evaluation of immunization training of medical … · collaborative study by nihfw, who country...

Collaborative study by NIHFW, WHO Country Office for India and UNICEF

Evaluation of Immunization Training of

Medical Officers, Cold Chain Handlers

and Technicians

National Institute of Health and Family Welfare, New Delhi

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Principal Investigators

Chief Investigators

Co-Investigators

Professor Jayanta K Das, Director, NIHFW

Dr Stephen Sosler, Deputy Project Manager, WHO Country Office for India

Professor M Bhattacharya, Head, Department. of CHA and Nodal Officer, Immunization, NIHFW

Dr Renu Paruthi, Training Focal Person, WHO Country Office for India

Professor Utsuk Datta, NIHFW

Dr Gyan Singh, NIHFW

Dr Sanjay Gupta, NIHFW

Dr Renu Shahrawat, NIHFW

Dr Nanthini Subbiah, NIHFW

Dr Arindam Ray, WHO Country Office for India

Dr P Deepak, NIHFW

Evaluation of Immunization Training of Medical Officers, Cold Chain Handlers and Technicians

ii

Preface

The National Institute of Health and Family Welfare (NIHFW) has been involved in capacity building of health functionaries by conducting various in-service training programmes on different health topics for state and district level health managers, faculty of training institutes and programme managers. For the immunization programme, NIHFW has conducted the training of trainers' courses for immunization training of medical officers (2009-10) and vaccine and cold chain handlers (2010-11). NIHFW with WHO Country Office for India and Ministry of Health & Family Welfare (MoHFW) and partner agencies had conducted the Performance Assessment of Health Workers' Training in Routine Immunization in India (2009). The findings of the study were used to improve the training of health workers in immunization subsequently.

By end December 2011, nearly half of the 60 000 medical officers and more than 43% of the 30 000 cold chain handlers in the states had been trained, it was decided to conduct an integrated evaluation of these trainings for better utilization of resources. The training status of district cold chain technicians was included in this study so that it would give us an indication of their performance requirements and training needs in the field. NIHFW is currently working on setting up a National Cold Chain and Vaccine Management Resource Centre (NCCVMRC), NIHFW and a National Cold Chain Training Centre (NCCTC) at State Health Transport Organization (SHTO), Pune for trainings of cold chain technicians and vaccine and and logistics managers.

This report provides the conclusions derived from the evaluation study and frames recommendations for the national and state governments to improve the progress and quality of training, knowledge, skills and practices of medical officers and cold chain handlers, and overall support for the immunization programme.

We are thankful to the MoHFW, WHO Country Office for India, UNICEF, state governments and other development partners for their enthusiastic participation in the study and their valuable insights in making this exercise meaningful. We hope that the results of this study will be helpful in reviewing and improving immunization training in the future.

Jayanta K DasDirector, NIHFW

iii

Foreword

The Ministry of Health & Family Welfare (MoHFW), Government of India (GoI) has provided additional resources through the National Rural Health Mission to all the states and declared 2012-13 as the year of Intensification of Routine Immunization. In this context, WHO, UNICEF and other partners have supported capacity building of the health service providers at all levels through the development of training materials for training of health workers, medical officers and cold chain handlers such as immunization handbooks for health workers and medical officers, handbook for vaccine and cold chain handlers, facilitators' guides and training kits.

The National Institute of Health and Family Welfare (NIHFW) with support from WHO Country Office for India and UNICEF has trained 1050 trainers of medical officers and 1728 trainers of cold chain handlers. Till date, 32 000 medical officers and 24 000 cold chain handlers have been trained in the country.

Assessing the impact of training on the performance of medical officers and cold chain handlers is an important step towards assuring the quality of immunization services in the country. We are grateful to the GoI for facilitating and supporting this study.

On the lines of the health worker's training evaluation study conducted in 2009, this study also is an excellent illustration of a wider partnership and coordination between the NIHFW, state governments and development partners.

We hope that this report will be a useful guide for the states to improve their future training activities and the quality of the overall immunization programme.

Mr Louis-Georges Arsenault UNICEF India Representative

Dr Nata MenabdeWHO Representative to India

Topics Page

Abbreviations 2

Executive summary 5

Chapter-1: Introduction, rationale and objectives 18

Chapter-2: Methodology 21

Chapter-3: Study results 26

Chapter-4: Conclusions and recommendations 70

State specific recommendations from the study 82

Annex-1: Study tools for phase-1 study 104

Annex-2: Study tools for phase-2 study 121

Annex-3: List of study team members for ph-1 and ph-2 study 141

Table of contents

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Abbreviations

ABSA Attirikt basic shiksha adhikari

ADS Auto disable syringes

AEFI Adverse events following immunization

ANM Auxiliary nurse midwife

ANMTC Auxiliary Nurse Midwife Training Centre

AP Andhra Pradesh

ARV Anti-Rabies Vaccine

AS Assam

ASHA Accredited social health activist

AVD Alternate vaccine delivery

AWW Anganwadi worker

AYUSH Ayurveda Unani Siddha Homeopathy

BCG Bacillus Calmette-Guerin

BDO Block development officer

BEE Block extension educator

BEmOC Basic Emergency Obstetric Care

BPM Block programme manager

BTF Block-level Task Force

CCH Cold chain handler

CDPO Child development programme officer

CFC Chloro Fluoro Carbon

CFW Commissioner (Family Welfare)

CHC Community health centre

CHO Community health officer

CMO Chief medical officer

CSSM Child Survival and Safe Motherhood

DF Deep freezer

DIO District immunization officer

DL Delhi

DPM District programme manager

DPT Diphtheria Pertussis Tetanus

DTC District Training Centre

DTO District training officer

DTT District training team

EVM Effective vaccine management

FAQ Frequently asked questions

FIR First Information Report

FSR Field Survey Register

GJ Gujarat

2

GoI Government of India

Gps Gram Panchayats

HA (M) Health Assistant (Male)

HA (F) Health Assistant (Female)

HEEO Health extension education officer

HepB Hepatitis B

HFWTC Health & Family Welfare Training Centre

HI Health inspector

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HQ Head Quarters

HR Haryana

HR Human resources

Hws Health workers

ICC Investigator cum computer

ICDS Integrated Community Development Scheme

ILR Ice lined refrigerator

IMNCI Integrated management of newborn and childhood illnesses

IPC Inter-personal communication

IO Immunization officer

JE Japanese Encephalitis

KA Karnataka

Kva Kilo Volt Ampere

LHV Lady health visitor

MCHIP Maternal Child Health Immunization Programme

MCP Mother and child protection

MCUP Measles Catch Up Campaign

MCTS Maternal & Child Tracking System

MH Maharashtra

MHS Male health supervisor

MN Manipur

MO Medical officer

MoHFW Ministry of Health & Family Welfare

MOIC Medical officer In-charge

MP Madhya Pradesh

MPHS (M) Multipurpose health supervisor (Male)

MPW Multipurpose worker

NCC National Cadet Corps

NGO Non-Government Organization

NIHFW National Institute of Health and Family Welfare

NIPI Norwegian-Indian Partnership Initiative

3

NRHM National Rural Health Mission

NPSP National Polio Surveillance Project

OD Odisha

OJT On-job training

OPV Oral polio vaccine

PHC Primary health centre

PHN Public health nurse

PIP Programme Implementation Plan

PIR Preliminary Information Report

PNA Performance needs assessment

PPC Post-partum clinic

PRI Panchayati Raj Institution

RCH Reproductive child health

RI Routine immunization

RIMS Routine Immunization Management System

SCCO State cold chain officer

SEPIO State expanded programme of immunization officer

SHG Self help group

SHTO State Health Transport Organization

SIHFW State Institute of Health and Family Welfare

SMO Surveillance medical officer

ToT Training of trainers

TA/DA Travel allowance / Dearness allowance

UIP Universal Immunization Programme

UNICEF United Nations International Children's Emergency Fund

UP Uttar Pradesh

VMAT Vaccine management assessment tool

VVM Vaccine vial monitor

VPD Vaccine preventable disease

VHND Village Health & Nutrition Day

WB West Bengal

WHO World Health Organization

WIC Walk-in cooler

WIF Walk-in freezer

WMF Wastage multiplication factor

WR Wastage rate

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BackgroundUnder the NRHM program, initiatives were taken for capacity building of the health service providers at all levels. Immunization-specific training of medical officers started in 2009 after the handbooks, facilitators' guides and training kits were developed and printed by GoI. The states started training the medical officers in 2009-10, after all the 1050 trainers of the medical officers were trained in 25 courses organized by NIHFW and WHO India NPSP. By January 2012, around 50% of medical officers were trained in the country. The cold chain handlers' training started in 2010-11 after the handbooks were developed and printed by GOI in 2010. A total of 221 state trainers were trained in National ToTs (2010-11). Another 1507 district level trainers were trained by state training teams in 2011. By January 2012, 43% of the 33000 Cold Chain handlers were trained. Cold Chain technicians were being trained by State Health Transport Organization (SHTO) Pune since 1990 but the training stopped in between from 2000 to 2006.

However, the progress in training varied from state to state. Therefore, it was decided to study the training system and the processes followed in select good performing states and some weak performing states to identify the factors affecting the progress and quality of training. A need was also felt to assess the effect of training on the performance of the medical officers and cold chain handlers. The study was proposed by the immunization division, MoHFW and was conducted by NIHFW in collaboration with WHO India NPSP and UNICEF.

