally- not to forget the private/NGO sector which provides much of the health care- we should partner with them in capacity building too. New initiatives of exposing the private sector to national health problems, policies, programmes and contribution they can make is a priority area to be given due consideration.

SUGGESTED SOLUTIONS

1.State & district need to prepare training plan based on National Training Strategy – Skilled manpower required for No. of facilities & type of services to be provided – No. of institutions required for imparting training. 2.To identity training institutions and trainers – Identify all available hospitals/institutions in all sectors i.e. govt., PSUs, railways, ESI, Armed Forces, NGOs & pvt. sector with adequate case load – Ensuring that personnel in these institutions are trained and are providing services as per GOI norms and they have necessary equipments and consumables.

3.Institutions: Each state to have its own apex training institutions linked, on one hand, to NIHFW, and, on the other, to the other training institutions in the state is essential. Each institute should be supported by appropriate subject experts with adequate field experience; co-opting local medical college faculty would benefit a lot. Training institutions should have infrastructure support like library, hostel, computers, communication, AV aids etc. SIHFW/state institutes should also be capable of undertaking training courses in organizational development/Change, leadership skills etc.

4.Coordination between MoHFW (training division), Program divisions, NHSRC and NIHFW for planning, implementation and monitoring, and resource material development. 5.Resource pool of trainers in different areas (including NGOs Experts, Retired Govt. Personnel interested in training, Experts from Corporate Sectors, Universities etc.). 6.Integration of training as far as possible.

Reduces time needed to train personnel – each category of worker learns skills for all tasks to be performed The primary and secondary care workers will learn about all the H&FW programmes and may learn to look at the multiple problems people have and learn to provide all needed care to the person/community, Ever-present problem of retraining of physicians when they get shifted to different levels, or between programmes eg. from RCH to malaria or malaria to TB will not be there. Horizontal integration at each level

7.Desk Monitoring:  Training information system - Collection, Compilation and analyze of monthly training performance reports submitted by States & providing feed back to States for any deficiency or lacunae for improvement.  State wise monthly/quarterly/annual performance reports on training  Quarterly and annual report would indicate number trained, how many of these trained came from institutions where that services was not being provided and how many institutions have been made functional with the services by using these trained personnel.  Analyses and providing feedback to MoH&FW every month.

8.Field Monitoring:  Developing monitoring tools for quality of training for various categories of health personnel.  NIHFW, SIHFW & office of the regional Director would undertake monitoring visits to (minimum of 5%): - assess hospitals and training institutions -assess content and quality of training

9.In order to enable routine monitoring GoI may incorporate progress in training in MIS; MIS should not only give numbers trained but also number of facilities where services have been made functional using such trained personnel. 10.Creation of GIS for available trainers in public and private sector for sharing resources and geographic coverage with training. Filling in the geographical gap based on the above exercise. 11.Supervision & monitoring of the trainings conducted by States/districts by the central teams on the lines of NRHM 12.Training Module for all health personnel need to be standardized including: – Core clinical content – Other required knowledge (Management, Finance, Gender, etc.) – Opportunities to practise the skills during training.

Summary There is a need for comprehensive & rational training plan Trainings to be conducted as per requirement & based on specific facility/district plan Once the training plan is developed : Identification of training sites/ centres Visit by programme officials Accreditation of training centres & trainers Send list of such accreted institutions to the state/centre Prepare schedule of posting of trainees & posting them after training Timely release of trainees by the states

Prepare Plan for Monitoring of training including budget. Monitor the quality of training during the training Follow up visit Submit the report by facility/districts wise

Training should be the priority for achieving the NRHM goals