service delivery protocol

This document is produced by the Nigerian Urban Reproductive Health Initiative (NURHI)”

SERVICE DELIVERY PROTOCOL


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Table of Contents

CHAPTER 1: INTRODUCTION………………………………………………………………………………………………………..………4

CHAPTER 2: SECTION 1 - SERVICE DELIVERY…………………….………………..……..…..…………………………..…..…5

❖ 72-Hour Clinic Makeover………………………..……………………………………….……………………………..….…..….6

❖ Minimum Equipment Requirement………………….………………………………….……………………...….……9

❖ Modified Clinic Makeover For Type 2 PHCs………………………………….………….…………..………………..10

❖ Engagement Framework…………………………………………………………………..………………………………..……..11

❖ Family Planning Service Integration….....……………………………………………………..……………….……..13

❖ Engagement Framework………………….………….………………….......…………………………………………….……..14

❖ Family Planning Health Talk………….…………………………………………………..………………….………………...…16

❖ Presentation Topics 1 - Benefits of Family Planning…………………….………………………………….…….16

❖ Presentation Topics 2 - Introduction to Family Planning……………………………………………………..…17

❖ Management of Side-Effects: Bleeding……………………………………………………………………………….…18

❖ Management of bleeding from Contraceptive Use………………..…………………………..…………….…....19

❖ Monthly Outreach…………………..………………………………………………………….…………………….……….……..20

❖ Minimum Requirement for Consumables per outreach………….………………..………………..…….……...22

CHAPTER 3: SECTION 2 – HEALTH SYSTEM STRENGTHENING………..………………………………………..…….23

❖ Whole Site Orientation (WSO)………………………………………………………………….…………………………....23

o Presentation Guidelines for Session 1 ……………………….……………………………………………......25

o Presentation Guidelines for Session 2 ………………………..…………………………………………………25

o Presentation Guidelines for Session 3 ………………………………………………………………………26

❖ LARC Training for CHO/CHEW…………………………………………………………………..………..………….....28

❖ LARC (Implant) Training for CHO/CHEW…………………………………………………………………………….28

❖ NURHI 2 LARC (Implant) Training Agenda for CHO/CHEW…………………….……………………………..30

❖ Family Planning Supportive Supervision (FPSS)……………………………………………….………………….34

❖ On-The-Job Training (OJT)…………………………………………………………………………………..…………………...36

❖ Engagement of Senior Community Health Officers (CHOs)…………………………………………………….…38

❖ Implementation Plan For Pharmacovigilance Rapid Alert System For Consumer Reporting

(PRASCOR)……………………………………………………………………………………………………………………………….40

❖ Addressing Provider Bias…………………………………………………………………………………………………….41

CHAPTER 4: APPENDICES……………………………………………………………………………………………………………48


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❖ 72-Hour Clinic Makeover Flowchart ………………………………………………………………………………48

❖ Scope of Work for 72-Hour Clinic Makeover……………………………………………………………………..48

❖ 72-Hour Clinic Makeover Schedule…………………………………………………………………………..………50

❖ FPSS Checklist………………………………………………………………………………………………………………..…..51

❖ QISS Monthly/Quarterly Reporting Template……………………………………………………………….…..58

❖ Observation of FP Consultation…………………………………………………………………………………………60

❖ Service Provider Interview………………………….………………………………..……………………………………….61

❖ Client Exit Form……………………………………………………………………………………….………………………63

❖ Family Planning Clinic Set-Up ………………………………………………………………………………………………..65

❖ How to fill the Bin Card ………………………………………………………………………………………………………….70

❖ How to fill the Daily Consumption Register (DCR) ………………………………………………………………….71

❖ How to fill the Requisition Issue and Request Form (RIRF) …………………………………………………….72

❖ How to fill the Daily Family Planning Register ………………………………………………………………………..73


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The NURHI 2 Service delivery strategies are focused towards;

1. Improving the quality of family planning service delivery 2. Expanding equitable access of family planning services through new and existing

channels. The successful implementation of these strategies is hinged on the availability of standardized, functional and appropriate tools, guidelines, job aids and other necessary material relevant for monitoring and measuring observed changes related to family planning in all the NURHI 2 supported project states.

This document provides an outline of the tools and guidelines needed to implement NURHI 2 service delivery activities. The activities discussed here include;

A. Section 1 – Service Delivery

72 Hour Clinic Makeover

Modified Clinic Makeover of Type 2 PHCs

Family Planning Service Integration

Family Planning Health Talk

Management of Side-effects: Bleeding

Monthly Outreach

B. Section 2 – Health System Strengthening

Whole Site Orientation (WSO)

LARC Training for CHO/CHEW

Family Planning Supportive Supervision (FPSS)

On-the-Job Training (OJT)

Engagement of Senior Community Health Officers (CHOs)

Implementation Plan For Pharmacovigilance Rapid Alert System For Consumer Reporting (PRASCOR)

Addressing Provider Bias

CHAPTER 1: INTRODUCTION


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72 Hour Clinic Makeover

Modified Clinic Makeover of Type 2 PHCs

Family Planning Service Integration

Family Planning Health Talk

Management of Side-effects: Bleeding

Monthly Outreach

CHAPTER 2: SECTION 1 – SERVICE DELIVERY


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Format The 72-hour clinic makeover is conducted from the close of business on Friday and completed on Monday morning with a commissioning when a newly refurbished center is opened to healthcare workers and clients. The process is commenced by;

Conduct Performance Improvement Assessment (PIA) to review; - Infrastructure including equipment - Human resources including distribution by cadre, skills proficiency and training

needs

Share findings with SMOH and all stakeholders

Develop Performance Improvement Plan (PIP)

Identify medical equipment vendors - Visit and inspect their facilities to verify their capacity to deliver on specifications.

Set-up state level procurement committees who will; - Review the scope of work required in each facility - Review the quantification and quotations submitted by artisans - Review processes and costs for direct purchases at the state level.

Identify local artisans in the community where the facility is located. Different artisans should be identified for; - Carpentry - Tiling - Plumbing - Electrical work - Mason - Painting

A minimum of 3 artisans in each specialty should provide quotations (including invoices) for the renovations identified.

Conduct a market survey for direct purchase of building materials, mainly paint, tiles, net meshing and PVC.

Group health facilities into batches and develop a schedule to cover a maximum of 5 facilities per weekend within the same LGA or locality. There should be 15 to 20 facilities per Batch.

Develop 72-hour clinic makeover budget - Equipment needs per facility - Quantification for renovations - Logistics budget (including transportation, haulage, cleaning, feeding, etc.)

Develop work plan, specifying the various roles and responsibilities of NURHI 2 staff Inspect all equipment and instruments on delivery to ensure they are meet the required

NURHI 2 standard/specification

72-HOUR MAKEOVER


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Minimum Requirement

Waiting Area Comfortable and well ventilated area

Tile Paint Notice Board Patient 3-seater chairs Ceiling or standing fans Meshing/netting on the windows Waste bin TV set or Radio to keep clients informed on FP while waiting

FP Counselling room Provide a private counselling room (separate and demarcated from the FP

insertion room) Tile Paint Counselling/Consulting table and 3 chairs (1 provider and 2 client’s chairs) Standing/Ceiling fan Notice Board ✓ Filing cabinet ✓ Card shelves ✓ Weighing scale Stethoscope and Sphygmomanometer Pedal bin Curtains

FP Insertion room Tile Paint ✓ Pedal bin ✓ Curtains Sink with running water or Spigot bucket on wooden stand with receiver Medium medicine cupboard Gynaecological couch Sterilizer/ Manual autoclave with camp gas Instrument trolley and tray Small and medium size drum for cotton swabs and gauze Bed screen Angle poise lamp and or Head lamp

Toilet close to or attached to FP room Tile Paint Sink with running water Flushing toilet


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Scope of Work Procurement of Equipment

Branding & Distribution of Equipment - This should be completed at least a week from the commencement of infrastructural

overhaul. - Complete Delivery of Equipment to HVS – Tuesday to Thursday

Payments/Advance for Artisans - Wednesday

Photographer - Pre-makeover pictures taken on Thursday - During makeover pictures taken on Friday & Saturday - Post-makeover pictures taken on Sunday at completion of renovation, cleaning and arranging

equipment Supervision of makeover

- Facility staff e.g. Nursing officer-in-charge - Social mobilizer - Community member e.g. Ward health committee member * It is important to involve community members within the facility in the engagement of artisans and for the supervision of the makeover. This encourages community participation in maintaining and providing oversite in the facility. General oversight during the clinic makeover will be provided by 1 NURHI officer per facility.

Plaques - Identify dignitaries and engrave their names on the plaques - Fitted at the HVS on Sunday

Setting-up the facility post renovation on Sunday - Complete Cleaning - Arrange and display all IEC materials, job aids and NHMIS Tools - Arrange all commodities & consumables in the relevant shelves and cupboards

Commissioning Event is conducted on Monday Write-up a detailed report highlighting lessons learnt, success stories and feedback from the

implementation of the 72-hour makeover – this should be completed within 1 day of commissioning


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ITEM ITEM/DESCRIPTION QUANTITY

1 Cheatle Forceps & Container 1

2 Instrument Trolley - two shelves and four wheels stainless (each wheel with stopper)

1 3 Manual Autoclave - stainless steel pot with meter/gauge 1

4 Camp Gas for manual autoclave- 10 kg gas 1

5 Provider table - wooden, 4ftx 2.5ft, with three drawers 1

6 1 Provider; 2 Patients 3

7 Drum for swab (small) 1

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IUD Kit - 1 x Field 750mm x 750mm Blue, 2 x Gallipots 150ml, 1 x Kidney Dish 700ml Clear, 1 x Vaginal Speculum Large, 1 x Scissor Mayo 23cm Straight with Green Handles, 1 x Sponge Holder 19cm Plastic, 1 x Tenaculum Forcep 25cm, 1 x Uterine Sound (Hysterometer CH14) 4.67mm with nozzle

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9 Instrument Tray - stainless steel with cover 1

10 Bed screen - four-fold hospital ward screen, made of iron steel and canvas, 4 pieces panel, Dimension: (W) 500x (H) 1750 mm x 4

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11 Patient chairs – 3/4 seater. Oxford joint chair for waiting area, made with 18 gauges. 3” x 2” rectangular tubes for chair stand and seat; with 25mm round tubes and perforated sheet

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12 Weighing Scale - electronic bathroom weighing machine 1

13 Sphygmomanometer - mercury, medical desktop upper arm blood pressure meter

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14 Stethoscope - acoustic, with bell upwards 1

15 Pedal Bin - stainless steel, 12 litre 1

16 Mackintosh 2

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Gynaecological couch – three section metal frame, adjustable head rest on ratchet with back uplifting, adjustable leg section on ratchet with standard leg holder, fixed middle section with "U" cut for wash basin, top of the table upholstered and covered with cushioned and washable material

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18 Vagina Model 1 19 Penile Model 1

20 Angle poise lamp - brushed aluminium, desk lamp, cast iron base (with aluminium cover), tension spring technology, direct light

1

21 Head lamp with white bulbs 1

22 Implant removal forceps 1

23 Medium-Sized Medicine cupboard 1

24 Notice Board (big and small) 2

25 Cabinet 1

26 Plastic bucket with tap 1

27 Wooden stand- 2 layered with rectangular wall bracket 1

28 Plastic bowl for receiving effluent 1

29 Plastic drain for receiving instrument 1

30 Transparent rectangular plastic bowl with cover

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MINIMUM EQUIPMENT REQUIREMENT PER FACILITY


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Background During the first phase of the project, the concept of ’72-Hour’ Clinic Makeover was introduced which is renovation, repairs and equipment support to NURHI supported family planning clinics and integration sites at the antenatal care (ANC), delivery, post-natal care (PNC), immunization clinics, post abortion care (PAC), HIV counselling and testing (HCT) to provide ideal family planning services in line with the National Performance Standards for Family Planning. The aim of supporting integration sites with equipment and renovations in these facilities is to ensure referrals to High Volume Sites (HVS) to avoid missed opportunities. Result from Performance Improvement Assessment (PIA) revealed that some facilities had equipment that required repairs, some required rearrangement and cleaning, hence the need to modify the extensive 72-Hour clinic renovation concept to cleaning, repairing, and making functional what exist in the facilities.