Executive Summary

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ObjectivesThe overall objective was to study the processes and factors affecting the progress, performance and quality of training on immunization for medical officers, cold chain handlers and technicians. The specific objectives of the study were as follows:

1) To identify factors affecting differential progress between states in RI training of MOs and cold chain handlers

2) To identify factors affecting the quality of training3) To assess the knowledge, skills and practice of medical officers, cold

chain handlers and technicians related to immunization4) To make recommendations for improving future training of medical

officers, cold chain handlers and technicians

MethodologyThe first two objectives were studied in the first phase between February and March and the second and third objectives formed part of phase-2 study conducted in April and May 2012. For the first phase, Twelve states were selected for desk review and field visits on the basis of MO-training progress by selecting four states (randomly) from each group of states with less than 40%, 40-70% and more than 70% MOs trained. For the second phase, six out of the original twelve states were selected (two from each category) mainly by excluding those states where training of medical officers was conducted recently for Measles catch-up campaigns. Then 12 districts, two from each of the six states, with moderate training coverage (one near and one away from state headquarter) were selected.

Study tools were developed for in-depth interviews, observations and records reviews during both phases of the study. 24 study teams were identified amongst officers from NIHFW, WHO, UNICEF, MCHIP, NIPI and state officials. During first phase, field visits were made to each of the twelve states for two to three days by a two member team to conduct in-depth interview of SEPIO, State Cold Chain Officer (SCCO), Director-SIHFW,

Phase-2 study

Uttar Pradesh, Madhya Pradesh, West Bengal, GujaratUttar Pradesh and West Bengal

Odisha, Manipur,Maharashtra, Delhi

Madhya Pradesh and Odisha

Andhra Pradesh, Assam, Haryana, Karnataka

Andhra Pradeshand Maharashtra

Selection of statesPhase-1 study

MO-Training < 40%

MO-Training 40-70%

MO-Training >70%

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Director-FW, MD-NRHM / other state level officials and trainers of the state/regional training centers. During the second phase, field visits were conducted to each of the 12 districts for three to four days by a two member team to conduct in-depth interview of DIO, DPM, cold chain technician, MOs, Cold chain handlers, HWs and trainers of the MO and Cold chain handlers.

The sample size was 400 (100 during first and 300 during second phase of the study). The sample included both trained and untrained Mos, Cold chain handlers and cold chain technicians. After data validation, state wise data was compiled and analyzed based on each objective of the study.

Salient findings of the studyMedical officers training

1.Factors affecting progress in immunization training of medical officers in the states

i. Enabling factorsFour states Andhra Pradesh (AP), Assam, Karnataka (KA) and Haryana (HR) had trained more than 70% MOs. Major factors responsible for good progress in training in these states were identified as follows:

• Review of progress in training Top priority was given to tracking and completion of immunization training during review by MD-NRHM/Director FW in AP and HR. There was proactive involvement of Director FW, MD-NRHM, and SEPIO in KA and Assam to facilitate the progress of training.

• Monitoring the quality of trainingGood monitoring was done by the state and district officials e.g. use of 'SKYPE' for online monitoring of training in Karnataka and monitoring of training in districts by SIHFW in AP.

• Decentralization of training Decentralization of MO-training to district level expedited the progress of training in Andhra Pradesh, Assam, Karnataka and Haryana. (West Bengal is exception).

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• Pool of trained trainers Large pool of trainers helped to improve the training progress.

ii. Barriers and issues in the progress of training

• Planning and coordination of trainingPriority was not given to training in the states with weak progress; there was no accountability for not attending the training. A database of trained personnel was not maintained. Trainings were cancelled due to poor attendance of MOs. Lack of coordination was found between SIHFW and state/district offices to follow up on the training nominations and progress.

• Training infrastructure and facilitiesThere were less number of training centres and lack of training infrastructure with no stay facility in majority of districts and in three states of Delhi, Gujarat and Manipur. There was shortage of trainers with vacancies at SIHFW; too many training courses in HFWTC/SIHFW. Lack of trainers was noticed as they were posted in NRHM and not available for actual trainings.

• Implementation and monitoring of trainingInadequate attendance of MOs was due to shortage of doctors in some states. MOs were not relieved for three days due to other priorities such as outbreaks, floods, school health programme and pressure to utilize PIP funds. CMOs were reluctant to spare MOs frequently as service delivery in PHC suffered, especially in last quarter of the financial year. No system of regular reporting and no mechanism for regular monitoring of training were in place.

• Release of funds and financial normsDelay in release of funds from NRHM office was reported as the reason for slow progress. RCH training norms were not followed and participants were not given TA/DA and trainers honorarium as per RCH norms. No trainings were conducted from April to June because funds were released from GoI in June. In-house trainers were not given honorarium leading to reluctance to train.

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2. Factors affecting the quality of medical officers training

Overall quality of training was found to be good as gathered from the trainers and the trainees.

I. Enabling factors

• Profile of trainers and medical officersRight types of officers were trained as trainers for MOs. They were faculty of training centres; medical colleges; SEPIO / Programme Officers; CMO / DIO / DTO; Paediatrician; Senior Medical Officers; Divisional Coordinators; NPSP SMOs; Retired Senior Health Officer etc. The Medical Officers who were involved in immunization program were trained as MO (PHC/CHC); contractual doctors; AYUSH Doctors and MOs of hospitals.

• Involvement of trainersAdequate numbers of trainers were involved on all three days during last three batches in all states except Maharashtra where only one trainer was involved.

• Training methodologyInteractive training methods as per facilitators guide and training kits were used in all states. Transport was provided for the field visits to practice supervision. The immunization handbook and handouts were given as a part of the training. Training kit and CD with films was used. Pre and post test was done and feedback received from the trainees. Certificate was given to each participant.

• Follow-up on feedback of traineesCorrective actions were taken after feedback from the participants. Training days were arranged such that the 3rd day was Immunization day. Quality of lunch and organization improved. More emphasis was given to supervision. Training was made more participatory. Disturbance due to noise was reduced.

• Involvement of SIHFWSIHFWs in Andhra Pradesh, Assam, Delhi and Gujarat proactively coordinated the immunization training for MOs in the state.

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ii. Barriers and issues in the quality of training

• Training facilitiesLack of training, hostel and mess facilities observed in the states of Delhi, Manipur and Gujarat were barriers.

• Lack of involvement of SIHFWsSIHFWs in five states of Uttar Pradesh, West Bengal, Haryana, Karnataka and Manipur were not at all involved in coordinating and monitoring the immunization training.

• Availability of trainersShortage of trainers was reported in Delhi, Gujarat, West Bengal, Odisha, Uttar Pradesh and Andhra Pradesh. Trainers were not present in full strength in Madhya Pradesh and Maharashtra. Reasons given were mainly transfer of trained trainers to other positions leading to shortage.

• Inclusion of immunization training in induction training of MOsThough all states except Delhi, Manipur and Assam had a policy for induction training of MOs varying from 2 - 6 weeks, only half to one-day sessions were allocated to immunization which was inadequate.

3. Knowledge and practices of medical officers in immunization

i. Knowledge level of trained and untrained medical officers To assess their knowledge level, all the MOs were asked 10 open ended questions from the immunization handbook. They were scored based on the correct responses. Comparison was made between the trained and untrained medical officers. Trained medical officers performed better than performance of the MOS in Uttar Pradesh, Maharashtra and Odisha was the lowest compared to rest of the states.

ii. Practices of trained versus untrained medical officers in PHCs

Good practices• Monitoring and using data for action after training

Performance of trained MOs in data analysis from the routine reports on immunization coverage, drop-outs and left-outs was better when compared to untrained MOs. The difference in their performance was statistically significant.

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• Conducting review meetingsReview meetings were held at block/PHC levels in all the states. The frequency was monthly in majority of the blocks and the participants were mainly HWs and ASHAs/AWWs. The feedback from data analysis was shared by the trained MOs with health workers during monthly meetings, to improve coverage.

• Conducting supervision and on the job trainingAll MOs who conducted supervisory visits gave good examples of problem solving and provided on the job training during supervision.

• Community involvement and communication activitiesAfter training, MOs supported various communities' involvement activities e.g. addressed various meetings in the community to educate the caregivers and the frontline workers. The MOs visited resistant families with local influential persons to counsel and motivate them.

• Supervisors' opinionsAll DIOs noted improvement in the performance of MOs after training in areas of cold chain maintenance, monitoring and supervision, community mobilization and injection safety.

• Health workers' opinions Health workers were able to appreciate change in the attitude of MOs following training. They came up with examples of on-the-job training provided, various topics discussed during the review meetings and activities conducted by the MOs for improving community involvement.

Gaps in immunization practices after training

• Inadequate involvement in RI-MicroplansMajority of medical officers had no role in micro-planning; it was prepared by PHN, LHV, MHS, MPHS (M), BEE, BPM and Community Health Officer. ANM roster and AVD plans were available in all the states. West Bengal performed poorest in availability of maps, estimation of beneficiaries and plans for supervisory visits.

