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Health System Strengthening

Investing in primary care human resources- the key pillar of a health system is a prerequisite for achieving comprehensive primary healthcare for all. Considering the proposed merger of FMR with its sister organization Foundation for Research in Community Health (FRCH), this area of ‘building capacities and competencies of human resource’ has been emphasized as one of the focus areas at FMR since 2019.

Growing demand for quality and sustainable health worker training in the context of Universal Health Coverage calls for strengthening of their skills through more effective and efficient strategies of education. Frontline health workers such as Auxiliary nurse midwives (ANMs), staff nurses, medical doctors and community health officers play a pivotal role in primary health care system, especially for provision of maternal new-born health (MNH) to the rural population where public health system is the preferred and probably the only available choice for seeking healthcare. Community health volunteers, more popularly known as ASHA (Accredited Social Health Activists) are a bridge between communities and formal healthcare systems. Explorations for assessing their preparedness, knowledge and skills, mentoring and support system, liaison and networking and gaps in their training is crucial for effective contribution of this cadre as envisioned by the National Health Mission.

The in-service training of all these health workers is vital for their continuous professional development, given the flux of issues in the public health system and the ever-evolving scope of their work. We believe that a health system with a resource of sustained competent trainers and a platform for continuous learning can only pave the way to build and sustain skilled health workers of quality healthcare. Our intervention research projects apply a complementary mix of directed and self-directed learning strategies and an in-built system of monitoring and evaluation for the training of health workers. The importance of demonstration-based training, adult learning principles and learner-centric approaches have been appreciated but merely incorporated. We adopted a blend of in-person and virtual learning modes for building the capacities of health workers.

Health System
Health System

PROJECTS

  • Principal Investigator

    Dr. Shilpa Karvande

  • Collaborators

    Government of Maharashtra- approval for the study; Municipal Corporation of Greater Mumbai and Pune Municipal Corporation- a) study approval b) sharing of experiences and perspectives about urban ASHA programme and Tuberculosis as key stakeholders

  • Project Team

    Ms. Vidula Purohit, Ms. Aarti Waghmare, Ms. Laxmi Govekar, Ms. Monika Hinge, (FMR); Ms. Pradnya Ghodake (Intern)

  • Funded by

    National Academy of Sciences, through PEER programme of USAID, USA as Women in Science Mentorship Program for Career Advancement, Private donation from Mr. N.B. Godrej & Maharashtra State Tuberculosis Association

  • Duration

    March 2022- January 2023

  • Budget

    INR 7.58 Lakhs

  • Status

    Completed

ABOUT THE PROJECT

This project is part of the PEER Programme- Women in Science Mentorship for career advancement (USAID) to encourage women researchers and scientists to excel in their research careers. It includes mentoring women researchers and a research project in the area of TB. The mentoring component includes focused mentoring sessions for the team of women researchers in the area of public health research and TB.

The research aims at assessing preparedness of urban ASHAs from Pune and Mumbai for delivery of primary healthcare in general and specifically in the area of TB control. The project is mixed-method exploratory research to learn the perspectives of key stakeholders- programme officials, supervisors and the community to understand the roles and responsibilities of urban ASHA, her training, knowledge and skills related to TB control and the challenges experienced by her. The research methods include a semi-structured survey of 200 plus ASHAs, focus group discussions of ASHAs (n=8) and in-depth interviews of key informants (n~15). The project is currently undergoing.

KEY ACHIEVEMENTS

  • Ongoing recruitment of urban ASHAs experiencing difficulties related to inadequate remuneration- 57% vacancies in Maharashtra
  • Retention of recruited urban ASHAs equally challenging on account of dealing with their false hope of becoming ‘permanent’ and waning interest against availability of other earning sources after COVID pandemic- higher attrition resulting in continuous need of recruitment
  • Challenges related to training of urban ASHAs in terms of a disjoint between trainers and on-job supervisors, inadequate focus on reporting & documentation during training and a need to have a dedicated team of ‘trained’ trainers, use of e-platform & avoid delays in arranging training.
  • Being ‘overburdened’ with ‘inadequate’ remuneration
  • Support- Absence of a supportive supervisory structure and cadre for on-job support, weak community support with absence of functional Mahila Arogya Samiti, however mostly having supportive families
  • Explicit gaps in TB related knowledge and training for TB especially about adverse drug reactions, nutrition, government schemes for patients and contact tracing
  • Inadequate communication skills, ambiguity about TB related roles against available time and workload, weak supervision and concerns about remuneration further making them reluctant to take up TB related roles.

Presently urban ASHA is a potentially valuable but an unstable cadre. Her roles as an incentivized worker need to be defined, training norms to be refined and an improved eco system for her support to be revised. Furthermore, suitability of urban ASHA as a TB functionary and expected roles need more clarity. TB related knowledge gaps pointed in this study need to be addressed through comprehensive TB training of appropriate duration and supportive supervision.