In the second year of the NURHI 2 project, Type 2 facilities will be supported to provide family planning services, including Injectables and implants. A Performance Improvement Assessment (PIA) will be conducted in these facilities to determine the extent of upgrade needed. Fifty (50) Primary Health Centres (Type 2 facilities) will be identified in each project state. These facilities should be situated around already existing NURHI supported HVSs in the supported LGAs. The Type 2 PHCs will be supported with basic equipment such as weighing scale, stethoscope, sphygmomanometer, 3-seater patient waiting chairs, ceiling fans, notice boards, consulting table and 3 chairs (i.e. 1 provider chair and 2 patients’ chairs). In addition, PHCs will be cleaned, painted, re-arranged, waiting area will be demarcated from insertion rooms (where possible), floor will be improved and toilet in the FP clinic or general toilet will be repaired where damaged.

Criteria for Selecting NURHI Type 2 PHCs The criteria for selecting Type 2 PHCs are:

- Should be located within NURHI 2 supported LGAs, within an underserved slum - Should be located close to/around NURHI 2 HVS - Should not be supported by any other partner - Readiness of PHC i.e. already providing FP services even if limited and willing to scale- up.

CHAPTER 2 – MODIFIED CLINIC MAKEOVER OF TYPE 2 PHCS


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These PHCs will be engaged through outreaches, referrals and modified/minimal clinic renovations/repairs.

A. Outreaches Outreaches will be conducted two days in a month in each of the Type 2 facilities on a quarterly basis with the aim of mentoring in-house providers by a trained provider from the HVS. Outreaches will help these low-performing PHCs to increase the number of new FP users and

utilization of Long Acting Reversible Contraceptive (LARC). Social mobilization will commence a day before and on the scheduled day of the outreach to direct traffic to the outreach sites.

B. Referral Referral linkages and mechanism will be established in each PHC. Referral forms will be made available and training conducted on its uses.

C. Proposed priority areas for renovation/repairs i. Provide NURHI SD/DG materials, job aids and SOPs

ii. Painting of FP clinic iii. Curtains in insertion room for privacy iv. Partition waiting area from insertion room where necessary v. Repair or make functional patient toilets

vi. ANC/FP waiting areas – flooring, painting, notice boards, 3-seater chairs and ceiling fans

D. Equipment Support (Proposed matrix of equipment that can be purchased)

S/NO EQUIPMENT QUANTITY

1 Instrument Trolley 1

2 Manual Autoclave 1

3 Camp Gas for manual autoclave 1 4 Provider table 1

5 1 Provider and 1 Patients chair for counselling room 2

6 Patient chairs (3/4 seater. Oxford joint chair for waiting area, made with 18 gauges. 3” x 2” rectangular tubes for chair stand and seat; with 25mm round tubes and perforated sheet)

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7 Weighing Scale 1

8 Sphygmomanometer 1

9 Stethoscope 1

10 Pedal Bin 1 11 Implant removal forceps 1

12 Medium-Sized Medicine cupboard 1

13 Big Notice Board 1

14 Plastic bucket with tap 1

ENGAGEMENT FRAMEWORK


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15 2 layered Wooden stand with rectangular wall bracket 1

16 Plastic bowl for receiving effluent 1

17 Plastic drain for receiving instrument 1

18 Transparent rectangular plastic bowl with cover (big) 1

Requirements 1. An outsourced provider is assigned to supervise each PHC 2. Set up mechanisms for referrals to our HVS

- Provide them with referral forms and list of HVS nearest to them - Orientation on NURHI referral manual

3. Provide NHIMS registers, client/appointment cards, tools, guidelines and job 4. Give them contact details of NURHI SD team

5. The SD team will coordinate integration with other services (HIV/AIDS, Immunization etc.) depending on services available for integration.

6. Equipment support. 7. All Social and Behaviour Change Communication (SBCC) materials made available and placed

in proper position for example hang danglers on corridor along FP clinic. 8. Make available commodities and consumables, etc. 9. Ensure source of running water either tap or plastic bucket with tap. 10. Ensure infection prevention measures are in place. 11. Provide list of social mobilizers and their contacts. 12. Hang danglers along FP clinic corridors and directions to FP clinic in all integration sites.

Expected Preparations by NURHI 2 SD Team 1. Identify slum areas in NURHI 2 LGAs 2. Send list of selected PHCs to Senior Technical Advisor- Health Systems Strengthening and

Service Delivery 3. Conduct rapid needs assessment on each PHC 4. Conduct planning meeting with State and LGA FP coordinators 5. Conduct outreach events once a month in each slum area 6. Share monthly outreach report

Expected Outcome 1. Improved infrastructural capacity at the FP units (and other integrated sites such as ANC)

of Type 2 facilities. 2. Increase in the number of new acceptors in Type 2 facilities. 3. In addition, there should be an increase in the number of documented and completed FP

referrals from the Type 2 facilities to the NURHI supported HVS


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Background In the health sector, integration has been defined as a facility providing more than one service during the same working hour, and clients are being encouraged by providers to consider using the other services during the same visit, to make those services more convenient and efficient. Integrated services should be offered at the same service delivery point but where that is not feasible, strong referral systems are required to ensure that clients receive the high-quality service that they deserve (National Guidelines for the Integration of Reproductive Health and HIV Programmes in Nigeria (FMOH, 2008).

NURHI 2 Service delivery strategy will continue to focus on strengthening the integration of Family Planning (FP) into all units that provide Maternal, New-born and Child Health (MNCH) services to avoid missed opportunities. This will be done by ensuring that all integrated points have the necessary requirements to provide quality FP services.

Priority Integrated Points for NURHI 2 The aim of integration is to increase FP uptake which in turn raises Contraceptive Prevalence Rate (CPR). The units within the HVS with the potential to increase uptake of FP services include;

1. Immunization 2. Delivery 3. Antenatal Care 4. Post Abortion Care (PAC) 5. PMTCT/ART 6. GOPD

Based on the above list, the integration approaches to be deployed are highlighted below:

S/N Integration Point Integration Approach

1 Immunization Clients receive SBCC materials, give health talk & counsel, refer using colour coded tally

2 Delivery One-on-one counselling (Pre-& post-delivery), clients receive SBCC materials, counsel on PPFP and provide services immediately based on informed choice

3 Antenatal Care Clients receive SBCC materials, give health talk & Counsel, refer to FP clinic

4 Post Abortion Care (PAC) One-on-one counselling, group health talk, clients receive SBCC materials, refer to FP clinic

5 PMTCT/ART One-on-one counselling, integrate health talk into existing group counselling, clients receive SBCC materials, refer using colour coded tally

6 GOPD Give health talk and group counselling, clients receive SBCC materials, refer to FP clinic

FP SERVICE INTEGRATION (INCLUDING INTER/INTRA FACILITY REFERRAL)


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Engagement will be both at the primary and secondary facilities. Primary Health Care Facilities – NURHI 2 will promote the provision of comprehensive integrated services. Secondary Healthcare Facilities - In the General Hospitals, the FP unit and other MNCH services such as routine immunization, growth monitoring and nutrition is usually supervised by the community health department. However, other departments such as the Obstetrics and Gynaecology (O/G) department also provide other RH services such as ANC, delivery, PNC & post pregnancy FP services. In Lagos state, the O&G department is often located at the MCC (maternal and child care centers) within the General hospital, whereas the FP unit is often located at a different block/building. For FP integration to be achieved at the secondary facilities, HCWs from the O/G department and the Community health units must be engaged and well-informed on NURHI activities and current best practices in FP service delivery. This will be achieved through clinical meetings and during Whole Site Orientation (WSO), such that both departments are able to harmonize FP service provision in their center, especially with regards to sharing service utilization data to avoid under reporting and strengthen intra-facility referrals.

Requirements - Identify providers in each integration unit to be trained on FP with focus on

Interpersonal Communication and Counselling (IPCC) skills and referrals. Trained provider to cascade training on return to facility especially with regards to counselling and referral

- Make Social and Behaviour Change Communication (SBCC) materials available at these units (at the patient waiting areas, doctors’ consulting rooms and procedure rooms).

- All integration points will have FP registers that capture counselling and methods. These data will be captured as part of monthly service statistics at the FP clinic. In addition, client cards will be made available at the delivery units and MVA rooms. These cards should be returned to the FP clinic immediately after the service is provided for further follow up.

- In GH, all integration points will have the contact details of the FP providers and their contacts for an effective 2-way referral. For ease, it will be pasted on the wall. Also, referral booklets (in triplicate) will also be made available to all integration points.

- Make available Daily Consumption Records (DCR) to integration units that directly provide FP methods (such as delivery unit). The consumption data should be shared with the FP unit monthly so a holistic consumption data can be collated at the end of each month.

- During clinical meetings, Contraceptive Technology Update will be presented and this platform can be used to emphasize the importance of integration to get the buy-in of the Head/In-charge at these integration units.

- Integration units will be supported with basic equipment to support quality FP service provision.

Expected Preparations by NURHI 2 SD Team 1. Ensure integration points have the required SBCC materials. 2. Participate and support FP focused clinical meetings. 3. Ensure these units have referral booklets/tallies as required, DCR where necessary.

ENGAGEMENT FRAMEWORK


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4. Providers at integration points should also be supervised and On the Job Training (OJT) on IPCC and referral to FP clinic provided when necessary. Involve FP coordinators and LGA supervisors in supervision to ensure the clients are counselled for FP and referred.

5. Work closely with R, M&E officer to collect, collate and analyze monthly referral data from integration points

6. RM&E officer to share monthly referral data from these integration points with NURHI 2 team, State & LGA FP coordinators and during RH/FP/feedback meetings.

Expected Outcome It is expected that this approach will contribute to an increase in the number of new FP acceptors and a general increase in FP uptake. This will subsequently contribute to an increase in the contraceptive prevalence rate (CPR).

NURHI 2 Referral Structure


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Format

FP health talks should be provided at all FP service integration points (e.g. ANC, PNC, PAC, PMTCT/ART clinics, etc.), including during health talks in other clinical units in the facility

Time frame - 30 minutes (allow 15 to 20 minutes for health talk and 10 minutes for discussion)

Develop an FP Health talk calendar such that the two topics are discussed in the same clinic within a 2-week period

Use FP flip chart and other FP posters during the health talks

Also use penile and vaginal models (where necessary) during health talks

Discuss; Benefits of FP to the woman:

- It helps the woman regain her strength - Helps the woman to regain lost blood and tissues from child birth - Helps the woman get time to perform her economic activities and further her education - Promotes good health/enhance quality of life - Promotes mother’s nutritional status - Helps the woman take care of the family effectively - Promote maternal survival/long life

To the father: - Eliminate the fear of unwanted pregnancy - Promotes father’s social wellbeing/long life - Allows father to plan for the family

To the child: - Enhances child survival - Promote bonding with the family - Enjoy better opportunity for better life

To the family: - Enhances family’s nutrition - Promotes economic growth - Promotes education of children

To the community: - Allows community to plan and manage its resources effectively - Discourages social delinquencies - Promotes community unity

FAMILY PLANNING HEALTH TALK

PRESENTATION TOPIC 1 - BENEFITS OF FAMILY PLANNING


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Discuss; What do you understand by Family Planning/child spacing Types of FP Methods

- Injectables - Oral pills - Implants - IUD - Emergency contraceptive - Natural methods - Condoms

PRESENTATION TOPIC 2 - INTRODUCTION TO FAMILY PLANNING


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Bleeding is a common but worrisome side-effect associated with the use of modern

contraceptives.