• Lack of supervisory visitsThough plans for supervisory visits were available in all the states except West Bengal, no records to support supervisory visits were available in majority of the PHCs.

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• Inadequate monitoring and using data for action after trainingAll trained MOs were not analyzing the routine reports to calculate the immunization coverage (%), drop-outs and left-outs. Coverage monitoring chart was not available in majority of the PHCs.

• AEFIs and VPDs Majority of the PHCs had not reported any AEFIs or VPDs during the last three months.

• Immunization waste management in the PHCWaste disposal was poor in all the states, though little better in PHCs with trained MOs. Waste disposal pits were not used properly. There were reports of burning waste and discarding syringes in to the pit.

iii. Programme support to the MOs• Guidelines for fund utilization

Clear guidelines for fund utilization for immunization activities were available with majority of the MOs. Some issues were highlighted as delayed or no receipt of funds from district for mobility for supervision; for AVD and for ASHA.

• Supervision of MOs

Majority of the medical officers were visited by the district immunization officers in last three months. Supervisors guided the MOs on micro-planning, cold chain, using data for action, injection safety and waste management issues etc.

• Role of the DIOs in immunization program managementMajority of DIOs were conducting supervisory visits, organizing review meetings and analyzing the data from monthly reports. But the coverage monitoring chart was displayed by only two out of 11 district immunization officers.

iv. Need for additional immunization trainingMajority of MOs felt the need for additional training in immunization. Untrained MOs asked for complete RI training while majority of trained MOs asked for refresher training at district level as HWs were to be trained repeatedly. Areas were specified as microplanning/planning, cold chain, logistics management, new vaccines, community involvement, records, reports and using data for action, AEFI, updates and changes in guidelines, waste disposal and role of AYUSH doctor.

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Key recommendations for improving training of MOs• Establish state/district training cell with one officer designated as training

coordinator to coordinate for all programmes; improve coordination among SIHFW, NRHM and directorate and ensure that overlapping with other trainings is avoided

• Review the progress of training as part of regular program reviews at state and district level. Devise mechanisms to ensure adequacy of batch size and mandatory attendance of nominated participants

• Strengthen and involve SIHFWs to coordinate and monitor the immunization training. Integrate immunization training in the induction training program for medical officers

• Training database should be maintained by the state and district training centres. Regular reporting of training should be ensured through HMIS

• Develop training infrastructure in all districts. Provide hostel and transport facilities in Delhi, Gujarat and Manipur. Districts with trained MOs, good training and residential facilities should be made training centres for MO training e.g. Hoshangabad in Madhya Pradesh

• Address shortage of faculty and staff at the training centres by hiring on contract basis under NRHM. Training cadre/faculty should be full time, regular and if required, transfer to other training centres only

• Conduct state ToT to increase the pool of trainers at the state and in all regional training centres. Provide regular refresher training to master trainers/ faculty members of SIHFW. Involve medical college faculty in all training courses on immunization

• Training monitoring should be institutionalized. Use of technology e.g. SKYPE should be encouraged. Involve the state trainers to monitor trainings at regional and district level. District trainers should follow-up the trainees on the job

• Revise financial guidelines for immunization trainings in line with RCH training norms. The budget of MOs training to be included in the state PIP of 2013-14 so that all MOs are trained by 2013 end.

• Train the untrained MOs including AYUSH MOs and organize refresher course at the district level. Encourage all MOs in addition to the MO-I/Cs to be actively involved in micro-planning, monitoring and supervision activities

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• Address non-training factors affecting the immunization services as release of funds, supply of logistics and conduct of supervision at all levels to enable the MOs to translate the training into good practices

Cold chain handlers training1. Factors affecting progress in CCHs trainingThe progress of training was good in all states except Uttar Pradesh and Karnataka. Major reasons for good progress were:• Regular reviews by Commissioner Family Welfare (CFW) and SEPIO

and intensive monitoring by dedicated person at state level• Trained trainers in adequate numbers were available in all the states

visited• Training was decentralized to district level• Development partners mainly UNICEF supported ToTs for CCH training

in seven statesReasons for slow progress were cited as delay in translation and printing of handbooks; HR shortage and SCCO on leave.

2. Factors affecting the quality of cold chain handlers trainingQuality of training was found to be good, as gathered from the trainers and the trainees. • Duration of training was two days in nine states and one day in Delhi,

Manipur and Uttar Pradesh• Number of Cold Chain handlers per cold chain point were two or more in

eight states• Handbook was translated and printed/available in local language in all

states except in AP and MN where the participants were comfortable in English

• Training was residential in all states except GJ• Three or more trainers were involved per batch for both days in all states

3. Knowledge and practices of cold chain handlers after training• The trained cold chain handler had better knowledge and skills in all

areas (storage of vaccines and diluents, maintenance of equipment, recording of temperatures and stock registers etc.) as compared to untrained handlers

• Knowledge and skill levels remained poor for both trained and untrained handlers in recording of diluents details in stock register and contingency actions, conditioning of ice packs and freezing of ice packs in deep freezers

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Cold chain technicians trainingi. Positive observations • All cold chain technicians had minimum required qualifications and were

in-charge of only one district • All were trained for repair and maintenance of ILRs/DFs• Maharashtra technicians also repaired and maintained hospital equipment• Few of the cold chain technicians were also involved in vaccine

management duties• The technician with a WIC under his charge had received trainings for

repair and maintenance of WIC/WIF and also for the servo stabilizers (for use with WIC/WIF)

• All technicians except one had tool kits• All were satisfied with the quality of trainings received at SHTO, Pune

ii. Areas of concern• One technician was not trained to repair 1 kVa voltage stabilizers used

with ILRs / DFs• Three cold chain technicians trained for WIC/WIF were currently posted

in districts without WIC/WIF. They were also not trained in repair and maintenance of servo stabilizers

• Training has not been provided for all the different types and brands of voltage stabilizers available in the field

• A technician each gave incorrect answers to two questions directly related to his job responsibilities. This indicates non-application in actual work of knowledge gained during training or the requirement of short refresher trainings to update knowledge after every few years.

• TA/DA receipt / reimbursement issues have been reported by two of the eight technicians

• Most of the technicians did not have dedicated rooms to be used as workshops/offices. They also did not have easy access to transportation to travel to repair broken down machines/ compressors and other spare parts

• High breakdown instances / rates for haier equipment and chintz stabilizers reported by at least two of the eight CCTs

• Many spare parts used commonly for minor repairs were neither available with technicians nor at state level

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Key recommendations for improving training of CCHs and technicians

Cold chain handlers (CCH)• A one-day refresher course may be recommended for cold chain

handlers trained for two days provided proper data base of trained cold chain handlers is available

• The cold chain handlers training should be followed by intensive supportive supervision and on job training to ensure that knowledge and skills acquired are used in the actual settings

Cold chain technicians (CCT)• For optimum utilization of resources, states may post technicians trained

in repair and maintenance of WICs/WIFs to districts with WIC/WIF. They should receive training on servo stabilizers before or immediately after getting posted to these districts

• Trainings on different types/brands of 1kVA voltage stabilizers need to be organized for technicians who have not received the training

• Training to be urgently organized for repair and maintenance of haier equipment and chintz stabilizers

• Refresher trainings need to be organized for technicians regularly as per training needs assessment

• Supply of spare parts for minor repairs should be made regular• TA/DA reimbursement issues of CCTs should be taken up by states and

districts regularly. • States and districts should ensure dedicated room as workshop for the

technician along with priority allocation of four wheeler vehicle for transportation of ILRs/DFs and heavy spare parts

Way forwardNational level• Revise and update the training materials for MOs based on feedback

received• Streamline the reporting of RI training, may include under HMIS

State level • Establish state training cell to coordinate with all the programme officers

and SIHFW• Develop / improve training infrastructure in SIHFW and all the districts• Training database of health service providers should be maintained by

district training centres and SIHFW• Give priority and ensure mandatory attendance of MOs through some

orders from state

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• Include RI training as a part of induction training of MOs• Conduct state ToT to increase the pool of trainers at training centres and

conduct refresher training for master trainers at SIHFW• Develop systematic monitoring plan by state officials to facilitate training

process and ensure quality of training

District level• Invite more nominations for better participation• After training ensure follow-up and on-the-job training by the district level

officers• Ensure that quarterly RI review meetings are held and are used to review

the training issues identified through supervision visits• Provide mobility support to the MOs and other supervisors at block/PHC

level to ensure supervision• Encourage all MOs in addition to the MO-I/Cs to be actively involved in

micro-planning, monitoring and supervision activities• Organize refresher course at the district level for all MOs in RI including

new vaccine being introduced and capacity building of HWs to utilize VHND for increasing awareness

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IntroductionExpanded Programme in Immunization started in India in 1978. It was

renamed as Universal Immunization Programme in 1985 to progressively

cover the whole country. Immunization performance is regularly assessed

through UIP review meetings and joint review missions organized by the

Government of India (GoI) with states and partners. A national UIP review

was also conducted in India in 2004, covering six states selected on the

basis of various criteria. These reviews have noted strengths in UIP

performance in India – notably in the better performing states - as well as

many constraints which need to be addressed. Immunization training of

MOs and health workers was conducted as part of CSSM and RCH

programmes. Impact evaluation of RCH training conducted in 2004 revealed

inadequate practical hands on exposure.

