1. Task sharing to auxiliary nurses to expand delivery of long-acting reversible contraception: PASMO Guatemala’s experience July 2016 Dr. Leonel Gómez

2. Source: PAHO 2013 CountryHealth Worker Density Guatemala12.5 Honduras13.6 Nicaragua16.0 El Salvador20.0 Belize23.8 Panama27.0 Costa Rica33.8 Health Worker Density in Central America, 2013 (Doctors, Nurses and Midwives per 10,000 people)

3. Health Worker Distribution in Guatemala, per 10,000 inhabitants Source: HAS –USAID/Abt

4.  Modern contraceptive prevalence rate (MCPR): 49%  MCPR much lower in the Western highlands (as low as 29% in one department) Source: DHS, 2014 (preliminary) Family planning in Guatemala

5. Insertion and removal of implants by auxiliary nurses? WHO guidelines

6. Insertion and removal of IUDs by auxiliary nurses? WHO guidelines

7. Piloting LARC insertion by auxiliary nurses With agreement from MoH and support from USAID’s SIFPO Project, PASMO trained and certified more than 400 MoH providers to insert LARCs (Copper-T IUD and Jadelle implants) in the context of voluntarily and informed choice. Doctors and nurses remained available to do removals 85% were auxiliary nurses, all in rural areas. National guidelines for FP prohibit auxiliary nurses from inserting implants, even though in practice they often do.

8.  Family planning methods, counseling, and provision  Medical eligibility criteria  Management of complications  Management & reporting of adverse events  Skills development  Practice with anatomical models and clients  Minimum 85% score on both skills and knowledge How: Training curricula and certification included

9. Quality assurance: Continuous supervision and medical audits Supportive supervision assessed provider knowledge and skills Ongoing training and assessments and constructive & immediate feedback closed performance gaps Medical audits were conducted for quality assurance Management of complications and adverse events

10. Results Implementation in 69 of the 133 facilities in SIFPO intervention area All facilities were staffed by auxiliary nurses who became responsible for offering voluntary family planning including LARC provision

11.  Increase in range of contraceptive methods offered by auxiliary nurses  Increase in number of women who chose to use more effective contraceptive methods Results: Services Training begins

12.  Persuaded by these results, the MoH has agreed to: –include LARC provision by auxiliary nurses in the next update to the national family planning guidelines (2017) –include training on LARC provision in the pre-service curriculum for auxiliary nurses once the guidelines change –Permanent access to medical instruments and consumable supplies specific for each method. –Communication efforts to increase clients’ awareness about the methods, their attributes and limitations, and to inform clients where they can find easy access to affordable, quality services. Sustainability

13.  Facility-based auxiliary nurses can be a valuable resource to expand contraceptive choice in underserved areas.  Ensure continuous monitoring processes, using on-the-job learning tools for closing gaps.  With rigorous research, test task sharing of LARC removals.  Best if the supervisor is also the trainer. Recommendations

14. Thank you Contact for questions about this presentation: Dr. Carlos Leonel Gomez, cgomez@pasmo-ca.orgcgomez@pasmo-ca.org

15. Adverse Event Reporting: COMPLICATIONS FROM IUD-IHS INSERCIONS (POST USER DISCHARGE) MEDICAL MANAGER Assist the treating physician via phone or in person to understand the user’s condition. Proceeds to give necessary recommendations and guidelines if needed (including a higher level referral). If necessary and nearby medical manager personally assists the treating physician in treatment of the user’s condition IMMEDIATELY reports complication to Medical Auditor Prepares a written report about the case addressed to the Medical Auditor, and must be submitted within 24 hours. Assist the treating physician via phone or in person to understand the user’s condition. Proceeds to give necessary recommendations and guidelines if needed (including a higher level referral). If necessary and nearby medical manager personally assists the treating physician in treatment of the user’s condition IMMEDIATELY reports complication to Medical Auditor Prepares a written report about the case addressed to the Medical Auditor, and must be submitted within 24 hours. MEDICAL AUDITOR AQV Reports IMMEDIATELY to PSI/PASMO Country Representative and Technical Supervisor. Follows up about the case with the MT of AQV from PlanFam or with the physician of the local team from PlanFam Prepares case report and submits to PSI/PASMO Country Representative and Technical Supervisor. Depending on the case, legal support and payment of user’s incurred expenses can be requested to the Country Representative. Closes the case from the medical point of view. Reports IMMEDIATELY to PSI/PASMO Country Representative and Technical Supervisor. Follows up about the case with the MT of AQV from PlanFam or with the physician of the local team from PlanFam Prepares case report and submits to PSI/PASMO Country Representative and Technical Supervisor. Depending on the case, legal support and payment of user’s incurred expenses can be requested to the Country Representative. Closes the case from the medical point of view. The user calls Health Service to inform her symptoms or goes directly to the CAIMI or Hospital. COUNTRY REP. Follows up on the case with Medical Auditor and PSI/PASMO Technical Supervisor. Reviews and signs the case report : returns it to the Medical Auditor and/or Technical Supervisor, to be send to PSI Washington. Prepares and signs the payment settlement for compensation of expenses incurred. Closes the case. Follows up on the case with Medical Auditor and PSI/PASMO Technical Supervisor. Reviews and signs the case report : returns it to the Medical Auditor and/or Technical Supervisor, to be send to PSI Washington. Prepares and signs the payment settlement for compensation of expenses incurred. Closes the case. USER TREATING PHYSICIAN The treating physician provides assistant to the user via phone or personally in the CAIMI or Hospital to understands the condition. If condition is able to be treated care is provided, if it is not user is referred to a service with the capacity to provide treatment. User condition is IMMEDIATELY reported to Dr. Carlos Ruiz, MT of AQV from PlanFam; advice is requested if necessary. Treating physician follows up directly with user or with the institution where user was referred to (this is documented). The treating physician provides assistant to the user via phone or personally in the CAIMI or Hospital to understands the condition. If condition is able to be treated care is provided, if it is not user is referred to a service with the capacity to provide treatment. User condition is IMMEDIATELY reported to Dr. Carlos Ruiz, MT of AQV from PlanFam; advice is requested if necessary. Treating physician follows up directly with user or with the institution where user was referred to (this is documented).