Although rarely dangerous, it is a major cause for the discontinuation of hormonal contraception and the resultant occurrence of unplanned pregnancy

Therefore, every NURHI supported facility should be equipped with the knowledge and skills to manage the side-effect of bleeding.

Format

Print and laminate the one-page instruction below, which should be available in all FP units and counselling rooms.

This document should be available for use by the FP service providers.

MANAGEMENT OF SIDE-EFFECTS: BLEEDING


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- Bleeding as a side-effect is not only peculiar to hormonal methods such as Implants and Injectables, but also IUDs.

- Adverse effects of hormonal contraceptives usually diminish to the point of acceptance with continued use of the same method.

- These complaints range from spotting to heavy bleeding and prolonged bleeding. - Whichever bleeding occurs, it is important to reassure clients that symptoms will likely

resolve within three months and oftentimes over the counter drugs will resolve most of the bleeding.

- However, some may need further evaluation and treatment. Educating clients about common adverse effects of hormonal contraceptives and IUDs helps to establish realistic expectations.

MANAGEMENT 1. HISTORY

Duration and quantity

If it coincides in timing with implant/IUD insertion/injectable use

Presence of abdominal pain or fainting 2. PHYSICAL EXAMINATION

Check for pallor

Check BP

Check the implant/IUD if it is still in place

Check for pregnancy and it related complications

*If no underlying condition is suspected (implant or IUD is still in place and bleeding started after initiation of the method)

- Reassure the client that bleeding changes are common in women who are using Implants, IUD and Injectables. They are not harmful and bleeding usually become less or stops altogether after the first year of use.

- If the client finds the bleeding unacceptable and there is no oestrogen contraindication, offer:

one cycle low-dose combined oral contraceptive (pill containing the progestin levonorgestrel). The same progestin present in the implants is best for controlling bleeding.

Suggest short course of non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen 400 mg bd for 3 days to be taken with food.

Or a short course of COCs for 1 to 3 months if there is no contraindication.

Vitamin C - If bleeding is very heavy (twice as much as usual):

check for anaemia. If present, treat and refer

advise on food containing iron/give iron tablets - If bleeding is unacceptable to the client or becomes a health threat, DISCONTINUE

IMMEDIATELY, counsel on alternative suitable and non-contradictory methods. - Uterine evacuation is not necessary and is CONTRAINDICATED.

MANAGEMENT OF BLEEDING FROM CONTRACEPTIVE USE


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Format

Draw out monthly calendar with the MCH, FP managers/supervisors, OICs and SMCs

Write activity profile, budget and dates to STL/ STA-SDHSS

Conduct planning meeting with facility OiC and FP supervisors to discuss logistics and how to ensure success of the outreach

Ensure availability of commodities at site, use of opportunity stock where necessary.

Social mobilizers will be engaged at the community level to create awareness and make referrals. Engage 2 SMs from the facility and 2 from the community/NURHI 2.

Modalities for mobilization are as follows; - Fliers are distributed in churches, communities during the neighborhood

campaigns/community dialogues. - Set up WhatsApp group where possible to keep track on the outreach and discuss

updates as the activity progresses - SMS blast: send text messages to disseminate information to leaders of groups,

mobilizers, influential persons, providers, MCH/RH coordinators and other community members.

- Use of town criers where applicable - Door to door and face to face mobilization

Consumables are purchased quarterly and distributed to the centers a day before the outreach using different modalities; 1. NURHI drivers drop the consumables 2. MCH/RH coordinators pick up 3. NURTW for distant facilities.

Ensuring Quality During Outreaches in Non-NURHI Sites/Type 2 Facilities

The providers in Type 2 facilities will be mentored by NURHI trained providers in both sites during outreaches

Provide basic equipment and job aids for infection prevention

Cluster the type 2 facilities/Non-NURHI sites with NURHI sites for referrals.

Next Steps

There should be a pre-planning meeting with SMCs, mobilizers and FP providers.

Conduct a debrief either by phone call or formal meetings with RH Coordinators, Head of facilities and SMCs to get a feedback on challenges experienced during the outreaches and come up with new strategies to improve the outreaches.

Document success stories and experience of service providers, clients, mobilizers and every team member that was involved during the outreach activities.

Begin early preparation for the next round of outreach activities for the next month

Create monthly outreach WhatsApp groups to share information and monitor the

MONTHLY FAMILY PLANNING OUTREACHES


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outreaches

Link outreaches with community engagements

Link non-clinical providers with outreach sites in the communities (Lagos)

Participant List

1. Facility based – In-house FP providers, cleaner, record-keeper and counsellor 2. Outsourced FP providers 3. Social mobilization consultants 4. Social mobilizers (community & facility based)


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S/N ITEM/DESCRIPTION QUANTITY/FACILITY 1 Latex Examination Gloves (100/pack) (10 packs/ carton) 2 packs

2 Needle & Syringe (5 mls) (1 pack x 100 pieces) 1 pack

3 Disinfectant Liquid (1 litre) (12 pcs x carton) 2 bottles

4 Antibacterial Hand Wash (500mls) (12 Pcs/ Carton) 2 bottles

5 Antiseptic Liquid (Purit/Salvon) (500 mls) (24 pcs x carton)

2 bottles

6 Surgical Gloves (50 pairs/1 box) (10 boxes x carton) 2 boxes

7 Universal Sample Bottle (1 pack x 25 pieces) 4 packs

8 2% Xylocaine Without Adrenaline (20ml) (1 Pack X 10 Pcs)

1 vial

9 Methylated Spirit (200mls) (48 Pcs X Carton) 2 bottles

10 Finger-length Plaster Strips 2 packs

11 Water For Injection (10mls) (100 Pcs/Pack) 25 pcs

12 Cotton Wool (500 gm) (25 rolls/pack) 2 rolls

13 Iodine (15mls) (12 Pcs/Pack) (144 Pcs/Carton) 2 bottles

14 Pregnancy Test Strip (50 pcs/pack) 4 packs

15 Surgical Scalpel Blade (100 pcs/pack) 2 packs

16 Sterile Underlay (50 pcs/pack) 10 pcs

17 Needle only (1 pack x 100) 1 pack

18 Needle & Syringe (2 mls) (1 pack x 100 pieces) 1 pack

MINIMUM REQUIREMENT FOR CONSUMABLES PER OUTREACH


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Whole Site Orientation (WSO)

LARC Training for CHO/CHEW

Family Planning Supportive Supervision (FPSS)

On-the-Job Training (OJT)

Engagement of Senior Community Health Officers (CHOs)

NURHI 2 Implementation Plan for PRASCOR

Addressing Provider Bias

Format The WSO is targeted at improving the knowledge and awareness of the health services that are available and offered within each health facility. It will be structured into existing meetings at facility level.

Sessions 1-3 will be completed with NURHI oversight and the repeated sessions will be facilitated by the OIC with NURHI as observers/ supervisors.

Sessions 1 to 3 will be conducted over a 6-month period, and then repeated again during the last 6 months of the year. This ensures that new or rotating staff is engaged within a short period of time.

A certificate of completion will be issued to each participant after completion of both sessions by the end of 6 months.

Time frame – 1 to 2 hours

Certificate of attendance after 6 months (desktop printed and laminated with signature of STL and STA-SD/HSS

Distribute DG fliers & method leaflets.

Use Standard flip chart

Involve the OICs/ trained provider to deliver the topics on the agenda.

Involve the FP managers and consultants.

On a case by case basis, consider merging WSO and FPSS in one quarter so that it is carried out the same time by the FP consultants/supervisors.

Participants attendance list

Provide some refreshments based on number of participants per facility.

Develop a presentation guide

Use flip chart as a presentation guide.

Session 1 Agenda/Topics

1. The role of family planning in improving the standard of living.

2. Traditional methods of birth spacing/family planning 3. Modern methods of FP (types, uses, benefits and side effects) 4. Myths and misconceptions about family planning (Addressing myths and

CHAPTER 3: SECTION 2 – HEALTH SYSTEM STRENGTHENING

WHOLE SITE ORIENTATION


24

misconceptions on FP)

5. Male involvement

Session 2

Agenda/Topics 1. Role of health care giver in promoting FP 2. Factors affecting utilization (Attitude, cost, method mix, side effect, biases, socio-

cultural, clinic environment etc.) 3. Referrals 4. Clinic organization/Infection prevention/Performance standard 5. Discussion on key Outcomes of Omnibus survey as it relates to program implementation and

successful outcomes 6. NURHI demand generation (drama series, radio/TV programs, FP slogans)

Session 3

Agenda/Topics

1. Adolescents and Youth.

2. Life Planning for Adolescents and Youth (LPAY) Services.

3. Key Components of Youth Friendly Healthcare Services.

4. Role of Health Care Giver in LPAY. Participant List

• All facility staff

• All support staff (cleaner, gardener, record officer, etc.) • Facilitator • FP Clinical Practicum Student • Interns • Key community members/stakeholders (optional) • Social mobilizers

Sustainability Plans 1. Leverage on the regular meetings that hold in the health facilities and dedicate one of the

meetings to WSOs. 2. Key into cluster meetings (general staff meeting) held in the LGAs and facility and

dedicating a session for WSO


25

1. How FP improves standard of living;

Define FP

Benefits of FP to the woman

Benefits to the father

Benefits to the children

Benefits to the community 2. Traditional methods of FP

Generate list of traditional methods within the community

Discuss new and old societal beliefs around rearing children

Discuss failures of traditional methods 3. Modern methods of FP

List modern methods

Uses

Side effects and how to deal with it, including when to report to the clinic 4. Myth and misconceptions/rumors

Define myth & misconception

Generate list of rumors & misconception

Address them 5. Male involvement

Discuss roles of men in FP/consent

Male methods of FP

Discuss how to get support of men in FP

1. Role of health care giver in promoting FP

Present overview of FP and its benefits (facilitator should briefly review the different FP methods and their benefits

Family planning method promotion through use of SBCC materials (jingles, radio drama TV series, neighborhood campaign) facilitators should discuss the various SBCC strategies of NURHI and find out if they are familiar with it

Outline the importance and the need to create awareness about these activities

Trainers should add on to roles enumerated by participants. 2. Factors affecting utilization of FP services (Provider’s Attitude, cost, method mix, side

effect, biases, socio-cultural, clinic environment etc.)

Discuss how the factors affect uptake of FP

Address issues raised based on the discussion

Reemphasize the importance of FP 3. Referrals

Discuss FP methods available in the facility

Discuss the involvement of the participants in referring potential clients to the facility.