For medical officers: Immunization

handbooks, facilitators' guides and training kits

were developed and printed by GoI in the last

quarter of 2008. Training plan was prepared

based on the training load of around 60 000

MOs and around 100 training centers identified

at state and divisional levels. As a first step, National Workshop for 40

master trainers was held at NIHFW during 9-11 September, 2008. During

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Chapter-1Introduction, rationale and objectives

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2009, all the 1050 trainers of the medical

officers were trained in around 25 Training

of Trainers (ToT) courses organized by

NIHFW and WHO-NPSP. The states

started training the MOs in 2009-10.

For vaccine and cold chain handlers: Handbooks in

English and Hindi were developed and printed by GoI

in June 2010. The States had to translate the

handbook in other local languages. At least one cold

chain handler per ILR point (PHCs and CHCs) with

20% extra as reserve and all handlers at

district/divisional/regional and state vaccine depots to

be trained. There were 221 state trainers were trained

in National ToTs (2010-11). There were 1507 district level trainers were

trained by state training teams in 2011.

For cold chain technicians (CCT): There are about 460 CCTs in the

country. SHTO, Pune (supported by UNICEF and GoI) has been conducting

training since early 1990's for cold chain technicians in (a) repair and

maintenance of ILRs/DFs, (b) repair and maintenance of WICs/WIFs, (c)

repair of different types of voltage stabilizers and (d) installation and

maintenance of solar refrigerators. No training was held from 2000- 2006.

RationaleOnly 50% of 60 000 MOs were trained in the country in two years, by January

2012. The progress in training varied from state to state. It was felt important

to identify the factors affecting the progress and quality of training by

studying the training system and the processes followed in select good

performing states and some weak performing states. Need was also felt to

assess the effect of training on the job performance of the MOs.

By January 2012, Only 43% of 33 000 CCH were trained in one and half

years, However, progress in training was different among states. Need was

felt to identify factors affecting progress and quality of training as also the

effect of training on job performance of CCH.

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Almost all CCTs were trained on repair and maintenance of ILRs/DFs; many

technicians posted at divisional/regional and state stores were trained in

repair and maintenance of WICs/WIFs. Only a few technicians were trained

in repair of voltage stabilizers. It was planned to assess training needs of

cold chain technicians to prepare future training programmes and also

identify systemic factors affecting their performance in the field.

ObjectivesThe overall objective was to study the processes and factors affecting the

progress, performance and quality of immunization training of medical

officers, CCH and technicians.

Specific objectives(1) To identify factors affecting differential progress between states in RI

training of MOs and cold chain handlers(2) To identify factors affecting the quality of training(3) To assess the knowledge, skills and practice of MOs, CCH and

technicians related to UIP(4) To make recommendations to improve future training of MOs, CCH and

technicians

I

Map-2.1: Selection of 12 states for phase-1 of Training evaluation study

< 40%

40% to 70%

> 70%

Map-2.1: selection of 12 states for phase-1 study

21

Chapter-2Methodology

Methods and materials The study was conducted in two phases1. Phase -1 was conducted for 20 February to 7 March 20122. Phase -2 was conducted for 23 April to 25 May 2012

Sampling technique1) Selection of states for phase-1 study

(to cover specific objectives 1 and 2)

Training progress of all the states was

reviewed. Twelve states were selected for

desk review and field visits on the basis of

MO-training performance. Four states

were selected randomly from each group

of states with MO-training coverage of <

40%, 40-70% and >70%. Kerala and

Tamil Nadu where RI training was conducted recently before introduction of

pentavalent vaccine were excluded. (Table 2.1)

Table 2.1: Categorization and selection of states for phase-1 study

Category A

MO-Training < 40%

UP, MP, WB, Gujarat

Category B

MO-Training 40-70%

Odisha, Manipur, Maharashtra, Delhi

Category C

MO-Training >70%

AP, Assam, HaryanaKarnataka

22

2) Selection of states and districts for phase-2 study (to cover specific

objectives 2 and 3)a) Out of original 12 states, six states were selected mainly by

exclusion criteria Assam, Haryana, Manipur and Gujarat recently

completed MCUP in the whole state or many districts were

excluded. Delhi being small state with doctors mainly posted in

dispensaries and Karnataka recently retrained all its doctors was

also excluded. The selected states were Uttar Pradesh, West

Bengal, Madhy Pradesh, Odisha Andhra Pradesh and

Maharashtra.

b) Based on MO-Training coverage, these states were grouped in

three categories. For these six states, mapping of all districts was

done based on training coverage. From each state, two districts

with moderate training coverage, one near state head quarter and

the other away from state head quarter were selected. (Table 2.2)

Table 2.2: Selection of states and districts for phase-2 study

Category A

MO-Training < 40%

Uttar Pradesh

Category B

MO-Training 40-70%

West Bengal

Category C

MO-Training >70%

OdishaMadhya Pradesh

Andhra Pradesh

Maharashtra

Ferozabad and

Jaunpur

North 24-PGS and Murshidabad

Hoshangabad and Satna

Ganjam and Khurda

Krishna and Medak

Raigad and Washim

c) In each district, it was decided to select

· The DIO, DPM and CCT· Ten MOs to be selected randomly from list of trained and untrained MOs

(including three-four MOI/Cs and one-two urban medical officers)· Six Cold Chain handlers available at cold chain points · Five ANMs/LHVs being supervised by MOs· Regional/district trainers for MO/CCH, if available in the district

23

Study populationAt state level, it comprised of

SEPIO, SCCO, Director

SIHFW, Director FW, MD-

NRHM and trainers of the state

training centers. At district

level, it comprised of DIOs,

DPMs, MOs, cold chain

h a n d l e r s , c o l d c h a i n

technicians, ANMs/LHVs and

trainers of the district/regional

training centers.

Map-2.2: Selection of 12 districts for phase-2 of Training evaluation study

Category A (<40%)Category B

(40% to 70%)Category C

(>70%)

Ferozabad, Jaunpur (Uttar Pradesh)

Hoshangabad, Satna (Madhya Pradesh)

Krishna, Medak (Andhra Pradesh)

24-PGS North, Mursh idabad (West Bengal )

Ganjam, Khurda

(Odisha)

Raigad, Washim

(Maharashtra)

< 40%

40% to 70%

> 70%

I

Sample size

Table 2.3: Number and category of Respondents interviewed at each level

N Category of respondents Number/ unitas planned

Total numberinterviewed

SEPIOSCCOTrainers of MOsTrainers of CCHDirector State/Regional Trg InstituteMD-NRHM / Director FW

DIO DPMTrainers of MOsTrainers of CCHCold chain technicianMedical officers (PHC)Cold chain handlersANMs and LHVsTotal number of respondents

Total number of respondents

District level1 per district1 per district1 per district1 per district1 per district10 per district6 per district5 per district26 per district

1 per state1 per state2 per state2 per state1 per state2 per state

121224241315

11117

1191147661300

100

1.2.3.4.5.6.

1.2.3.4.5.6.7.8.

State level

24

Data collection methods and procedures • Techniques of interview, observation and desk review of records were

used to collect data. • Planning meeting for the training evaluation study was held on 25

January 2012 at NIHFW with participation from GoI and partners

along with faculty of NIHFW. • Phase-1 study protocols and tools were finalized and shared with all

the study team members during briefing meeting held at NIHFW on

15 February 2012.The following tools were developed to meet the objectives of the study

(Annex-1):Study tool-1 for State EPI Officer and SCCOStudy tool-2 for State level Trainers of Cold Chain HandlersStudy tool-3 for Trainers of State Training Centre for MO trainingStudy tool-4 for the Director of State Training CentreStudy tool-5 for Director FW and MD-NRHM

• Twelve study teams were identified amongst officers from NIHFW and

partners. Field visits were made to each of the twelve states for two to

three days by a two member team to conduct in-depth interview of

SEPIO/SCCO/Director-SIHFW/Director-FW/MD-NRHM/other state

level officials and trainers of the state/regional training centers during 20

February to 7 March 2012. • Data collected during field visits was analyzed to identify the factors

affecting the progress and quality of training. Meeting was held at

NIHFW on 10 April 2012 with faculty of NIHFW, partners and GoI to

share the results from Phase-1 study and finalize the plan for second

phase of the study.• Phase-2 study protocols and tools were finalized and shared with all the

study team members during briefing meeting held at NIHFW on

20 April 2012.

The following tools were developed to meet the objectives of the study

(Annex-2):Study tool-1A for District Immunization Officer (DIO)Study tool-1B for District Programme Manager (DPM)Study tool-2A for Trainer of Medical Officer (MO)Study tool-2B for Trainer of Cold Chain Handlers (CCH)Study tool-3 for District Cold Chain Technician (CCT)

25

Study tool-4 for MO (Block/PHC)Study tool-5 for CCH (Block/PHC)Study tool-6 for ANM/LHV being supervised by the interviewed

medical officers.

• Twelve study teams were identified amongst officers from NIHFW and

Partners. Field visits were conducted to each of the twelve districts for

three to four days by a two member team to conduct in-depth interview of

DIO, DPM, cold chain technician, medical officers, cold chain handlers,

HWs and trainers of the MO and CCH during 23 April to 25 May 2012.

