Regional Training Institute (RTI), Peshawar

Munir Afridi

Ministry of Population Welfare

Regional Training Institute (RTI), Peshawar

Pakistan

Project title: Training of Afghan refugee’s doctors and

Community health workers in IUD insertion and removal techniques.

Project Duration:One year (August, 2002 to July, 2003)

Sponsoring agency:Packard and Gates foundations USA.

Executing Agency:Regional Training Institute, Peshawar.

Project cost:US$ 4,000

Major Objective:

To include one additional long-term effective contraceptive method Intra Uterine Device (IUD) in the family planning service package to Afghan refugee women in Pakistan.

Specific Objectives:

1. To train 10 female Afghan doctors (who run their private clinics around Afghan refugee camps) in case selection. IUD insertion and removal, and aseptic techniques

1. To train 10 female Afghan community health workers (CHWs) who are working in NGOs clinics inside the camps, in motivation, counseling, quality of care, referral and follow up techniques

Training of Afghan Refugee’s Doctors and community health workers

(CHWs) In IUD insertion and removal techniques.

Background:

Since 1978, Pakistan has hosted one of the world’s largest refugee populations, which is more than 2.5 million at present. A majority of these are living in the officially recognized refugee camps, whereas around 800,000 are living in the major cities of the country. There are however, hundred of thousand of refugees living in non-recognized camps, majority of whom are women and children and not receiving any assistance including social services (such as primary health care, food, sanitation, clean drinking water, etc) from the Government and Donors. In addition the reproductive health needs are most often forgotten for this vulnerable population despite agreement by the world’s governments in 1994 at international conference on population and development that all human beings including refugees should have access to reproductive health care. There are a few NGOs that provide primary health care services but their assistances are diminishing gradually. The health status of refugees, particularly maternal and child health, is the worst in these camps and dependent on the utilization of private clinics run by Afghan doctors in and around the vicinity of the camps.

Rationale:

The magnitude of the problem of reproductive health status of Afghan refugee women is not well documented. The population growth rate is as high as 3.54 percent per year (World Health day Report 2001,WHO EMRO). There is high infant mortality (165 per 1000 live births) and maternal mortality (820-1700 per 100,000 live births) associated with repeated pregnancies and lack of primary health care services including reproductive health (World Health day Report 2001,WHO EMRO). The needs assessment carried by the International Red Cross in 1996 has identified high-risk pregnancies as one of the major problems due to socioeconomic conditions including poverty, malnutrition, lack of education, non-availability of health and FP services. (Lorelei Goodyear. Providing FP and EO care to Afghan refugees, IRN 1997.) The recent surveys of the camps conducted by several international NGOs including CDC/IRC 2001 indicated that the Total Fertility Rate (TFR) is very high (13.2 percent) and contraceptives use rate is very low (less than10 percent). The current focus is only on provision of oral pills (17%), inject able (68%) and other contraceptives including natural methods (15%) (Tomeezyke, B et al. Summary from RH survey among Afghan refugee, Pakistan.). Long-term reliable and effective methods are either not available or service providers need training in their dispensation. It has been reported that there is very high unmet need (48%) for family planning in the Afghan refugee camps (Tomeezyke, B et al. Summary from RH survey among Afghan refugee, Pakistan.) Further, one of the areas identified for improvement in provision of effective family planning services is to develop strong motivational, counseling, referral and follow-up skills among the service providers (community health workers of NGOs) as well as training of private Afghani doctors in provision of long term contraceptive methods such as Intra Uterine Devices (IUDs).

Addressing the problem:

More effective and long-term family planning methods such as IUDs are required to be introduced for the married women in the camps through training of private lady doctors who are running their private clinics in and around the camps. The community health workers, working in the NGOs and UNHCR clinics in the camp area need to be trained in motivation, counseling, referral and follow –up techniques to provide quality of family planning services so that the FP methods including long term methods become more acceptable to the clients. The availability of IUDs will enable the refugee women to reduce the likelihood to become pregnant and there by reduce the chances of mortality associated with pregnancies. In addition, the introduction of IUDs in family planning service package will satisfy part of the unmet need for FP in the camps area.