PRESENTATION GUIDELINES FOR SESSION 1 TOPICS



26

Discuss the importance of creating awareness in the community (in church, Mosque and community gatherings)

Discuss the importance of completed referrals (documentation and follow up)

Discuss the various levels of referral (when and where to refer clients). 4. Clinic organization/Infection prevention/Performance standard

Discuss the importance of infection prevention (waste disposal, hand washing and disinfection/decontamination)

Discuss the role of participants towards ensuring infection prevention 5. Discussion on key Outcomes of Omnibus survey as it relates to program implementation and

successful outcomes

Discussions on key issues identified from the conducted survey

Generate views from participants on their roles in addressing these issues

1. Adolescents and Youth

Definition of adolescent/youth (including physical, mental and emotional development)

Discuss characteristics of adolescents and youth

Discuss common challenges of adolescents and youth

Outline the youth/adolescent RH needs

2. LPAY Services

Components of LPAY services

Outline factors that inhibit uptake of LPAY

Outline factors that promote uptake of LPAY

Discuss the importance of integrating LPAY in other health and social programs/intervention

Discuss Counselling and Information for LPAY

Discuss Service Provision for LPAY

Discuss Referral for LPAY

3. Key Components of Youth Friendly Healthcare Services

Define and outline the components of Youth Friendly Healthcare Services

Discuss importance of neat, attractive and private settings

Discuss importance of simple and fast client flow within the facility

Discuss the importance of interpersonal communication skills in LPAY

Discuss the importance of confidentiality & privacy in LPAY

Discuss the importance of referral and linkage to appropriate services in LPAY

4. Role of Health Care Giver in LPAY

Discuss the role of HCW in LPAY

Outline telling signs used to identifying AYRH issues/needs in the community

Outline again the importance of adequate referrals and linkages to LPAY



27

Outline importance of linking youth and adolescents to confidential counselling/social services

Discuss linkage between HCWs and Social support services/relevant agencies or line ministries – outline state specific processes and contact details


28

Several NURHI 2 project health facilities have Community Health Workers (CHO/CHEW) as the family planning providers or as an assistant providing some FP services, but without adequate capacity to provide such services, especially in areas such as provision of LARC services.

The inadequate training capacity of these mid- and lower-level cadre health workforce contributes to limiting the access to effective contraceptive services in many settings.

Implementation of the Task Shifting policy is one of the essential interventions identified to address this gap.

NURHI 2 will contribute to the roll-out of this policy by implementing a Training on Implants (Implanon NXT and Jadelle) for CHO/CHEW in Year 2, and then subsequently implement a Training on IUD for CHO/CHEW in Year 3.

In Year 1 & 2, NURHI 2 trained CHO/CHEW on IPCC & Injectables.

In Year 3 & 4, NURHI 2 will further train these CHO/CHEW on LARC (Implants and IUD).

Format

The training will be held in 2 batches (25 participants per batch) per project state

Participants will be drawn from NURHI 2 supported facilities.

It is designed as a 2-week training comprised of;

1 week didactic lectures

1 week practical sessions

Post-training supervision through FPSS and review meetings will inform subsequent interventions provided such as mentoring, study trips or on-the-job training (OJT).

Technical Approaches:

Follow-up with PO-SD and Advocacy & DG team on ensuring SMOH’s domestication and dissemination of task shifting policy within the state.

Select participants from NURHI 2 supported HVS where the CHO/CHEW are FP providers or assisting in FP service provision.

Identify trainers from the pool of NURHI state master trainers, and hold a pre-training meeting with the trainers.

Conduct the training in 2 batches at each state level. This should comprise of 1 week didactic sessions and 1 week practical.

Each participant will be provided with a practical log book to record their practical experiences and technical support received towards ensuring proficiency.

Develop a supportive supervision schedule to commence 6 weeks after completion of the training and subsequently once every quarter.

During supervisory visits, emphasis should be placed on monitoring; - Adherence to provisions in the Task-shifting policy

LARC TRAINING FOR CHO/CHEW

LARC (IMPLANT) TRAINING FOR CHO/CHEW


29

- Adherence to National FP service protocols and guidelines

- Knowledge and skills proficiency

Use the findings from FPSS to plan interventions to address any identified quality gaps.

Expected Outcome

Increase in the number of service providers able to provide a wide range of contraceptive methods including LARC.

Expanded FP access to increase FP uptake.


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TIME SCHEDULE DELIVERABLES

Day 1 - ADDRESSING KNOWLEDGE AND SKILL GAPS: ADHERENCE TO SOP/GUIDELINES 30 mins Participants’ Registration, Pre-Test

10 mins Opening (Prayer, Introduction, Welcome Address)

30 mins Overview of Task shifting and Family planning in Nigeria

1. Brief overview of FP in Nigeria 2. Relate FP overview to

demography and population issues in Nigeria

3. Discuss Task shifting policy and reasons behind it

4. Roles and limitations of CHO/CHEWs in Task shifting policy (each state should clearly define state guidelines in roll out of the Task shifting policy) STATE FACILITATOR (CHO Board or SMOH)

1 hour Male & Female Reproductive System 1. External and Internal organs relating to FP

2. Facilitator should relate the presentation with the models

3. Ovulation, Misconception, Fertilization and conception 30 mins TEA BREAK

1 hour LARC 1. Definition 2. Mention IUD and explain that it will

not be part of this training 3. Train on Implants (Jadelle &

Implanon NXT) - Definition, Mode of action, side effects, management of complications 1 hour Client assessment 1. History Taking & Physical examination

2. Laboratory investigation 3. Use of MEC Wheel & SOP

1 hour Family Planning Counselling BCS, Counselling skills- Teach the right technique 45 mins LUNCH

1 hour Role play 1. Client Assessment (use scenarios - 48 hours’ post-partum and breast feeding,

hypertensive, normal woman, HIV) 2. Pick participants to role play in front of

entire class or group the class into 2-4 participants per group

30 mins NURHI DLE videos Watch and discuss the supportive & unsupportive provider videos

NURHI 2 LARC (IMPLANT) TRAINING AGENDA FOR CHO/CHEW


31

30 mins Wrap up: Discussions, questions & matters arising

DAY 2 - ADDRESSING KNOWLEDGE AND SKILL GAPS: INCLUDING ADHERENCE TO SOP/GUIDELINES

20 mins Day 1 Recap

40 mins Management of side effects and complications of Implants

Adherence to SOPs

30 mins NURHI DLE videos Watch and discuss helpful and unhelpful provider

30 mins Role play Counselling and addressing a client with side effects from implants (Bleeding, weight gain & change in libido- act out these 3 scenarios)

20 mins TEA BREAK

1 hour Demonstration and practice of Jadelle insertion procedure on model

1 hour Demonstration and practice of Implanon NXT insertion procedure on model

30 mins Reflections from model practice sessions

45 mins Dispelling rumors and misconceptions

1. Definitions 2. Identify and discuss factors that fuel the

common rumors and misconceptions 3. Identify common rumors and

misconceptions 4. Roles and responsibilities of health care

workers in relation to rumors & misconceptions

45 mins LUNCH

1 hour Discussion & reflection session using pictures (HCD values clarification model)

Use HCD prototype/concept note to deliver this session

30 mins Handling difficult situations in counselling

Scenarios- Method failure & Missing implant


DAY 3 – HEALTH MANAGEMENT INFORMATION SYSTEM

20 mins Day 1 &2 Recap

1 hour Overview of NURHI 2 1. NURHI 2 and FP 2. NURHI 2 Activities- DG, SD & Advocacy

3. Expectations of CHO/CHEWs


32

2 hours FP monitoring tools 1. Daily Family planning register 2. Referral slip 3. Client record/appointment card 4. FP monitoring chart 5. Monthly summary form STATE HMIS

20 mins TEA BREAK

1 hour Group work/ Practical filling of forms/Plenary

Monitoring tools

1 hour CLMS 1. Daily consumption record (DCR) 2. Requisition issuing and request form (RIRF) STATE/LG FP COORDINATOR

30 mins Group work/Practical filling of forms/ Plenary

CLMS tools

45 mins LUNCH

1 hour Demand Generation 1 1. Outreaches and its documentation- use of referral slips

2. Mobilization- using referral cards 3. Link to Radio/TV drama

30 mins Demand Generation 2 Health Talks- using NURHI standardized talking points at integration points


DAY 4 – INFECTION PREVENTION PRACTICES/ IMPLANT REMOVAL TECHNIQUES

20 mins Day 1, 2&3 Recap

1 hour Infection Prevention: General Hygiene/Clinic setting and Management

Lectures & Demonstration/ Practical session

1 hour Infection Prevention: Aseptic Technique & Hand washing/ Gloving


20 mins TEA BREAK

1 hour Infection Prevention: Decontamination and Sterilization


1 hour Infection Prevention: Waste Segregation & Disposal

Colour-coded Bins and Disposal of Sharps

2 hours Implant removal techniques 1. Demonstrate & practice removal of Jadelle 2. Demonstrate & practice removal of

Implanon NXT

45 mins LUNCH

1 hour Continue practical session on Implant insertion and removal


DAY 5 - INSERTION/REMOVAL TECHNIQUE CONTINUES


33

30 Recap: Day 1 to 4

1 hour NURHI DLE video on CLMS Followed by Role play & Discussions 1 hour NURHI DLE video on DG &

Testimonials Discussion & Reflection of Key issues

20 mins TEA BREAK

1hour 30mins Continue practical session on Implant insertion and removal

30 mins Preparation for practical


Recap of participants’ roles & responsibilities in relation to the Task shifting policy & NURHI 2 activities

45min Lunch/ Closing

TIME SCHEDULE FACILITATOR

WEEK 2

DAY 6 to 9 - PRACTICAL SESSION AT CLINICAL SITES

9:00-3:00pm Practical (clinical sites)

3:00-4:00pm Reflections from Clinical Practices (at the clinical sites)

4:00-5:00pm Adjournment

DAY 10 - NEXT STEPS & CLOSING

9:00-1:00pm Practical (Clinical sites)

1:00-1:30pm Participants’ re-convey to the training hall

1:30-2:00pm Review of sessions

2:00-3:00pm Post test

3:00-3:30pm LUNCH

3:30-4:00pm Training evaluation

4:00- Closing


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Format Supervision is an important activity that helps strengthen service delivery through provision of technical assistance and mentorship. Supportive supervision helps to ensure that service providers give optimal quality of service at the service delivery point such that side effect and complications are reduced to the barest minimum. FPSS provides opportunity for supervisors to detect early critical issues needing attention and to identify other capacity building needs of service providers. In NURHI 2 supportive supervision will be conducted at three different levels such that all facilities will be covered during the quarter.

The first level of supervision will be carried out by Family planning supervisors at the LGA level using the summarized FPSS checklist. Report of such will be shared with NURHI 2 (QISS Officer). This is very important to institute the culture of supervision as a sustainable strategy. The second level will be conducted by NURHI 2 consultants who will also integrate other program activities such as WSO and OJT. The third level of supervision will be conducted by the QISSO to ensure that facilities with critical issues are given priority attention. The HVS will be shared among the consultants in a way that will facilitate prompt conduct and reporting of the activities and the findings will inform the next level supportive supervision & OJT. Prior to the commencement of supervisory visits, the consultants and FP supervisors will be given a one-day orientation to further strengthen the trainings earlier received. This orientation will also include the newly hired consultants and newly deployed supervisors.

Technical Approach

QISSO to develop FPSS calendar with the LGA FP supervisors and FPSS consultants and shares it with the NURHI team.

QISSO to hold planning meeting with the LGA FP supervisors and consultants to tease out critical issues from previous FPSS reports.

Appropriate checklists should be used i.e. NURHI HSS template, and the post training supportive supervision tool (for the post training assessment).

LGA FP supervisors will conduct their routine visits to the facilities for monitoring and supportive supervision. NURHI 2 should liaise with them to use the findings from this visit to enrich the planning and conduct of the subsequent levels of FPSS visits.

FPSS consultants will conduct supportive supervision in the 3rd week in the 2nd month of the quarter to all NURHI supported facilities.

The third level FPSS will be conducted by the QISSO to bridge the gaps identified during the structured quarterly FPSS conducted by the consultants. This will further strengthen the capacity of FP service providers.