List of study team members is given at Annex-3.

Data validation and data analysisData validation exercise was conducted for all the data collected. This

included cross checking and matching the data from hard copies in to the

soft copies and clarifications sought after interacting with the investigators.

Then, state wise data was compiled and analyzed based on each objective

of the study, leading to preparation of graphs and tables for inclusion into the

report.

Chapter-3Study results

26

The observations from the study are presented under the

following four sections as follows:

PART-1: General profile of all the respondents of the study

PART-2:Results from evaluation of MO training in immunization. These are

organized under the following heads:

1. Factors affecting differential progress between states in RI

training of MOs 2. Factors affecting the quality of immunization training of

MOs3. Knowledge, skills and practices of MOs in immunization.

PART-3: Results from evaluation of cold chain handlers training

PART-4: Results from evaluation of cold chain technicians training

27

PART-1: General profile of the respondents of the study

State immunization officers: Twelve state immunization officers were interviewed. Seven out of twelve SEPIOs had post graduate qualification in public health or child health. All SEPIOs had more than two years of public health experience. Nine out of twelve SEPIOs had additional charge of RCH, NRHM or other programs except Assam, Manipur, Uttar Pradesh.

State cold chain officers: Twelve state cold chain officers were interviewed. Ten of them were trained as trainers for cold chain handlers either at national or regional level. In Uttar Pradesh and Haryana, they had recently joined. The training of cold chain handlers was being coordinated by either SEPIO or SCCO at the state level.

District immunization officers: Eleven district immunization officers were interviewed. Majority of DIOs (8/11) had less than two years of job experience. In two states of Andhra Pradesh and West Bengal where the MO training was decentralized to district level, the DIOs were also trainers of MOs.

District programme managers: Eight out of eleven DPMs had more than two years of job experience.

Medical officers: One hundred fourteen medical officers were interviewed. there were 51 MOs in-charge (45% of total MOs) and 63 were other MOs.There were 92% Mos who were MBBS and 8% AYUSH; 82% had rural posting and 18% had urban posting, 79% had regular posting while 21% had contractual appointment. Seventy two per-cent MOs had >two years of job experience and 32% had >10 years of job experience.

Out of 114 MOs interviewed, 68 (60%) were trained and 46 were untrained. Out of 68 trained MOs, 30 were MOI/C and 38 were MOs. Out of total 51 MOI/Cs, 30 (59%) were trained and 21 (41%) were untrained. Out of total 90 regular MOs, 55 (61%) were trained and 35 (39%) were untrained.

Trained medical officers included MO (PHC/CHC); Contractual doctors; AYUSH Doctors; MOs of hospitals. The medical officers involved in immunization program were trained.

28

Trainers of medical officers: MO trainers were available in all the 12 states

and in six districts of three out of six states visited (Andhra Pradesh, West

Bengal and Odisha). Trainers were faculty of training centres; medical

colleges; SEPIO / programme officers;

CMO / DIO / DTO; pediatrician; senior MO;

divisional coordinators; NPSP SMOs;

retired senior health officer etc. Right types

of officers were trained as trainers for MO.

Trainers of cold chain handlers: Trainers

were SEPIO / SCCO; MO / DIO / CCT / RM /

store in-charge; Faculty from SIHFW / DTC

/ HFWTC; programme officers; pharmacist; medical college faculty.

Cold chain handlers: Seventy-six cold chain handlers were interviewed.

Out of which 82% were in service for more than 10 years while 65% were

incharge of cold chain for more than two years; 16% were pharmacists,

mainly in Andhra Pradesh while 59% were ANM, LHV or Male MPW. Out of

76 CCH interviewed, 54 (71%) were trained. Trained cold chain handlers

were ANM / LHV; pharmacist (in seven states); MO; BEE / PHN; MHS /

MHW. Out of the repondent cold chain handlers 35% had been made in-

charge of cold chain in the past two years.

Health workers: Out of 61 Health workers interviewed 81% had more than

five years of job experience.

68, 60%

46, 40%

Trained UntrainedTrainedTrained UntrainedUntrained

Fig.3.1: % of trained and untrained MOs

29

PART-2: Medical officers training in immunization

1. Factors affecting differential progress between states in RI

training of MOs

MO training progress in 12 states: Before the study, three categories were

formed based on MO training progress in the states. Category A had <40%

coverage, category B had 40-70% and category C had >70% MOs trained.

Each category had four states.

After the phase-1 study, two states of Uttar Pradesh and West Bengal

remained in category A, while Gujarat and Madhya Pradesh moved to

category B. From category B, Maharashra and Manipur moved to category

C while Delhi and Odisha remained at the same place. Haryana and Odisha

showed reduced progress due to increase in training load.

2225

3236

4549

56

7173

78

85

94

29

54

35

43 42

79

66

74

64

89

100

93

0

10

20

30

40

50

60

70

80

90

100

WE

ST

BE

NG

AL

GU

JA

RA

T

UT

TA

R

PR

AD

ES

H

MA

DH

YA

PR

AD

ES

H

OD

ISH

A

MA

NIP

UR

DE

LH

I

MA

HA

RA

SH

TR

A

HA

RY

AN

A

KA

RN

AT

AK

A

AS

SA

M

AN

DH

RA

PR

AD

ES

H

% MO trained as of Dec'11 % MO trained as of Mar'12

Figure 3.2- MO-training progress in 12 states

Category A-<40% Category B-40-70% Category C->70%

Table 3.1: Categorization of states before and after the phase-1 of training evaluation study

Name of the states

Before the study

After the study

Category A: <40%

UP, WB, MP, Gujarat

UP, WB

Category B: 40-70%

Delhi, Manipur, Odisha, Maharashtra

MP, Gujarat, Odisha, Delhi, Haryana,

Category C: >70%

AP, Assam, Karnataka, HaryanaAP, Assam, Karnataka, Maharashtra, Manipur

30

West Bengal and Uttar Pradesh were the lowest performing states with only

29% and 35% of MOs trained respectively. No of trainers of MO in immunization training trained since 2009:• National level –178 (Highest number from Uttar Pradesh- 70)• State level–773 (Highest number from Assam- 286 and then West

Bengal-142)Though large number of trainers were trained in Uttar Pradesh and West

Bengal, the progress of training was slow.

SEPIOs attended training of medical officers: Five SEPIOs Delhi, Andra

Pradesh, Haryana, Manipur, Maharastra were trained as trainer for MO

training. Additional four SEPIOs had observed MO training Gujarat, Odisha,

Uttar Pradesh and KarnatakaThree states of Assam, Madhya Pradesh and West Bengal had new SEPIOs

who joined less than one year back. In these states, the MO training was

mainly coordinated by the earlier SEPIOs who were trained. All SEPIOs

involved in MO training were exposed to MO training as trainers or

observers.

Coordination of MO training at the state level: MO training was coordinated

at the state level by SEPIO in five states of Haryana, Manipur, West Bengal,

Karnataka and Assam; by the state training coordinator in three states of

Uttar Pradesh, Odisha, Maharashtra; by the state NRHM consultant in

Madhya Pradesh; by SIHFW/HFWTC in three states of Aadhra Pradesh,

Delhi and Gujarat. Coordination of MO training by SEPIOs led to good

progress in MO training (West Bengal was exception).

31

Table 3.2: Relation between coordination and progress of MO trainingin the state

MO training coordinated at state level

State EPI officer

State Trg coordinator/State NRHM consultant

SIHFW/HFWTC

States

HR, MN, WB, KA and AS

UP, OD, MH, MP

AP, DL and GJ

Progress of training

Good in all states except WB

Slow in UP, MP, OD

Slow in GJ

Table 3.3: Involvement of SIHFW in medical officers training

SIHFW coordinated MO training in the state

AP, Assam, DL and GJ

SIHFW conducted TOT for MO training

MP, MHand OD

SIHFW not at all involved in MO training

UP, WB, HRKA and MN

Support of development partners mainly WHO Country Office for India and

UNICEF was available for technical assistance and monitoring in all states

except , Delhi and Manipur.

Training centre at the state headquarter was not available in MP, GJ and

MN, MP had state level training centre in Gwalior.

Haryana

0

1

2

3

4

5

Category A Category B Category C

No

.of

Sta

tes

No Yes

Fig3.3: Trg Centre available at state level Fig3.4: SIHFW coordinated training for the state

0

1

2

3

4

5


No

.o

fS

tate

s

No Yes

State training centre was coordinating immunization training in four states of

DL, GJ, AP and Assam. It was involved in conducting TOT for MO training in

MP, MH and OD. SIHFW was not at all involved in UP, WB, HR, KA and MN.

32

In Andhra Pradesh and Assam, the progress of MO training was good due to

the proactive involvement of SEPIO as well as the SIHFW. In Haryana,

Karnatka and Manipur, SEPIOs were very pro-active. It was a missed

opportunity to not involve the SIHFW in Uttar Pradesh and West Bengal where

the progress in training was very slow.

Table 3.4: Progress of MO training based on number and level of trainingcentres in the state

Venue of MO trainingState level Regional level

States (no. of Trg centres)DL (1), MN (1)MP (3), GJ (5), OD (7), UP (11), MH (7)

Progress of Trg.