In order to include IUD insertion and removal services in the overall package of family planning services, we need to train 10 private female Afghan doctors in case selection, IUD insertion and removal and aseptic techniques. The training program will also include training of NGOs community health workers (10) in motivation, counseling, referral, follow-up of FP clients in the community. The lady doctors would be equipped with IUD kits, IEC material, client record cards and a regular supply of IUDs. The number of doctors and CHWs to be trained has been reasonably proposed in view of the availability of funds. This training would not only benefit the doctors and refugee population residing in Pakistan but after their repatriation, which is currently underway, it is expected that they will provide the same services in their home land in more comfortable and effective manner. Upon their return, they are expected to train additional doctors and paramedics in Afghanistan in family planning particularly in IUD insertion to cater the unmet need for family planning in the country.

Overall aim of the project:

To reduce maternal mortality associated with unwanted repeated pregnancies by offering voluntary access to IUDs as an effective long-term method for birth spacing.

Major objective of the project:

To add one additional long-term effective contraceptive method IUDs to family planning service package available to Afghan refugee women in Pakistan.

Specific objectives of the project:

1. To train 10 female Afghan doctors in case selection, IUD insertion and removal, and aseptic techniques

1. To train 10 female Afghan community health workers who are working in NGOs clinics inside the camps, in motivation, counseling, quality of care, referral and follow up techniques

Strategy and activities:

Just to begin with the project, a stakeholder analysis would be carried out with all key stakeholders such as NGOs having health centers in the camps, UNHCR health staff, service providers of other organization working in the camps, private lady doctors practicing around the camps, department of population welfare of the province of NWFP, in-charge of the Regional Training Institute (RTI) in Peshawar. The venue of the meeting will be RTI where a joint consensus would be developed on the operationalization of the project including services to be offered, identification of trainees both doctors and community health workers training schedule, availability of supplies, supervision, referral, evaluation and institutionalization of the activities by the NGOs and doctors after completion of the of the project in July 2003.

The Principal of the RTI in Peshawar will be the focal point for the project. He will be responsible for the over all execution of the project including supervision and monitoring.

The community health workers (CHWs) will be identified through consultation with the NGOs who are providing services through health centers established in the camp. Similarly, doctors will be identified through direct contact with them at clinics. The trainee doctors are to give an assurance that they will provide FP services at reasonable and affordable cost through their clinics on voluntary basis. The paramedics through their NGOs will give an assurance that they will provide motivation and counseling services at the health centers and at the community through home visitations.

The community health workers (CHWs) will be actively involved in the referral of clients to lady doctors. They would contact the married women of reproductive age, motivate and counsel clients for IUD use. They would provide them with a slip to utilize the services available with designated doctors, and provide regular follow-up for IUDs and any other complication or side effects associated with the use of contraceptives. The doctors after receiving clients for IUD insertion will keep all the record of patient on client record card to be maintained at clinics. The patient will be given the referral slip back with necessary remarks on the services provided. The slip will be collected by the health workers so they will know whether the doctor has inserted an IUD or given any other advice, and will be followed up in subsequent visits by the community health workers. Both the NGOs and lady doctors will keep close liaison with the Regional Training Institute for supply of contraceptives, IEC material, submission of progress report of FP activities etc.

Project Inputs:

The project inputs would include training, IUD insertion kits, contraceptive (IUDs) and IEC material related to IUDs for the clients, client record cards, and referral slips. The description of each input is as under.

1. Training of doctors and community health workers:

Training of female doctors and community health workers would be the major activities of the regional training institute in Peshawar. These trainees will be paid traveling allowance and per diem according to the laid down criteria (doctors are usually paid higher per diem than community workers). A total of 10 doctors would be trained in IUD case selection, IUD insertion and removal techniques, aseptic procedures and quality of care while offering services. The duration of the training would be 12 days. Both theoretical and practical training would be arranged in two groups (5 doctors per group) The theoretical training would be for seven days at RTI, which will consist of lectures, role play, demonstration, dummy exercises and hospital visits. Practical training would be arranged with FP clinic where each doctor would be required to insert a minimum of five IUD at the FP clinic run by the population welfare department. Similarly, 10 community health workers would under go for 10 days training in two batches (5 per batch). The training would consist of 8 days theoretical part whereas 2 days will be practical training in the community. The major focus of the training would be on motivation, counseling, referral and follow-up of FP clients. Both groups of trainees (doctors and paramedics) will follow the standard curricula already in place with the training institute.