The supervisors at each level will write and submit reports detailing the outcomes of the exercises, technical assistance provided and suggest recommendations for improvement.

The QISSO will use the findings/outcomes to plan for OJT, WSO & subsequent support as necessary.

Active follow-up on all outstanding issues identified should be carried out and concluded during the quarter.

FAMILY PLANNING SUPPORTIVE SUPERVISION (FPSS)


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General Description of Responsibilities of FPSS Consultant

Visit the designated HVS during the period of the supportive supervision exercise as agreed with NURHI state office

Meet with each recently trained FP provider to elicit any concerns; assess performance using the checklists, HSS template

Check record of cumulative FP service delivery post training using the ‘Clinical Practical Record Booklet’

Observe FP service delivery and correct any identified gaps in skills especially counselling & service delivery for proficiency, as well as use of IEC materials/posters, USAID FP Chart etc.

Assess the infection prevention; hand washing, waste disposal/management, decontamination& sterilization process and other aseptic techniques with FP procedures

Support the trained providers for effective use of FP Job aids and guidelines (service protocol, MEC wheel, BCS/Counselling materials, performance standard etc) for quality counselling and service provision

Observe completion of HMIS and CLMS records and provide technical support where gaps are identified

Jointly ascertain FP commodity stock level with the provider

Ascertain linkage/referral system with the integration points PMTC, PAC, Delivery, immunization etc.

Meet with and brief FP unit heads and LGA supervisor on findings and jointly arrive at solutions/way forward

At exit, discuss findings and consensus with NURHI team (STL & QISSO)

Submit report to NURHI team (STL & QISSO)

Other task that will enhance quality FP service delivery at the FP units & their integration points (such as Whole site orientation, meetings as agreed with the QISSO) during the FPSS

See Appendix.

FPSS CHECKLIST


36

Format To address gaps in quality of FP service provision, NURHI will address quality improvement issues arising from the supportive supervisory visits to plan On-the-Job training (OJT) for FP service providers (i.e. CHEWs & nurses/midwives). An on-site intervention will ensure hands-on practice and demonstration of techniques, thereby improving providers’ confidence. OJT can only succeed if key stake holders buy into the system and participate actively in the decision-making process. It must be embedded within Government structures and driven by their functionaries. Therefore, LGA FP supervisors will conduct the OJT with oversight from NURHI staff. They will use a simplified OJT document/checklist and On-the-Job Training Manual, as the core tools during their visits to the facilities. This helps streamline their work and promotes sustainability of OJT activities.

Objectives To ensure that FP providers are mentored and practice of new skills reinforced with feedback to ensure competency.

Tools

Performance Standard for Family Planning Services in Nigerian Hospitals (FMOH)

OJT Manuals (counselling, logistics, clinical)

OJT Checklist

Technical Approach

The QISSO will identify and categorize the supported facilities into those that have CHEWs as providers and those with Nurse Midwives as providers.

The QISSO will also identify those facilities that have a CHEW as the assisting provider, so that these assistants will also be included in the OJT for CHEWs schedule.

The QISSO will also consider the facility overall level of performance to cluster facilities with similar identified gaps to plan the OJT.

In every quarter; Month 1

- Conduct FPSS for CHEWs and Nurse Midwives - Provide immediate on-site technical support/coaching/mentoring - Analyzed reports should be ready by the end of the month

Month 2

- Follow-up on issues identified in Month 1 - Repeat FPSS for CHEWs and Nurse Midwives - Provide immediate on-site technical support/coaching/mentoring - The QISSO will tease out findings/feedbacks from the different reports to inform the

planning for the quarterly on-the job training

ON-THE-JOB TRAINING (OJT)


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Month 3 - Conduct structured OJT for the specific cadre (CHEWs/Nurse Midwives) on a quarterly basis. - The LGA FP supervisors and NURHI FP consultants will conduct the OJT with technical

oversight by the QISSO.

- Plan and conduct the OJT in batches, such that providers with similar gaps in knowledge or skill will be clustered into small groups of 5-10 participants.

- The duration of the OJT per cluster will be based on their scope of work and identified gaps, usually for 3 days ranging between 3 to 4 hours per day.

- Write and submit detailed report with pictures and signed participants’ attendance sheet. - Reporting Requirement - Two copies of the written report (including an electronic version) should be submitted by the

consultants 3 days after completion of the activity. - The QISSO will provide feedback to relevant officials including the trainees and facility

personnel before the next supportive supervision. - Reports should summarize key findings during the OJT highlighting strengths, improvements

made (based on FPSS previous observations), areas that need further improvement and recommendations for improving performances.

- The report is important in identifying and following up actions required for improving performance of trainees at various facilities.

Process of OJT

Identify OJT needs

Develop agenda together with the supervisor and share topics

Determine number of training days

Cluster facilities for effectiveness

Determine a suitable venue for both didactic and practical sessions

Inform facility ahead of time and conduct OJT, outlining major achievement in the reports and other gaps identified

Guide on how to fill the checklist

Tick as appropriate all topics covered with date

Indicate in the remark section all outstanding and important information regarding the OJT

CHECKLIST FOR ON-THE-JOB TRAINING


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Background

Senior CHOs are the CHOs who have the highest experience in the Primary Healthcare Centres (PHC) of the local government areas (LGAs). They report to the Medical Officer of Health (MOH) or RH/FP coordinator in the local government. The most senior CHO is usually a member of the LGA PHC Management Committee and is registered with the National Association of Community Health Practitioners as with other CHOs. They are responsible for supervising and monitoring other community health workers as well as TBAs. As regards FP, they are allowed to counsel as well as give pills and injectables. Following the dissemination of the task-shifting and task sharing policy at the National level, and adoption and domestication at the state level, the CHOs are now allowed to offer long-acting methods.

Therefore, the scope of work of the senior CHO’s include;

- Provision of FP counselling and services

- Supervision of other junior cadre staff and non-clinical HCWs

NURHI 2 will train the Senior CHOs in order to equip them with the necessary knowledge and skills to adequately carry-out their duties. This will help ensure sustainability of NURHI 2 engagement with non-clinical providers and will strengthen supportive supervision of non-clinical providers thus ensuring optimal quality of FP service delivery at all levels of care.

NURHI 2 will support the senior CHOs through;

• Capacity building through TOT: To equip them with knowledge and skills in IPCC, FP, referrals and supportive supervision. This will also help to establish a pool of trainers at the state level who are then able to cascade the training to other CHOs, CHEWs, VHWs and TBAs.

• Provision of tools, FP materials and job aids for them to carry-out their roles and responsibilities.

• Hands-on coaching and mentoring to equip them with the skills to replicate same to their subordinates in their communities.

The scope of NURHI’s engagement of the CHOs will be achieved in the following ways;

1. TRAINING – This will involve training to address the knowledge and skill gaps identified. The training will cover FP, IPCC, referral, use of tools and supportive supervision skills.

Objectives:

To equip them with knowledge and skills on FP counselling and services.

To equip them with knowledge and skills for supportive supervision.

Scope of Training:

Knowledge and skills on IPCC

ENGAGEMENT OF SENIOR HEALTH OFFICERS


39

Knowledge and Skills on FP (including LARC)

RH policy and Adolescent friendly services

FP Referral and linkages

Supportive Supervision and OJT

Methodology:

Demonstrations and return demonstrations.

Presentations.

Role Plays.

Practical Sessions.

Expected Outcome:

Increased number of service providers for a wide range of FP service provision Including LARC.

Improved IPCC skills.

Increased pool of competent community health workers.

Adolescent/Youth friendly community health workers.

Improved supervisory skills for effective FPSS and OJT functions.

2. PROVISION OF TOOLS AND JOB AIDS – This may include printing and distribution of the existing NURHI tools to all the senior CHOs. The tools and job aids include tools for supportive supervision, NURHI job aids, MEC wheel, BCS card and the RH wheel.

3. PERIOD OF MENTORSHIP WITH THE LGA FP COORDINATOR – This will be to create the opportunity for direct observation and learning from the mentoring skills from the FP coordinators.


40

Background In Nigeria, NAFDAC coordinates the activity of pharmacovigilance and distributes the pharmacovigilance forms (Yellow Forms) to most hospitals/clinics in the country to report on drug complications or adverse drug reactions with a goal to sensitive the public and conduct further in-depth research of the ingredients of the drug causing the reaction including family planning commodities. There has been difficulty in ensuring that hard to reach areas always have constant supply of these forms and to cash in on the use of mobile forms for reporting, NAFDAC designed Pharmacovigilance Rapid Alert System for Consumer Reporting (PRASCOR) which is a short code service for consumers to alert NAFDAC of drug safety and quality issues via SMS. With the use of PRASCOR, pharmacovigilance reporting is easier to document and track.

How it works The service works in three simple steps Step 1: A consumer sends information with the name of the medicine or product and the suspected ADR by SMS to the number (short code) 20543 for free on MTN, Glo and Etisalat. For example: “I took paracetamol and cannot sleep”. Step 2: An auto response acknowledging receipt of the alert and next steps is sent to the consumer (sender). Step 3: The information is forwarded to NAFDAC by secure email to be accessed only by NAFDAC staff at the National Pharmacovigilance Centre; the received message will help NAFDAC to contact you for more information that will be used to fill an ADR reporting form if needed or to guide the consumer on what next to do.

Implementation Plan for NURHI 2 Project

Share PRASCOR short code during FPSS visits with service providers both at HVS and Type 2 facilities.

Document on yellow forms

Collate and report on any adverse drug reaction monthly

PHARMACOVIGILANCE (PRASCOR)

RAPID ALERT SYSTEM FOR CONSUMER REPORTING


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NURHI 2 adopted 3 main strategies to address provider bias and positively change service providers

attitudes towards the use of modern contraceptive methods irrespective of the clients age, marital

status or parity. The section of this document addresses how each of these strategies is deployed on the

field.

Background

The values clarification session is an important component of the National Family Planning (FP)

training curriculum. The game was remodelled to deliver the session in a more interactive manner that

challenges providers to explore the reasons behind their beliefs which stimulate insight for behaviour

change.

Format

This involves three exercises;

• A Post-It Exercise

• Use of problem statements

• Use of 5 Why Techniques

Discussion Topics

It involves discussion on the problem statement listed below:

Problem Statements

1. FP promotes promiscuity.

2. Most community members do not view teen pregnancy as a problem.

3. My religious beliefs do not allow me to provide certain methods to certain clients.

4. All couples should have a child within a year of getting married

5. Young unmarried individuals should have access to FP services

6. Side effects are a major constraint in providing modern FP methods

7. I tell women to use non-hormonal methods so they don’t have side effects

8. A woman must have had a child before using the IUD

9. I would give a young person family planning to help prevent unsafe abortion or death.

10. I would require partners’ consent before giving any family planning.

11. Women that do not have children should not use FP because it can cause a delay in pregnancy

Before the Session

• Write each problem statement on a different flip chart and demarcate each flip chart into four

segments and label them according (strongly disagree, disagree, agree, or strongly agree).

• Paste each flip chart on the wall of the meeting venue.

ADDRESSING PROVIDER BIAS

A. MODIFIED VALUES CLARIFICATION GAME


42

• Ensure updated National guidelines and tools are available such as the Medical Eligibility Criteria

Wheel, Service Protocol and necessary job aids

During the session

• Facilitator introduces the session, explains how the remodelled values clarification session defers

from the previously conducted values clarification sessions.

• The facilitator emphasises that there are no wrong or right answers and the aim is to reflect on

the content of the discussion while always referring to national guidelines

• Facilitator read each problem statement and participants are given post-it notes to paste their

preferred choice for each statement.