On track/GoodSlow in all states (35-54%) except MH (71%)

District level AS (27), AP (23), HR (21),KA (30), WB (19)

Good in all states (64-99%) except WB (29%)

Delhi and Manipur being small states had only one training centre at the

state level. Regional training centres were conducting MO training in

Madhya Pradesh, Uttar Pradesh, Maharashtra, Gujarat and Odisha. MO

training was decentralized to the district level in Andhra Pradesh, Assam,

Karnataka, Haryana and West Bengal.

Training progress was better in states where it was decentralized to district level and more numbers of training centres were involved. (Except WB)

Number and level of training centres involved AND the progress of MO-training

0

1

2

3

4

5


No

.o

fS

tate

s

Less than 15 15 or More

Fig.3.5: No. of training centres used

for MO training

0

1

2

3

4

5


No

.ofS

tate

s

District level Regional level State level

Fig.3.6: Venue of MO training

Reporting of MO training progress from all the states was ad hoc, as and

when asked from national level. There was no system of regular reporting of

training from the state to the national level.

33

Monitoring of MO training was conducted by only four out of 12 states. There

was a system to compile monitoring feedback in Andhra Pradesh,

Karnataka and Haryana (not in Manipur). SEPIOs of Eight states informed

the reasons for not conducting monitoring; SEPIOs of three states informed

about the feedback system and the major issues identified. The states

conducting monitoring of training had good progress in MO training.

Table 3.5: Monitoring of immunization training of MO, feedback and issues

Reasons for no monitoringin 8/12 states

System to provide feedbackin AP, Karnataka and Haryana

Major issuesidentified

• No monitoring plan and no funds earmarked for monitoring RI training

• Training centres are far off from state HQ.

• M a n y o f f i c e r s h a v e additional charge

• T r a i n i n g starting late and ending early

• Feedback is provided to SEPIO and Commissioner FW

• Reports submitted to MD (NRHM) for use in review meetings. CMO and DIO were also provided with copies for local action.

• SEPIO takes action on feedback from partners and RCHOs.

Other RI related trainings for medical officers were held in last two years on

measles catch-up campaigns, AEFI and HepB in all states except Odisha.

Except measles catch-up training, other trainings were of short duration for

orientation only.

Reasons for the variable progress in training asinformed by SEPIOs

Box 3.1: ON TRACK progress in AP, Assam, HR and MN • Proactive involvement of Director FW, MD-NRHM, SEPIO and

Director SIHFW • Top priority given to TRACKING and completion of immunization

training during review by MD-NRHM/Director FW

34

Box 3.2: FAST Progress in Karnataka• 2011-12 was declared as the Year of Immunization in Karnataka .

Finances were made available. Good support from DHOs and RCHOs.• Non cascade, special RI training plan was made by the state for all

the MO, irrespective of previous RI training history.• Instead of calling MOs to State/Regional training centers, all were

trained in their own districts. • Good monitoring by the state and district officials e.g. use of 'SKYPE'

for online monitoring of training.

Barriers and suggestions to improve the training progress and

quality:SEPIOs came up with the following barriers and suggestions to improve the

progress and quality of training:

Table 3.6: Barriers for slow progress and suggestions by SEPIOs toimprove the progress and quality of MO-training

• Training was not a priority in slow performing states.

• Less no of Training centres and lack of trainnig infrastructure.

• No accountabi l i ty for not attending the training.

• Shortage of doctors in the state, so not relieved for training.

• MOs not relieved for three days due to other priorities as dengue outbreak, floods.

• Multiple training courses for MOs.

• Too many training courses in HFWTC/SIHFW

• Delay in release of funds from NRHM office.

•and ensure mandatory attendance.

• I m p r o v e t r a i n i n g infrastructure in all districts.

• State training cell with one coordinator to coordinate with all agencies and SIHFW.

• Training plans should not clash with other training courses.

• SIHFW to be functional and responsible for all training centers in the state.

• SIHFW should maintain a training database.

• Include RI training as a part of induction training of MOs.

Give priority to MO training

Barriers for slow progress in training Suggestions

35

• Funding norms less than RCH

training norms followed.• Pressure to utilize PIP funds in

March. • School health programme for

three months.• No activity from April to June

because funds were released

from GoI in June.

• Conduc t s ta te ToT to increase pool of dedicated trainers at training centres and conduct refresher training for the master trainers at SIHFW.

• Invite more nominations for better participation.

• Include reporting of RI training under HMIS.

• Follow-up and OJT by the District level officers.

• Systematic monitoring plan with fund support in PIP to facilitate training process and ensure quality.

• Institutionalize monitoring of training. Use the state trainers to monitor training.

2. Factors affecting the quality of immunization training

of medical officersRole of SIHFW in coordination and monitoring of immunization training

activities. Though SIHFWs in six out of twelve states i.e. Andhra Pradesh,

Assam, Gujrat, Haryana, Karnataka and West Bengal had the control of all

the training centers in the state, in three states of Haryana, Karnataka and

West Bengal, they were not at all involved in immunization training.

Training policy for induction training of MOs Nine out of twelve states (except Delhi, Manipur and Assam) had policy for

induction training of MO. Duration of induction training was 12-15 days in

Karnataka, Madhya Pradesh, Maharashtra and West Bengal; 18-21 days in

Andhra Pradesh, Gujrat and Odisha; four-six weeks in Haryana and Uttar

Pradesh. Half to one day sessions were allocated to immunization in all

these states.

36

Training facilitiesDelhi and Manipur did not have hostel and

mess faci l i t ies, so no residential

arrangements were made. Gujarat had no

training facility at state level, the training

courses were conducted in hotels after

getting exceptional approvals from the state

authorities. Electricity back up was not

available in Madhya Pradesh and Odisha. Training, hostel and mess facilities were available in nine out of twelve

states.

At district level, five out of six districts had training centre but training was

residential only in one out of six districts (Ganjam in Odisha). Reasons given

for not staying overnight were that majority of MOs stayed near the HQ;

suitable trainnig. centre with accommodation facility not available.

Number of trainers involved Three or more trainers were involved on all three days during last three

batches in all states except Maharashtra where only one trainer was

involved.

Training methodologyAll states gave I MM handbooks, handouts and certificates to all participants;

conducted pre and post test evaluation and improved training based on

feedback received from the participants; used the training kits with games

and CDs with films during the training; organized field visit and provided

transport. Maharashtra was not using interactive training methods in 4/7

sessions; Uttar Pradesh and Gujarat were not using interactive methods in

3/7 sessions.

Based on feedback by participants, trainers took actions for improving the

food and organization of training, methods made more participatory and

included examples of practically showing formats and verifying in field.

All states were following the training guidelines and majority of the state and

district trainers were using interactive training methods as per the facilitators'

guide.

0

1

2

3

4

5


No

.ofSta

tes

No Yes

Fig.3.7: Residential facilities for

MO training

37

Problems faced by trainersThere were no issues in six states. Other states/districts reported issues of

shortage of trainers / not available in full strength; inadequate attendance of

MOs in training; only one training hall, group work is difficult; no

accommodation facilities; shortage of funds and handbooks.

Quality of training as perceived by the trained MosMajority (78%) of the 68 trained MOs attended training six months to two

years back. Venue of training for 63% was state or regional level, for 34%,

district level and for 3% in West Bengal it was sub-district level. Duration of

training was three days according to 90% MOs; however, 10% had attended

two days training (West Bengal, Odisha and Uttar Pradesh). Three or more

trainers were available on all days of training according to majority (86%) of

MOs. Immunization film was shown during training according to 75% of

MOs. Field visit was organized during training according to 90% of the MOs.

88% MOs reported to have received the certificate and 99% reported to have

received immunization handbook during training. At the time of study,

immunization handbook was available at the PHC with 51% of the trained

MOs. Quality of training as perceived by majority of the trained medical

officers was good. Field visit was not conducted for all sessions in UP and

WB.

Handbook units found

most useful Majority of the trained MOs

found cold chain and logistics

unit to be most useful, followed

by immunization schedule and

F A Q s , p l a n n i n g /

microplanning, records, reports and using data for action etc.

Handbook units found most difficult to understand by MOsPlanning/microplanning was found difficult by 1/4th of participants to understand the calculations of vaccines for number of sessions; followed by cold chain and logistics/stock management and records, reports and using data for action.

0

20

40

60

80

100

Uttar Pradesh West Bengal Madhya Pradesh Odisha Andhra Pradesh Maharashtra

Immunization film shown during the training Field visit organized during training for supervision

Certificate distributed during training Imm Handbook received during training

Fig. 3.8: State-wise quality of training as perceived by MOs

38

Handbook units found difficult to impart training to by few trainers on microplanning and VPD surveillance.

Fig3.9: Immunization handbook units found usefuland difficult by MOs and trainers

3

3

3

9

3

4

9

17

12

3

4

6

6

7

13

15

28

Supervision

Community mobilization

AEFIs

Safe Injection & waste Disposal

Using data for action

Microplanning

Imm schedule & FAQs

Cold Chain & Logistics

MOs foundUseful

MOs founddifficult

Trainers founddifficult

Box 3.3: Training handbook used as a resource after the training

Medical officers used the handbook

• To provide orientation/training to all HWs / HAs on all topics and training to

cold chain handlers

• As a reference for cold chain, micro planning, community involvement,

records, reports and using data for action, injection safety, handling

AEFIs etc.