Media coverage of the dissemination of project findings held on 24th January 2023 in Mumbai.

PUBLICATIONS

  • Purohit, V., Karvande, S., Shah, D. Y., Vallepawar O. B., Yadav, O. J. & Mistry, N. (2024). Engagement and preparedness of urban Accredited Social Health Activists (U-ASHAs) for delivery of tuberculosis (TB) care: Findings from two cities in Maharashtra, India. Indian J Community Med, (Accepted)

CONFERENCE PRESENTATION

  • Karvande, S. Invited Presentation ‘Bolstering Health Services to Bridge the Health Gap’ at Clairvoyance 2023- The 25th Annual Conference of School of Health Systems Studies organized by TISS, Mumbai, 28th January 2023.
  • Principal Investigator

    Dr. Nerges Mistry

  • Co-Investigator

    Dr. Shilpa Karvande

  • Collaborators

    District Health Office of Palghar and Public Health Department, Government of Maharashtra a) Review of the training material of the project b) Active involvement in terms of providing health officials and health providers of various cadres to work as local master trainers in this project

  • Project Team

    Ms. Vidula Purohit, Mr. Prashant Kulkarni, Mr. Rajendra Kale

  • Funded by

    H.T. Parekh Foundation of HDFC Ltd.

  • Duration

    September 2019- March 2022

  • Budget

    INR 150 Lakhs

  • Status

    Completed

ABOUT THE PROJECT

Maternal and newborn health (MNH) was considered as a window for the training intervention project in Palghar. The objective was to generate a local resource of trainers and through them, build the capacities of community health providers for the provision of MNH and nutrition services. It involved training various cadres of a primary health system, nutrition-sensitive intervention focusing on the first 1000 days and context-specific subjects such as anaemia, management of low birth weight babies. The Sister Foundation for Research in Community Health (FRCH) conducted a pilot project in Pune during 2016-19 to build capacities and competencies of Auxiliary Nurse Midwives (ANMs) in MNH. The trainers of this pilot project were utilized as core trainers to train local master trainers in Palghar. A team of clinical experts from the UK and Nutrition Society of India (NSI), Mumbai Chapter, provided technical inputs for the development/ adaptation of the training material and conducting the training of trainers in Palghar.

The process of developing local resource of trainers (n=32) involved assessment of potential candidates, training of trainers, continuous hand-holding and frequent sessions of quality assessments using face-to-face and virtual platforms. Their teaching and pedagogical skills were equally emphasized as their clinical knowledge and skills throughout the project training activities for training 500 plus health providers. Use of mannequin for demonstration of clinical skills, a reverse demonstration by every participant, case-based learning, the mix of various cadres in every training batch, de-centralized and convenient training venue were some of the key features of all the training activities. Subsequent use of the Extension for Community Healthcare Outcomes (ECHO) virtual platform helped the participants to refresh their knowledge and served as an opportunity to nurture the culture of sharing, appreciation and constructive feedback. Self-learning strategies- writing articles in a biannual newsletter- ‘Dialogue’ and learning through and skills mall complemented the formal directed learning.

KEY FINDINGS/ACHIEVMENTS:

  • Generation of local resource of 32 Palghar trainers with a three-fold effect on a) improvement in clinical competency b) increased confidence as a trainer and c) recognition and credibility
  • Significant improvement in knowledge and skills of trained health providers (n=505) with a challenge to retain it over the time
  • Ready-to-use kit of training manuals for trainers and various cadres of health providers focusing on MNH and nutrition

Key recommendations are a) the need for creating avenues for refresher training in pre- and in-service education b) development and institutionalization of strategies for nurturing sustainable resource for competent trainers in the public health system and c) extension of project learning to other crucial subjects of comprehensive primary health care such as maternal mental health.

PUBLICATIONS

  • Karvande, S., Purohit, V., Balakrishnan, S. S., Allott, H., Serle, E. Jha, R., Mullick, S., Chavan, M., Kulkarni, P., Mathai, M. & Mistry, N. Building sustainable local training capacity in maternal and newborn health within the public system- A training intervention research in Palghar District, western Maharashtra, India. medRxiv preprint doi.org/10.1101/2024.01.01.24300686

CONFERENCE PRESENTATION

  • Karvande, S. Setting up a cadre of local trainers as a sustainable skilled human resources for maternal and newborn healthcare – Lessons from rural Maharashtra, India. Oral Presentation. International Maternal Newborn Health Conference (IMNHC) 2023, 8th-11th May, 2023, Cape Town, South Africa.
  • Purohit, V. Are the nutrition rehabilitation centres serving the ‘purpose’? A study in Palghar district of Maharashtra. Poster Presentation. Virtual Symposia on “Optimizing nutrition for maternal, newborn and child health”, organized by Keystone Symposia, 21st- 23rd October, 2020.