• As soon as the voting for each problem statement is concluded, the statement and responses

that follows are discussed, while counting number of post-it notes under each segment (strongly

disagree, disagree, agree, or strongly agree).

• The facilitator carefully uses the ‘5-Why’ technique to dig deep and get to the understand the

beliefs participants hold strongly that hinders quality service provision.

• During each discussion, facilitators should provide the correct information by referencing the

National FP service protocols, FP guidelines and tools such as Medical Eligibility Criteria (MEC

Wheel). These tools should be available at the venue.

• This session will last for 30 - 45 minutes.

After the Session

• The facilitators will then provide an opportunity for general discussions around the participants’

involvement in the session and the lessons learnt

• Participants are allowed to then vote again on their preferred choices to see if any attitudes have

shifted.

• At the end of the meeting or training, the number of “before” votes will be compared with the

number of “after” votes.

• This session will last for 10 – 15 minutes.

Participants List

Participants include State Ministry of Health and Local Government coordinators and supervisors,

family planning service providers, family planning master trainers and anyone involved in family

planning service delivery programming.

Sustainability Plans

The session is designed to be incorporated into meetings, fora or other engagements that involves

service providers such as trainings, Reproductive Health/family planning quarterly coordinators

meetings at the state level, during On-The-Job Trainings among others.


43

Background

This approach was designed to explore how the continuous dialogue between providers and clients

can improve client-provider interactions, provide correct information and enable FP service providers

to reflect on the effect of their biases on actual people

Format

The fish-bowl approach is employed to conduct group discussions between family planning service

providers and clients. There are equal numbers of participants in each group, ten participants in each.

Using the fish-bowl arrangement, chairs are arranged in two circles, the inner chairs are arranged for

clients (10 chairs) and outer circle of chairs for providers (10 chairs) as discussion starts with the

clients.

A facilitator is assigned to coordinate the entire process, guiding the discussion to remain within

context and relating participants’ responses to recommendations from the National service protocols

and guidelines.

The proceedings of the dialogue is as follows:

• Participants in the inner circle (starting with the clients) begin the discussion process while

participants in the outer circle (service providers) listen without contributing.

• At the end of the first discussion, there is a swap in the sitting arrangement of participants such

that the participants initially in the outer circle move to the inner circle and participate in the

discussion process.

• All participants are given the opportunity to participate, listen, share their views, reflect and

outline a way forward.

• At the end of both group discussions, the facilitator allows both groups to interact, resolve

matters arising including any follow-up questions raised and share insight into the issues raised.

This is also the time when the influencers share their comments and concerns.

• The facilitator will close the session with a summary of the proceedings.

Discussion Topics

Discussion is based on the group in the inner circle per time. Starting with the clients specifically family

planning users to intenders then those who have discontinued any family planning method. Facilitator

can start with a question such as:

• What are some of the beliefs that you have heard/exist regarding family planning? Why? Why?

Why?

B. CLIENT-PROVIDER DIALOGUE


44

Family Planning Users Intending Users Discontinued

Why did you decide to use family planning? Why? Why? Why?

Why would you like to use family planning? Why? Why? Why?

What family planning method(s) where you on before now?

What has your experience been like using family planning? Why? Why? Why?

Why haven’t you started using family planning yet? Why? Why? Why?

Why did you discontinue the method?

What are some of the challenges you have faced when accessing family planning services? Why? Why? Why?

What are your concerns around using family planning? Why? Why? Why?

Did you seek for services from a service provider? Why? Why? Why?

What has your experience been like with the family planning service providers at your health facility (e.g. your interaction with the provider, the way you were counselled)? Why? Why? Why?

What are your concerns around going to the health facility, in particular? Why? Why? Why?

What has your experience been like with the family planning service providers at your health facility (e.g. your interaction with the provider, the way you were counselled)? Why? Why? Why?

What recommendations do you have for how family planning service providers might improve the experience for family planning clients? Why? Why? Why?

What would encourage you to go for family planning services? Why? Why? Why?

Below are talking points for service providers, starting with general questions before asking questions

related to provider bias.

• How do you describe family planning to your clients? Why? Why? Why

• What should I expect from you if I come in for FP services? Why? Why? Why

• Should FP be provided to unmarried young girls and women? Why? Why? Why

• Should FP services be provided to newly married couples? Why? Why? Why

• Who is eligible to receive family planning services? Why? Why? Why?

• Do you require clients to get consent from their spouse before rendering services? Why? Why?

Why?


45

Participants List

Family planning providers, clients (including users, non-users and clients who have discontinued any

family planning method) and in some cases influencers such as gatekeepers, friends, community and

family members who play a role in the client’s FP decision making


The dialogue is intended to be integrated into existing community or facility meetings, which will be

facilitated by State and Local Government Area coordinators who have been trained.

Background

The Distance Learning Education (DLE) platform was developed in response to the need for the re-

enforcement of family planning skills after the period of training. The post-training tool is intended to

supplement existing forms of traditional training and supportive supervision with the aim to enhance

counselling skills for the management of side effects including addressing myths, improve adherence

to clinical protocols for providing family planning and increase ability to correctly and consistently

maintain contraceptive logistics management systems in the health facility. It also allows FP service

providers self-assess and make the necessary corrections based on appropriate lessons designed to

address common challenges encountered in FP service delivery. All videos in each component

(counselling, clinical and CLMS) modelled the ‘unsupportive’ and ‘supportive’ providers in different

scenarios.

Format

The application has five modules namely:

• FP counselling

• FP clinical method provision

• FP CLMS

• Demonstrative videos

• Instructional videos

• Library

Discussion Topics

Topics focus on each module listed above entail:

Family Planning Counselling

These videos address key barriers to quality counselling such as providers attitude, respecting clients’

needs and provider biases due to age, parity, spousal consent and marital status. The scenarios depict:

B. DISTANCE LEARNING EDUCATION APPLICATION


46

• Counselling following the Balance Counselling Strategy

• Integrating FP messages and referral at GOPD

• Post Abortion Care

• Post Pregnancy FP

• Counselling based on age, marital status and young unmarried, newly wedded couple and marital

status

Family Planning Clinical Service Provision

These videos explain basic clinical examination procedures, basic elements of clinical counselling, steps

required for FP provision including the use of the Medical Eligibility Criteria (MEC) wheel and managing

side effects associated with bleeding. The scenarios in this module depict:

• Management of bleeding secondary to FP use

Contraceptive Logistics Management System (CLMS)

These videos serve as a refresher to FP providers on the importance of logistics management. It also

reinforces the correct process for keeping accurate records and addressing common errors in filling of

the family planning LMIS forms listed below:

• Daily Family Planning Register

• Daily Consumption Record

• Bin Card

• Requisition Issue and Reporting Form

Demonstrative Videos

These videos are ‘How-to’ guide which illustrates what should be done when face with certain

circumstances to maintain delivery of quality services. These are:

• Clinic setting

• General Hospital Hygiene

• Steps to hand washing

• Steps to hand gloving

• Management of side effect secondary to FP use

• Documentation and reporting of services rendered to clients

• Segregation of medical waste

Instructional Videos

The content of these videos provides a step-by-step process of clinical procedures such as:

• Implant insertion, removal and common errors in administration

• IUD insertion and removal and common errors in administration

• Administration of Sayana Press


47

Library

This module contains relevant resources for FP providers such as:

• The Balanced Counselling Strategy cards

• Balanced Counselling Strategy Algorithm

• Medical Eligibility Criteria Wheel (2015)

• Method Specific Leaflets

• Infection Prevention Posters

• Frequently Asked Questions Booklets

Participants List

Participants to use this application include all healthcare workers especially Doctors, Nurses and

CHEWs at the family planning unit and other Maternal Newborn and Child Health (MNCH) unit,

General Outpatient Patient Department (GOPD).


The application is available on Google Play Store which is made available to as many healthcare

workers that is interested in downloading the content for use accordingly. Also, the link will be shared

with Federal and State Ministry of Health so it can be widely disseminated across all states in the

country.


48

*NOTE: Friday to Sunday – Renovations; Sunday – Cleaning and Arranging Equipment; Monday - Commissioning

Activity Monday Tuesday Wednesday

Thursday Friday Saturday Sunday

Commissioning

Branding and Delivery of Equipment

Payment of artisans

Photography Post pictures & commissioning pictures/video

Pre – pictures

During Pictures/video

Supervision of facility renovations

Nursing OIC, NURHI 2 staff, WHC rep

Nursing OIC, NURHI 2 staff, WHC rep

Nursing OI, NURHI 2 staff, WHC rep

Plaques

Setting-up post renovation

72-HOUR CLINIC MAKEOVER FLOW CHART

CHAPTER 4: APPENDICES

SCOPE OF WORK FOR BATCH 1 72-HOUR MAKEOVER


49

ACTIIVITY TIMELINE KEY

RESPONSIBLE/SUPERVISOR NURHI

LAGOS AHQ

Procurement of Equipment

Should start at least 1 week before makeover starts

Branding & Distribution of Equipment

Branding Equipment – 1 week Complete Delivery of Equipment to HVS – Tuesday to Thursday

Advance Payments for Artisans

Wednesday *Direct purchase of building materials and delivery to facility (Wednesday to Thursday)

Photographer

Pre-makeover pictures – Thursday During makeover pictures – Friday & Saturday Post-makeover pictures - Sunday

Social Mobilizers

- To inform community heads, WDC, etc about commencement of makeover activity - For Commissioning Ceremony

Plaques Confirm names written on plaque & fitted at the HVS – Sunday

SBCC Materials Complete Cleaning & Arranging – Sunday *All FP rooms will be arranged with equipment and SD materials after completion of the renovations

NHMIS Tools

Commodities & Consumables

Documentation

Write-up a detailed report highlighting lessons learnt, success stories and feedback from the implementation of the 72-hour makeover – this should be completed within 1 day of commissioning

Commissioning Event

Ribbons and Decorations should be in NURHI Colours *30 minutes to 1 hour event depending on request & preparations from the community

*KEY DATES:

Delivery of Equipment to NURHI Oyo Office – 15th to 19th August

Branding of Equipment for Batch 1 – 17th to 19th August

Batch 1 = 20 HVS over 1 month (i.e. 5 HVS every weekend for 4 weekends)

1 NURHI Officer to supervise 1 HVS during makeover (i.e. 5 NURHI Officers every weekend supervising; STL gives oversight function)


50

*Example with dates

DATES KEY DATES Name of Facility Supervisor Per Site

25TH to 27TH

August

- Delivery of Equipment from NURHI Office to 1st set – 22nd to 24th August

- Pre-implementation meeting with artisans & advance payment – 24th

August - Commissioning – 29th August

1st to 3rd

September - Delivery of Equipment from NURHI

Office to 2nd set – 29th to 31st

August - Pre-implementation meeting with

artisans & advance payment – 31st

August - Commissioning – 29th August

9th to 11th

September

- Delivery of Equipment from NURHI Office to 1st set – 5th to 7th September

- Pre-implementation meeting with artisans & advance payment – 7th

September - Commissioning – 12th September

16th to 18th

September

- Delivery of Equipment from NURHI Office to 1st set – 12th to 14th

September - Pre-implementation meeting with

artisans & advance payment – 14th

September - Commissioning – 19th September

72-HOUR CLINIC MAKEOVER SCHEDULE


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FAMILY PLANNING SUPPORTIVE SUPERVISION TOOL/CHECKLIST

Name of Provider: -------------------------------------------Cadre---------------Phone no-------------------- Name of Facility: ----------------------------------------------------------------------------- Name of Supervisor/Trainer: ---------------------------------------------------------------- LGA: ------------------------------------------- State: ---------------------------------------- Date of Assessment: ---------------------------------------

1 = POOR; 2 = FAIR; 3 = GOOD; 4 = VERY GOOD; 5 = EXCELLENT Mark Yes or No (as appropriate) and rate each task as assessed at each facility and/ provider

S/N

Availability /Performe d or indicate no.)