• Displayed the immunization schedule and used FAQs for client counseling

and referral

• As a guide for supervision during VHND visits, for doses calculation,

schedule, AEFIs and for HepB introduction

39

Box 3.4: Examples of measures taken by the MOs to improve

immunization after training

•

session, AVD plan initiated. Number of sessions/month decreased from six to

four

• Trained ANMs on cold chain and improved arrangement of vaccines in ILR,

preparation of contingency plan, maintenance of temperature chart,

conditioning of ice packs and defrosting. Improved logistics management

avoided stock outs and reduced vaccine wastage

• Trained ANMs on safe injection practices and improved injection technique

and site of administration; writing date and time of reconstitution; ensuring

that measles vaccine is used within four hours. Ensured use of hub cutter and

disinfection of waste before disposal

• Guided health workers on AEFIs. Kept emergency drugs and counseled the

parents on AEFIs. Analyzed the data to facilitate reporting of AEFI

• Community mobilization and communication with community improved by

tracking dropouts through service registers and meeting parents. Involved

Maulana in Muslim areas and NCC cadets for mobilization. Motivated HWs to

communicate key IPC messages at the session site and follow-ups after

vaccination

• Supervised HWs, conducted session monitoring and on- job-training by using

monitoring checklist. Supervisory visits reduced to two sessions per day.

Trained ANMs to prepare coverage monitoring chart and keep counterfoils in

tracking bag. Monitored routine immunization in review meetings

Microplanning improved, due list prepared by ANM one day before the

40

Difficulties faced by MOs during training Jaunpur MOs informed unavailability of electricity (training conducted in

open varandah space); session started at 12:30pm (average duration of

training was three hours/day) with field visit for one hour and non residential

training (travel distance of 40-45 kms one way was a disadvantage). Some

informed that the training was very compressed in time.

Suggestions given by MOs to improv future immunization training• Three days training can be taken as base training. Practice sessions

and field visits must be increased. More detailed session on planning

and logistic management.• Refresher / reorientation of already trained persons for one day, once

a year in a decentralized manner at a place nearer to the PHC. • Post training follow up is recommended.

Suggestions given by trainers for future training coursesCourse contents for addition / modification• Add chapters on new vaccine introduction; special strategy for urban

areas; immunization for HIV and premature / malnourished; emerging

diseases HMIS / MCTS; measles catch-up and national as well

as state specific scenario, data and guidelines; procurement policies• Add injection administration techniques from HW handbook• Include how to prioritize issues following desk review• Facilitate developing RI monitoring plan, orientation on NRHM formats

and RIMS/ HMIS needed• Coverage evaluation methods, rapid assessment• New MCP card• VPD surveillance to be made simpler to understand; more informative,

case management latest protocols to be added. JE should be dealt in

more detail• AEFI: AEFI chapter needs to be updated with details of AEFI

treatment (cross reference with measles catch-up guidelines give

more clarity on AEFI investigation – PIR, FIR, etc., amount of antigen

required for potency check. Treatment of anaphylaxis to be clearer

and elaborate with dose of adrenalin and other drugs. Add contents of

AEFI treatment kits and media handling post AEFI

41

•

handbook. Domestic refrigerator use – conflict with storing AVS, ARV;

role of MOs to be clarified, more actionable orientation; financial

management issues; cold chain hold over time for haier ILR is 24hrs

only; domestic refrigerator (In chiller tray, should not keep anything)• Unit on community participation to be more detailed as the major

reason for poor coverage in RI is lack of community involvement

Training methodology• Micro-planning – every exercise should be done by every person• Increase duration of training to four to five days, more time for field visits.

Day three should coincide with session day. Refresher training for one

day• Maintain training data base to avoid duplication in online portal with free

access.• Certificate should be delivered following satisfactory discharge of

responsibilities based on new training methods imparted.

Classroom, hostel and transport facilities are required at the training

center in Delhi, Gujarat and Manipur. Districts with trained MOs and

excellent training and residential facilities should be made training

centres for MO training e.g. Hoshangabad in Madhya Pradesh.

More trainers required in Gujarat and Haryana, as a number of untrained

doctors need to be trained.

Funds: Increase DA for participants in Haryana, Gujarat and Manipur.

Increase honorarium of trainers in Maharashtra and MP. Funds should be

provided as for IMNCI and BEmOC training.

Cold chain contents should tally with that in Cold Chain Handler

42

3. Knowledge, skills and practices of MOs in

immunization

I. Knowledge level of trained

and untrained medical officers To assess their knowledge level, all

the MOs were asked ten open

ended ques t i ons f r om the

immunization handbook. They were

scored based on the correct

responses. Comparison has been

made between the trained and

untrained medical officers as follows:

a) Percentage of MOs who answered correctly at least five out of 10

questions• It was definitely higher for trained

MOs as compared to untrained

MOs in all the six states studied.

All districts except two i.e.

Jaunpur in Uttar Pradesh and

Satna in Madhya Pradesh had

improved scores after training

• The p of in-charge

MOs who answered correctly at least five out of ten questions, it was

higher for trained MOs as compared to untrained MOs in five out of six

states except Maharashtra. All districts except three i.e. Jaunpur in Uttar

Pradesh, Satna in Madhya Pradesh and Washim in Maharashtra had

improved scores after training

• The p of non-in charge MOs who answered correctly at least

five out of ten questions, it was higher for trained MOs as

compared to untrained MOs in all the six states studied. All districts

except four i.e. Jaunpur in Uttar Pradesh, Satna in Madhya Pradesh,

Khurda in Odisha and Raigad in Maharashtra had improved scores

after training

ercentage

ercentage

Fig.3.10: Assessing knowledge –All MOs-Trained vs. Untrained

31

67

25

38

29

0

33

22

0

13

25

54

0

10

20

30

40

50

60

70

80

90

100

Uttar Pradesh West Bengal MadhyaPradesh

Odisha AndhraPradesh

Maharashtra

Trained MO Untrained MO

Total questions : 10


13, 4N1, N2=

Total MOs interviewed = 114 (68 trained & 46 untrained)Note : N1=Trained MOs interviewed, N2 = Untrained MOs interviewed

12, 9 8, 9 8, 8 13, 8 14, 8

(% MOs answered correctly at-least 5 out of 10 questions)

Fig.3.11: Assessing knowledge –incharge trained MO vs. incharge untrained MO

50

75

50

57

14

0

50

0

17

33

25 25

0

10

20

30

40

50

60

70

80

90

100

Uttar Pradesh West Bengal Madhya

Pradesh

Odisha Andhra

Pradesh

Maharashtra

Incharge trained MO Incharge untrained MO



4, 2N1, N2= 4, 4 4, 4 4, 2 7, 6 7, 3

Total incharge MOs interviewed = 51 (30 trained & 21 untrained)

N ote : N1=in-charge trained MOs interviewed, N 2 = in-charge untrained MOs interviewed

(% MOs answered correctly at-least 5 out of 10 questions)

43

b) Comparative mean score of MOs based on correct answers (Add total score of each MO, divide by number of MOs = Mean score) • Comparative mean score of total medical officers was definitely higher

for trained MOs as compared to untrained MOs in all the six states

studied. The range for trained MOs was three to six and for untrained

MOs, it was two to three. All districts except two i.e. Jaunpur in Uttar

Pradesh and Satna in Madhya Pradesh had improved scores after

training• Comparative mean score of in-charge MOs was definitely higher for

trained MOs as compared to untrained MOs in all the six states studied.

The range for trained MOs was three to seven and for untrained MOs, it

was three to four, all districts except three i.e. Jaunpur in Uttar Pradesh,

Satna in Madhya Pradesh and Washim in Maharashtra had improved

scores after training• Comparative mean score of non in-charge MOs was definitely higher for

trained MOs as compared to untrained MOs in all the six states studied.

The range for trained MOs was three to six and for untrained MOs,

it was one to three. All districts except two i.e. Jaunpur in Uttar Pradesh

and Satna in Madhya Pradesh had improved scores after training

Fig. 3.12: Assessing knowledge –all MOs-trained Vs untrained

3

6

3 34

2

3 3

22

3

5

0

2

4

6

8

10



Maharashtra

Trained MO Untrained MO



13, 4N1, N2=


12, 9 8, 9 8, 8 13, 8 14, 8

(MOs answered correctly - comparative mean score)

Fig. 3.13: Assessing knowledge –

incharge trained MO vs. incharge untrained MO

3

7

4

5

33

44

3 33 3

0

2

4

6

8

10

Uttar Pradesh Wes t Bengal Madhya

Pradesh

Odisha Andhra

Pradesh

Maharashtra

Incharge trained MO Incharge untrained MO



4, 2N1, N2= 4, 4 4, 4 4, 2 7, 6 7, 3

Total incharge MOs interviewed = 51 (30 trained & 21 untrained)Note : N1=in-charge trained MOs interviewed, N2 = in-charge untrained MOs interviewed

(MOs answered correctly - comparative mean score)

44

Table 3.7: Question wise comparison: Percentage of MOs who answered correctly(trained vs untrained)

Question

What vaccines can be given to a child who comes for the first time at 16 mths?

