Page 98 - GHES-2-4

Global Health Economics and
Sustainability
Sustainable, competent health trainers

recommended this district for the scale-up phase of the and content adapted for Palghar were reviewed and
project. endorsed by experts from the State Family Welfare Bureau,
The primary health-care system of the district consists the Government of Maharashtra, and the District Health
of 46 primary health centers (PHCs) and 311 health Office of Palghar.
subcenters (HSCs). A PHC, the first port of call to see a The Pune CTs were oriented regarding their roles in
qualified doctor in the public sector, typically covers a the Palghar scale-up phase, and a 4-day refresher learning
population of 30,000 in plain areas and 20,000 in hilly, session was delivered, followed by a series of virtual
tribal, or difficult areas. It acts as a referral unit for continuous learning sessions, each focusing on one key
HSCs. An HSC is the first point of contact between the subject related to MNH, over 3 months. These sessions
primary health-care system and the community, covering included lecture practice using PowerPoint presentations,
a population of 5000 in the plains and 3,000 in tribal followed by clinical skill demonstrations with feedback
and hilly areas for the provision of essential preventive provided by the UK team experts to enhance their clinical
and promotional services and a few curative and referral knowledge, practical skills, and teaching skills as CTs.
services (Indian Public Health Standards, National Health A specific session was conducted by the UK experts about
Mission, n.d.). “How to become an effective trainer?” with practical tips

2.2. Project design and guidance for the Pune CTs.
This project was implemented in Pune (13 rural blocks) 2.2.2. Phase 2: Developing a local cadre of skilled
during 2016 – 2019 (Karvande et al., 2020) as a pilot and master trainers in Palghar
scaled up in the Palghar district during 2019 – 2022 (at a The approach of developing a local cadre of skilled MTs for
time when India experienced three waves of the COVID-19 the Palghar district involved six steps:
pandemic). Both of these projects were implemented with
on-site (for Pune) and virtual (for Palghar) support from (i) Step 1: Pre-ToT screening of identified candidates by
the technical partners – a team of obstetricians and a Pune CTs and project researchers.
pediatrician – from the United Kingdom (UK). The Palghar A group of 48 candidates (medical officers, staff
project design involved two phases: (i) preparing for the nurses, community health officers, obstetricians, and
scale-up and (ii) developing a local cadre of skilled MTs. pediatricians working as clinicians and/or administrators
at various levels of health facilities across all the blocks
2.2.1. Phase 1: Preparing for the scale-up in Palghar of the district) were identified as potential trainers.
A group of eight clinically competent trainers, including The initial exploratory and baseline study aided both
seven general nurse midwives (GNMs) and one medical understanding of diverse geographies and identification
doctor (out of 38) from the Pune pilot project, were selected of health facilities with relatively poor access to referral
as the “core” trainers (CTs). These trainers were selected hospitals and a higher number of childbirths. The potential
for their ability to imbibe and repeatedly demonstrate the trainers represented such facilities, which was a step
expected training pedagogy. They expressed willingness toward increasing the outreach of skilled human resources
and commitment to work in the Palghar scale-up phase. across the district. The potential trainers were identified
They had received sustained feedback concerning clinical through field-based interactions with Palghar district
and teaching skills from the UK team during the pilot health officials and health providers and observations by
phase. Acknowledging the seriousness of the prevalent the project researchers during initial exploratory visits
health issues in the Palghar district, the scale-up included and baseline assessments. A pre-ToT screening of these
two major adaptations in the training content. First, the identified potential ToT candidates over 4 days focused
training content was adapted to include or emphasize local primarily on the assessment of their work profile, previous
context-specific subjects related to MNH, for example, experience as trainers, if any, interest and commitment to
the management of low-birth-weight babies, anemia, work as trainers, and demonstration of baseline teaching
and malnutrition. Second, it targeted additional cadres skills. The teaching skill demonstration was assessed
of health providers. While the Pune pilot project focused for session preparations, clarity in conveying messages,
on auxiliary nurse midwives (ANM), the Palghar scale-up ability to engage participants, and respectful behavior
opted to train an entire team of multidisciplinary health during teaching sessions. They were scored using a three-
providers – including medical officers, staff nurses, point grade scale: excellent, fair, and unsatisfactory. The
community health officers, GNMs, and ANMs – since candidates who received “excellent” or “fair” grades were
MNH case management is typically handled by such teams considered potential ToT participants (n = 32), including
at PHC/HSC. The Pune pilot project’s training materials 25 medical doctors and seven GNMs.

Volume 2 Issue 4 (2024) 3 https://doi.org/10.36922/ghes.2963