Performance rating

Scor e

Comments/remarks

Yes No 1 2 3 4 5

A Clinic management (setting/ organization, system etc.)

1 FP counselling room assessed

1. No counselling room 2. Not organized 3. Adequate and fairly organized 4. Adequate, organized and clean 5. Adequate, organized, clean and provides privacy

2 Assess FP Procedure room

1. No FP procedure room. 2. Adequate procedure area, equipment. 3. Adequate procedure area, equipment,

privacy. 4. Adequate procedure area, equipment,

privacy, good ventilation and lighting

Adequate procedure area, equipment, privacy, good ventilation, lighting and clean floor and walls.

FPSS CHECKLIST


52

3 FP Job aids/guidelines in place (SOP, performance standard, MEC wheel, BCS cards etc)- (These should be sighted)

1. 0 – 1 job aids available 2. 2 – 3 job aids available 3. 4 – 5 job aids available 4. 5 – 6 job aids available 5. 6 - job aids available

4 Updated CLMS & HMIS tools (FP register, DCR, RIRF, Referral forms etc.)

1. all tools not available 2. Only one available and

not updated 3. 2 tools available and not

updated 4. 3 tools available and

updated 5. All tools available and

updated

6 Contraceptives stock (please comment on availability by method with physical count)

0 -2 = 1

2 - 4 = 2

4 - 6 = 3

6 - 8 = 4

> 8 = 5

7 Infection prevention (hand washing, gloving, waste disposal & processing instrument)


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1. Poor handwashing, gloving and processing instruments

2. Good handwashing, poor gloving and poor instrument processing

3. Good hand washing, good gloving and poor instrument processing

4. Good hand washing, good gloving and fair processing instruments

5. Good Infection prevention (hand washing, gloving, waste disposal & processing instrument)

8. SBCC Materials- (indicate type available)

-FP methods leaflet per HVS

-Be Successful leaflet per HVS

-Be Beautiful A4 size leaflet

-Methods Poster

-Child birth spacing method

poster

-Yoruba method leaflet

-FAQ (English) and FAQ (Yoruba)

-Be Successful Leaflet

-Newman Street CD (Episodes

1&2)

-Newman Street fliers

-Se Rigbo fliers

-USAID Poster

-Method Specific Leaflets


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B No of trained available till date & assess equipment & infection prevention

Total no. of providers (by cadre):

DR= N/M= CHEW/CHO=

13 No. trained on Fresh

14 No. trained on refresher

15 No. trained on LARC

DR= N/M=

16 No. trained on IPCC & Injectables

NM= CHEW/CHO=

17 No. trained on CLMS

18 Provider transferred in

19 Provider transferred out

20 Service statistics & uptake (assess record of FP method uptake, discontinuation etc for the month/quarter

C COUNSELLING SKILL & SERVICE PROVISION

21 Confidentiality/privacy

1.No privacy 3. Limited privacy 5. Privacy

22 Uses visual/ job aids). Tells (give factual information) client about ALL FP methods

Screens client with the MEC chart to rule out contraindications or any other problems

Efficacy of method

Mechanism of action

Common side effects

How to use method


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23 Use of Job aids to support FP decision making

D Observe knowledge and skill to provide services with observation (insert names if available & indicate if not)

25 -Oral pill

1. Provider does all 7 = 5 2. Provider does 5 -7 = 4 3. Provider does 3-5 = 3 4. Provider does 2-3 = 2 5. Provider does 1 -2 = 1

26 -Injectable

15 = 5

12 = 4

9 = 3

6 = 2

3 = 1

27 Implanon NXT,

Jadelle

IUD


56

1. No pre choice and choice counselling, no client preparation, poor insertion technique, poor post insertion care and instruction and poor follow up counselling

2. Good pre choice and choice counselling, good client preparation, poor insertion technique, poor post insertion care and instruction and poor follow up counselling

3. Poor pre choice and choice counselling, good client preparation, good insertion technique, good post insertion care and instruction and good follow up counselling

4. Good pre choice and choice counselling, good client preparation, good insertion technique, poor post insertion care and instruction and good follow up counselling

5. Good pre choice and choice counselling, good client preparation, good insertion technique, good post insertion care and instruction/counselling and good follow up counselling

E General Comments: hospital setting, equipment, counselling & service provision, gaps etc. PLEASE RATE THE HVS

General comment:

F TECHNICAL SUPPORT PROVIDED

OVERALL RATING (If Immediate & serious, Moderate or Mild, & occassional attention needed)


57

G Follow up action points


58

S/N ITEM Indicate Number of Facilities Visited

Month Month Month %

Achieved Remark/Actions Taken

A. NURSES AND NURSE MIDWIVES FPSS

1 Number of facilities visited

2 Availability of FP Registers (HMIS & CLMS tools)

3 Availability of Job aids

4 Contraceptive stock (zero stock-out)

5 DLE Videos watched

6 Availability of SBCC materials

7 Trained provider

8 Infection prevention - Hand washing

9 Segregation of waste

10 Sterilization (Disinfect, Decontaminate and Storage)

OJT Topic -

B. CHEW

FPSS for CHEWs 1 Number of facilities visited

2 Availability of FP Registers (HMIS & CLMS tools)

3 Availability of Job aids

4 Contraceptive stock (zero stock-out)

5 DLE Videos watched

6 Availability of SBCC materials

7 Trained provider

8 Infection Prevention- Hand washing

9 Segregation of waste

10 Sterilization (Disinfect, Decontaminate and Storage)

OJT for CHEWs

Topic

Review Meeting for CHEWs

QISS MONTHLY/ QUARTERLY REPORTING TEMPLATE


59

C. Other Activities

WSO

Session1

Session 2

QIT QIT Inauguration

QIT Meeting

D. Summary of Activities/Findings (Use Bullet Points for each Sub-heading e.g. Training)

Description

Outstanding Activities and Plans for Achievement


60

(New User)

Perform the following: - Greetings, Introductions - Explain purpose of observation - Assure client and provider of confidentiality - Ask if there are any questions - Request for consent (from client and provider): Do you your permission for me to observe this consultation? If you wish, you ask me to leave at any time Proceed with the interview if consent is given

Background Information City/Town Name of Facility Date and Time of Observation

Questions 1. Does the provider ask about the client’s needs/wishes regarding FP methods?

2. What FP methods are discussed?

3. Does the provider use the contraceptive methods wall chart or other counselling materials during the session?

4. Is the client given any SBCC materials to take home?

5. Does the client appear to understand the options presented?

6. Does the provider pressure the client to use a particular method?

7. Does the client make the decision about which method to use?

8a. For the method that is chosen, what information is provided?

9. Did the provider discuss the benefits and possible side effects of this FP method with client?

10. Did the provider give appointment for follow up

OBSERVATION OF FAMILY PLANNING CONSULTATION


61

Perform the following: - Greetings, Introductions - Explain purpose of interview - Assure interviewee of confidentiality - Ask if there are any questions - Request for consent: Do you agree to participate in this interview? If you wish, you may end this interview at any time

Proceed with the interview if consent is given Background

Information City/Town Name of Facility Date and Time of Interview Name of Person Interviewed Position of Person Interviewed

Questions 1. What kind of FP/RH services do you offer in this facility?

2. How many FP methods are available in this facility? please name the methods

3. Do you counsel each client on all the FP methods? were told of other methods, by age, parity, SES, and marital status

4. What SBCC materials do you offer FP clients?

5. a Are clients allowed to choose any method of FP even if it is not available in this facility?

b. How do you address the needs of clients who desire FP methods that are not available in this facility?

6. Do you counsel and provide FP method to clients regardless of age, parity, marital status, etc., if

SERVICE PROVIDER INTERVIEW


62

yes which method and why?

7. (a) Are there incentives to encourage FP acceptance in this facility?

(b) If yes, what incentives?

8. Are all clients counseled on STI/HIV prevention and safer sex practices including condom use?

9. How is your performance as an FP provider assessed? Do you receive support from your supervisor(s)

10. Do FP providers have target numbers for FP acceptors in this facility?

11. Do you require consent from clients who want to obtain FP method? If yes, why

13. What are your recommendations for improving performance of FP providers?

Observations - Inspect for FP posters on the walls - Observe for other SBCC materials available for clients - Review HMIS and CLMS tools to check for variety of methods offered and for referrals


63

- Perform the following: - Greetings, introduce yourself - Explain purpose of interview - Assure interviewee of confidentiality - Ask if there are any questions - Request for consent: Do you agree to participate in this interview? If you wish, you may end

this interview at any time

Proceed with the interview if consent is given Background

Information

City/Town Name of Facility Date and Time of Interview 1. Are you currently using a family planning method? (If yes, answer all questions except question 9. If no, answer questions 6-11) 2. If yes, which FP method are you using?

3. How did you choose this FP method?

4 a. Were you told about other FP methods during counselling before you chose the method you are using currently------

b. If yes, Were you told about the benefits and possible side effects of this FP method?

5. Were you provided with any incentive to accept a FP method?

6. Did you feel your choice was respected by the provider?

7. What information did you receive on the different FP methods?

8. a Do you believe in FP myths and misconception? If yes, please mention one

b. if no, mention one myths and misconception that you have heard about

9. Were you given any pamphlets or brochures with information on different FP methods to read (or have someone read for you) at home?

10. Were you denied any benefits or services based on your decision not to accept a family planning method?

CLIENT EXIT INTERVIEW


64

11. (a) Did you receive any information on STI/HIV prevention and condoms from this facility?

(b) If yes, what information did you receive?

12. Do you believe more women are using family planning? If yes, why? -------------------------------- ------------------------------------------------------------------------------------------------------------------------------- -------------

If no, why do you believe other women are not using family planning …………………………………………………………………………………………… 13. Would you want to come back to this center or refer a friend or family member for family planning services, if yes why?..................................................................................

If no, why?...........................................................................................................................

14 a. Did you discuss family planning with you partner within the last 6 months, if No why?

b. If yes, what did you discuss?

15. Please do you have recommendations that will help improve the FP activities?


65

At resumption of work in the morning, the daily process in chronological order is as follows;

STEP 1 - All areas should be cleaned and dusted in preparation for the arrival of clients.

- Waiting Area –

▪ Ensure the waiting area is clean and tidy

▪ Ensure FP posters and leaflets are well displayed and can be sighted and picked by clients

▪ Black dustbin liners placed in all the trash bins

▪ Make adequate chairs available for all clients

- FP Counselling Room –

▪ Provider ensure all job aids are well laid on the table (MEC wheel, BCS cards, FP Method

leaflets, Client card, Appointment card)

▪ Demonstration tray with all the method samples should also be placed on the table

▪ Ensure the environment is clean

▪ Prepare the counselling chairs and tables

▪ Ensure proper display of posters and availability of FP guidelines/Job aids

▪ Ascertain the environment will support privacy

▪ Ascertain the availability and functionality of the basic equipment such as weighing scale,

sphygmomanometer & stethoscope

- FP Procedure Room –

▪ Ensure clean & aseptic environment/infection prevention practices such as setting for

processing used instrument for decontamination and sterilization

▪ Ensure sufficient lighting in the procedure room, availability and functionality of Angle-

poise lamp etc

▪ Prepare gynaecological couch

▪ Line dustbins with black bags.