1. IUD insertion kits:

Each lady doctor after successful completion of training would receive an IUD insertion and removal kit to facilitate provision of IUD services at their clinics. The doctors would be responsible for the safe custody, maintenance and regular sterilization of the kit. 10 IUDs kits would be required under the project for which necessary provision has been made in the budget.

1. Contraceptives including IUDs:

The Ministry of population welfare will provide contraceptives including IUDs on the subsidized rate to the private lady doctors through provincial population welfare department. These doctors would be registered with population department for supply of contraceptives. To start with, 10 Copper -Ts would be supplied to each doctor after completion of training at RTI. Subsequent demand for replenishment could be made with population welfare department on quarterly basis. These doctors can also make a request with the department for supply of oral pills and inject able if they want to provide these services in addition to IUDs, which will be supplied to them on subsidized rate.

1. IEC material and client record cards:

IEC material related to family planning, particularly to IUDs, will be provided to all doctors and health workers after completion of their training. These are available in regional language and appropriate for local use. These will include pamphlets, flip charts, posters, booklets etc. The CHWs would also be given referral slips for referring IUD clients from the camps to doctors. Each doctor would be given a minimum 50 client registration cards (CRC) to keep the record of the clients for follow up and subsequent evaluation. All these supplies will be requisitioned from the ministry of population welfare on subsidized rate for which a provision has bee kept in the budget.

1. Supervision of the project:

The faculty of the RTI Peshawar through clinic visits would supervise the activities once in a month. They will provide on the job training, support and guidance both to the doctors and paramedics to provide quality services to women. Supervisory cost has been reflected in the budget sheet.

Project outputs:

The project outputs would be measured against activities envisaged under the project. This would include;

• Number of doctors trained against the target.
• Number of community health workers trained against the target.
• Number of clinics providing IUD services,
• Number of paramedics involved in motivation, counseling and referral of clients.
• Number of women using IUDs,
• Number of clients followed-up, number of clients given motivation and counseling services, number of clients referred by health workers
• Availability of contraceptives, IEC materials, IUD kits, etc.

Impact of the project:

Impact of the project would be assessed in term of clients using Family Planning services including IUD, its continuity and its retention or early removal. It is expected that the use of contraceptives would go up by 25 percent in the first year and 40 percent in the subsequent year as compared to the current use rate, which is less than 10 percent. The contraceptive awareness and method specific use rate will also be increased. The project would contribute to a reduction of total fertility among the refugee women and will improve the quality of life of Afghani married women. The doctors and paramedics after being trained would be in better position to provide FP services especially IUDs as well as offer better motivation, counseling and assistance to clients in choosing contraceptives and their suitability. The paramedics will also ensure follow up of clients thereby ensuring continuity in use of FP methods including IUDs.

Project sustainability:

After completion of the training activities and supply of necessary material, these doctors would provide FP services including IUD insertion to the married afghan refugee women on a reasonable fee for charge basis at their existing clinics. We understand that they are already providing other curative services particularly for women and children. The inclusion of FP services will be an added attraction to their clients, which is expected to increase their caseload for other ailments as well, hence increasing their income. After the initial support of training and supplies from the project, these doctors will attract local population for seeking quality advice and treatment on health care in general and reproductive health in particular. This will provide them additional income and will further expand their services in order to cater demand for curative and preventive health care services. Additional manpower will be engaged by these doctors at private clinics to satisfy the need of the community for reproductive health and FP services. The Afghan refugees are expected to go back to their country once the situation become normal and essential services are made available. This training will not only benefit the doctors and the refugee population residing in Pakistan but after their repatriation, it is expected that they will provide the same services in their homeland and will transfer their skills to other fellows to provide the much needed services in field of reproductive health in Afghanistan.

Monitoring and evaluation of the project:

The project will be monitored and supervised by the in-charge (Principal) and faculty of Regional Training Institute in Peshawar, which is one of the attached departments of Ministry of Population Welfare in Islamabad. The doctors and CHWs under the project will submit their monthly report to the Principal of the RTI in Peshawar on a prescribed format. The faculty of the institute will conduct monitoring and supervisory visits to the clinics to provide support and guidance to the doctors in such a way that each doctor is visited once in a month. They will also conduct monitoring visits to NGO clinics in camps to monitor the activities of the community health workers. The in charge of the NGOs will institutionalize the monitoring of FP activities in their own monitoring plan to make the project successful. The RTI will be responsible for over all implementation of the project activities including administrative, financial and operational responsibilities.