▪ Ensure the sharp box is in place

STEP 2 - Set-up all work areas as follows;

- Waiting Area -

▪ Wall Posters on display should include –

✓ Welcome/Client’s Right Poster

✓ Hand Washing Poster and

FAMILY PLANNING CLINIC SET-UP


66

✓ FP Method Poster

✓ Know Talk Go poster

✓ Ask me Dangler

▪ Registration table – Items should be brought out from the cabinet or drawer and

displayed on the table. These include;

✓ Sphygmomanometer & Stethoscope

✓ Weighing scale

✓ Documentation tools –

o Clients Record Card

o Clients Appointment Card

o Referral forms

- FP Counselling Room

▪ Wall Posters on display should include –

✓ FP Methods Poster

✓ USAID Tiahrt Poster

▪ Ensure consulting table, chair for provider, 2 chairs for client and partner are available

▪ Items should be brought out from the cabinet or drawer and displayed on the table. These

include;

✓ Samples of contraceptives in a tray,

✓ Penile and vagina model

✓ Documentation tools – *Note: service provider should use pencil to fill forms

o HMIS Daily Family Planning register

o Daily Consumption Record (DCR)

o Requisition, Issue and Report Form (RIRF)

o Bin Card

✓ Sphygmomanometer & stethoscope should be properly displayed

✓ Counselling tools/guidelines

o MEC Wheel

o Performance standard

o Service protocol

o BCS cards

o BCS Algorithm

o FP Flipchart

o Method Specific Leaflets

o Be Beautiful and Be Successful

✓ Hand Washing Poster

✓ Family Planning Commodities


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- FP Procedure Room

• Wall Posters on display should include –

✓ Waste Segregation Poster

✓ Disinfect, decontaminate and store sterilized equipment Poster

✓ How to disinfect Poster

✓ Hand Washing Poster

STEP 3 – Be ready to receive/attend to clients following the outlined processes;

- Waiting Area

▪ For new clients, health attendant fills the Client Record Card and explains to client reason

for filling card which is to take medical history

▪ Health Attendant gives the Clients Appointment Card to hold so service provider can fill

appointment day after FP services are provided.

▪ Client then waits for her /his turn

- FP Counselling Room – When a patient enters;

▪ Provider welcomes client, makes atmosphere friendly and ensures privacy in the

counselling room by closing the door.

▪ Provider ensure good ventilation.

▪ Provider introduces herself, greet client, offer client a seat to make client comfortable and

confirms clients name on Client Record Card

▪ The BCS Algorithm and BCS cards are used to counsel client showing samples in the

commodities tray

▪ Based on clients selected method, provider uses the MEC Wheel to check for medical

eligibility. Providers’ protects clients’ rights throughout his/her visit

▪ Provider conducts physical examination

▪ Provider fill her findings on the client card

▪ Provider fills the Daily Family Planning Register

▪ Provider offers method and give client post method counselling information

▪ Gives Client Appointment Card for follow up and encourage clients to comeback if any

issue arises before appointment day or on day of appointment.

▪ Provider gives client Method Specific Leaflet based on method offered for additional

information

▪ At the end of the day, provider transfers total commodities dispensed from the Daily

Family Planning Register into the Daily Consumption Record and Bin Card against each

contraceptive method.


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➢ For Revisit/Returning Client;

▪ Provider welcomes client, makes atmosphere friendly and ensures privacy in the

counselling room by closing the door

▪ Provider enquires if client is on appointment, requesting for Client’s Appointment Card,

however, services are provided even when client is not on appointment.

▪ Provider counsel’s client based on reason for revisit and reassures client, giving

appropriate SBCC material

▪ Provider documents action taken (even if it is counselling) in the Daily Family Planning

register




- FP Procedure Room

▪ Gynaecological couch should be prepared for clients.

▪ Sterilized kits should be available for procedures.

▪ Provider ensure commodities are available and accessible.

▪ Injection tray with swabs and antiseptics

▪ arranged properly

▪ Waste bins placed

▪ Decontaminants prepared and placed properly

STEP 4 – At the end of clinic, closing for the day

- Waiting Area –

▪ Items and forms displayed on registration table should be put away and properly kept.

▪ Waiting area should be cleaned

- FP Counselling Room –

▪ Counselling room should be cleaned and made tidy.

▪ Commodities, demonstration models, equipment such as sphygmomanometer &

stethoscope and other items should be stored safely in a cabinet to prevent pilfering.

▪ Update commodity and service records- FP register, DCR –




▪ All forms and registers are locked in the cabinet for confidentiality purposes.


69

- FP Procedure Room –

▪ Procedure room should be cleaned, bins emptied and sheets removed for washing.

▪ All used equipment decontaminated and cleaned are to be stored dry ready for

sterilization.

▪ Dispose the sharp box appropriately if full.

At the end of two months,

▪ Provider collates records of commodity consumption on the DCR and service utilization on

the FP register

▪ Makes a projection for the upcoming months by filling the Requisition, Issue and Report

Form, indicates the projected quantities per methods.

▪ Submits the RIRF for resupply of FP commodities to the LGAs coordinator

▪ Follow up to ensure prompt resupply of commodities.


70

HOW TO FILL THE BIN CARD

NOTE: ❖ The Bin Card provides information on the quantities of

contraceptive stock on hand of a product, losses or

adjustments and lead time (period/time between the placing

of an order and actually receiving the ordered commodity).

❖ The Bin Card should be filled daily, at the end of the day, for

proper the DCR to minimise stock out.

❖ Each contraceptive method and brand is filled on a different Bin

Card.

1. Product Name: Enter the contraceptive method and the brand. E.g. Injectable, Depo-provera

2. LGA: Enter the name of LGA in which the facility is located

3. Health Facility: Enter the name of the Health Facility for which these records are being compiled.

4. Maximum Stock Level: Enter Maximum stock level. For SDP, Max stock level is 4 months

5. Minimum Stock Level: Enter Minimum stock level. For SDP, Min stock level is 2 months

6. Unit of Packing Enter the number of individual pieces contained in the package for this product.

7. Date: Record the date that the client attended the health facility in the format - dd/mm/yy.

8.Quantity Received: Record the total quantities of commodities received from any source for that day (e.g. LGA Store, NGO or any facility)

9. Quantity Issued: Transfer total quantities of each commodities Issued from the DCR to the Bin Card (e.g. to clients, CBD or any facility)

10.Losses & Adjustment: Record any damaged or expired contraceptives removed from stock.

11. Balance on Hand: Do a physical count of commodities and record the number counted in this column

12. Comments The comments section can be used by the Service Provider to provide any additional information such as explanations for losses or discrepancies between the Stock-on-Hand and the Physical Count.


71

HOW TO FILL THE DAILY CONSUMPTION REGISTER (DCR)

1.Record the month and year Enter the month and year of the Reporting Period, e.g., January 2006

2. State, LGA and SDP name

Enter the name of the SDP’s State, LGA and SDP

3. Beginning balance (column A)

Enter the beginning or opening balance (equal to the closing balance of the previous month’s DCR). Confirm with Bin Card From column G of the previous month’s DCR

4. Quantity received (column B)

Enter the quantity received during the month for each product From RIRF form, every second month. Any emergency orders, donations from other sources or loans from another facility during the month would also be included in Quantity received. Loans between SDPs are discouraged because contraceptives should always be obtained from the LGA store. Loans should be exceptional and explained using the comments column on this form and the RIRF Comments section

5. Quantity dispensed on every working day (column 1 to 23)

Enter daily the quantities of each product dispensed to clients taken from the FP client record. Number of working days in a month varies from 20 to 23 Number of working days in a month varies from 20 to 23

6. Quantity dispensed to client (column C)

Sum/add up the quantity dispensed each day for each product and enter it in column C. C=Q1+Q2+…Q21+Q23 Number of working days in a month varies from 20 to 23

7. Quantity dispensed to CBD (column D)

Enter the quantity dispensed for each product to CBD agents from the CBD vouchers from the current month and enter the sum in column D

8. Total quantity dispensed during the month (column E)

Sum the quantity dispensed to clients (column C) and the quantity dispensed to CBD Agents (column D) and enter the sum in column E E=C+D

9. Quantity lost during the month (column F) Enter any quantity lost for each product due expiration or damage (Column F). Losses include breakages, expiries, damages, theft and other things that render commodities unsuitable for use. Loans out to other facilities would also be included as a loss in column F

10. Closing balance (column G) Enter the closing balance by adding the beginning balance to the quantity received minus the quantity sold during the month minus the quantity lost G=A+B-(E+F)

11. Comments Note any comments in this column

Comments should highlight any unusual transactions such as emergency orders, donations from other sources or loans from another facility during the month or supply problems requiring assistance from the LGA RH Unit. Comments can be communicated through the RIRF, other communications or during supervision visits. Additional comments may be attached to this form for the SDP‟s records or to the RIRF as needed

Please note: each month should start on a new page


72

HOW TO FILL THE REQUISITION ISSUE AND REQUEST FORM (RIRF)

1.Reporting Period Enter the Starting

Month, Ending Month

and Year of the

Reporting Period, e.g.,

January/February 2018

2.SDP Name, LGA, State Enter the name of the SDP. LGA and State.

3. Stock balance at the beginning of the 2 months (Column A) When you start a new form, stock balance at the beginning of the 2 months (A) must always be equal to Physical Count (F) from the preceding reporting period’s RIRF which must tally with figure on Bin Card for that month

4. Quantities received during the last 2 months (Column B) Quantities received during the last 2 months should be equal to Quantity Supplied (Column M) from the preceding reporting period’s RIRF plus any additional commodities received through loans or emergency orders.

7. Stock on Hand (Column E) Stock on Hand (Column E) is a calculated value used for monitoring purposes, calculated as follows E = A + B – (C + D) This should be equal to the Close Balance (Column G) of the Daily Consumption Record from the month immediately preceding the report

8. Physical Count (Column F) At the end of the 2-month reporting period, before any commodities are dispensed in the new reporting period, count all commodities in the facility wherever commodities are kept. If there is any discrepancy between Column E and Column F please note the reason for the discrepancy in the Comments Box at the bottom of the form.

9. Average monthly Consumption (AMC, Column G) AMC = Consumption over the past two months (Column C) divided by 2. G = C ÷ 2

10. Maximum Quantity (Column H) Maximum Quantity is the maximum stock level a facility should have at any given time. This level should not be exceeded (over stock). At the SDP level, this is equal to four months‟ of average monthly consumption. H = G x 4

11. Order Quantity (Column I) The Order Quantity is equal to the Maximum Quantity (Column H) less the Physical Count (Column F). I = H – F

12. Quantity Supplied (Column M) The Quantity Supplied is equal to the quantity issued by the LGA store to the SDP.

13. Prepared by Signed and dated by the service provider who has completed columns A to L.

14. Authorized& Received by Signed and dated by the service provider at the SDP

15. Prepared & Supplied by Signed and dated by LGA RH Supervisor

5. Consumption over the past 2 months (Column C) Equal to the sum of Quantities dispensed over the past two months (Column E of the Daily Consumption Records for the immediate past two months) E.g., if you are reporting on March 1, the immediate past two months are January and February).

6. Losses (Column D) Equal to the sum of Quantity Lost (Column F of the Daily Consumption Records for the immediate past two months) E.g., if you are reporting on March 1, the immediate past two months are January and February). Losses include things like breakages, expiries, damages, theft and other things that render commodities unsuitable for use

16. Comments The comments section can be used by the Service Provider to provide any additional information such as explanations for losses or discrepancies between the Stock-on-Hand and the Physical Count. It may also be used by the LGA RH Supervisor to provide any needed notes or comments related to supply problems.


73

HOW TO FILL THE DAILY FAMILY PLANNING REGISTER

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