UP

T

13

39

15

46

39

39

23

0

31

8

31

WB

U

4

25

25

50

50

0

0

0

0

0

0

MP

U

9

33

22

44

56

33

44

11

11

22

22

UP

U

9

11

33

67

44

22

56

0

33

22

0

OD AP UP MH

T

12

75

67

57

83

75

92

17

33

50

58

T

8

38

50

75

63

50

13

13

13

0

0

T

8

50

38

25

63

25

63

0

0

50

13

T

13

54

39

54

92

62

69

23

0

31

31

T

14

57

21

57

43

79

29

14

21

29

7

U

8

88

25

25

13

13

25

13

0

0

0

U

8

50

13

38

38

25

63

0

0

0

0

U

8

63

25

75

38

38

25

0

0

13

0

How many minimum sessions are required per year to fully immunize all infants in a hard to reach village with population of less than 1000?

What is most important criterion to prioritize sub-centers for action?

Which vaccines are sensitive to freezing?

How will you prevent f r e e z i n g o f f r e e z e sensitive vaccines in PHC and during vaccine distribution?

How are the diluents of BCG and Measles stored before use?

What is minimum stock level to place an order?

What are serious AEFIs?

How do you calculate Drop-out rate between DPT1 and DPT3?

What tools are used to track drop-outs?

SN

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

N=

Though responses were better in trained MOs as compared to untrained MOs, the responses to questions 7, 8 and 10 were very poor in majority of the states. WB performed well in all questions; AP in five questions; MP and OD in four questions each and MH in three questions. Performance of UP MOs in terms of knowledge gain was lowest.

RI-Microplan availableat the PHC

Map of catchment area

UP

4

50

50

100

50

75

25

WB

2

0

50

50

0

25

0

MP

4

50

75

50

50

0

25

UP4

50

100

75

100

100

100

OD AP UP MH

4

0

25

75

50

0

0

4

25

25

50

50

50

25

4

75

25

75

0

25

0

7

71

57

100

71

57

14

7

29

0

57

71

100

43

2

50

0

50

50

52

0

6

61

17

83

33

50

17

3

100

0

100

33

100

50

45

Fig. 3.14: Percent RI microplan components

available at the PHC

33

25

38

6769

5050 50

63

17

38

0

83

63 6367

92

70

33

50

75

17

54

60

0

20

40

60

80

1 00

Uttar Pradesh West Bengal Madhya Pradesh Odisha Andhra Pradesh Maharashtra

Map of Catchment area Estimation of beneficiaries and Logistics

ANM work-plan / roster AVD plan to supply the vaccines

N = 6 8 8 6 13 10


Percent

75

0

50

25

100

25

0

100

5250

100

57

0

10

20

30

40

50

60

70

80

90

100



Maharashtra

MOIC trained MOIC untrained


4, 2N1, N2= 4, 4 4, 4 4, 2 7, 6 7, 3

(% of PHC where day-wise plan for supervisor field visits available)

Total MOs interviewed in PHC = 51 (30 trained & 21 untr ained)Note : N1=Trained MOs interviewed in PHC, N2 = Untrained MOs interviewed in PHC

Fig. 3.15: Day-wise plan for supervisor field visits available at PHC

Estimation of beneficiaries

ANM work plan or roster

AVD plan to supply vaccines

Day wise supervisory plan

Special plan for high risk and hard to reach areas

All microplanning components were

available in UP. Special plans for hard

to reach areas were available only in

very few PHCs. ANM roster and AVD

plans were available in all the states.

WB performed poorest in availability of

maps, estimation of beneficiaries and

plans for supervisory visits.

Though WB MOs showed improved knowledge after training, they were not

involved in microplanning. UP had microplans may be due to guidelines from

the state and partner support.

25

0

25

0

43

0

25

100

0

17

50

14

0

10

20

30

40

50

60

70

80

90

100



Maharashtra



4, 2N1, N2= 4, 4 4, 4 4, 2 7, 6 7, 3

(% of PHC where special plan for high risk & hard to reach areas available)


Fig. 3.16: Special plan for high risk and hard to reach areas available at PHC

RI-microplan

Table 3.8: Availability of micro-plan components in PHCs with trained (T) and untrained (U) MOs

ii. Practices of trained versus untrained MOs in PHCs Comparison was made between trained and untrained MOI/Cs in various immunization components

46

Role of MOs in micro-planning and reasons for in-complete RI

micro-plans

Majority of MOs had no role in micro-planning; it was prepared by PHN, LHV,

MHS, MPHS (M), BEE, BPM and Community Health Officer.

Reasons for incomplete micro-plans were given as: no formats / guidelines

received from district/state; not aware of the need; not aware of map; logistic

calculation was done on the basis of previous month; not aware about

estimation of beneficiaries and beneficiary list.

At some PHCs, logistics estimation was done in 2009; microplan was not

revised / updated in subsequent years, only roster was prepared. According

to some MOs, ANM diary was the only plan; unlike polio, RI microplan was

not mandatory; it increased the workload of ANMs and overall emphasis on

RI by the district / state level was not high.

Very few MOs supervised the process of preparation of the plan; built

capacity of staff and provided hands on training during preparation of

microplans; reviewed microplans and coordinated corrective action;

calculated number of sessions required; identified missed villages, high risk

and low coverage areas for inclusion.

Supervisory visits by MOs

Plan for supervisory visits was available in

all PHCs of MH, majority of PHCs in MP

and UP followed by AP and OD. It was not

available in WB. Difference between

PHCs with trained and untrained doctors

was seen only in UP. Percentage of MOs

who conducted at-least five supervisory

visits was lowest in WB and MP.

Reasons given by MOs for <four supervisory visits in last three months were

shortage of doctors, no mobility support, busy in OPD and clinical work.

44 43 44

100

38

88

42

30

50

20

62

25

38

11

0

10

20

30

40

50

60

70

80

90

100


Pradesh

Odisha Andhra

Pradesh

Maharashtra Total

MOs trained MOs untrained


(% MOs with at- least 5 supervisory visits conducted to SC/Session site )

Fig. 3.17: Supervisory visits conducted by MOs during last 3 months

9, 2N1, N2=


10, 8 5, 9 8, 8 13, 8 14, 8 59, 43

47

Records available to support

supervisory visits: No records were

found in majority of the PHCs, followed

by filled in checklist/monitoring format,

movement register, supervisory report

and diary of MO.

29

16

0

76

2 27

61

8

00

10

20

30

40

50

60

70

80

90

100

Filled in

checklists/moni tor ing

format

Supervisory reports Movement re gisters Any other No records

MOs trained MOs untrained

Fig. 3.18: Records availability at PHC to support supervisory visits

16, 6N1, N2=

Total MOs inter viewed = 114 (68 trained & 46 untrained)Note : N1=Trained MOs interviewed, N2 = Untrained MOs inter viewed

1, 0 4, 0 1, 3 34, 28

48

Box 3.5: Examples of improved practices after training (problem solving and on-job-training during supervision)

As informed by the MOsImmunization schedule: Clarified vaccines to be given in case of

skipped doses; how long the measles and BCG vaccine be given.

Asked HWs to give vaccine to children with minor illness.

Cold chain maintenance at session site: Prevention of exposure to

sun light; vaccines storage and keeping vaccine in proper manner; VVM

to be maintained, placing vaccine carrier in shade; keeping reconstituted

vials on icepack, open vial policy and AVD to reach in time.

Safe injection practices: Corrected route, site and technique of

injection administration; positioning of child; BCG and measles have to

be used within four hours; hand washing; no cleaning with spirit; not to

touch the needle. Demonstrated use of hub-cutter and observed for

correction; waste disposal as per guidelines.

Communication and social mobilization: Supervised giving four key

messages to parents and tracked mobilization by ASHA, defaulter

counseling and counseling after AEFI; visited the houses of migratory

and resistant population with ANM and AWW and convinced the

unimmunized/resistant for vaccination. Emphasized on due list of

beneficiaries to be prepared and used to mobilize drop outs by ASHA /

AWW. Previously sessions were conducted at CHC only, now MO

sorted out the problems and sessions are being conducted in the field

also.

Records and reports: Explained formats, promoted updating of

counterfoil and explained use of tracking bags; reporting AEFIs. ANM

was told to enter in immunization register as soon as child is immunized.

ASHA was told to update simultaneously. Show causing for not updating

register, MCTS updating. Asked supervisors to monitor, helped them to

arrange session in systematic manner.

Coverage monitoring chart was available only in 24% (12 out of 51) PHCs, only in MP and OD.

Fig. 3.19: Health staff conducting

the analysis of data from routine 32

18

10

8

65

Health Supervisor MOI/c/MO BPM/BEE/BPO PHN Statistical staff IO

90

75

40

71

46 44

0

10

20

30

40

50

60

70

80

90

100

Immunization Coverage Drop-outs Left-outs

MOICs trained MOICs untrained

Fig. 3.20: Analysis of routine reports being done

N1, N2=

(% of PHCs where routine reports are being analyzed)

20,16 17, 10 13, 9

Total MOICs interviewed in PHC = 51 (30 trained & 21 untrained)Note : N1=Trained MOICs interviewed in PHC excluding missing values, N2 = Untrained MOICs interviewed in PHC excluding missing values

49

As informed by the HWsMos taught how to prepare due list; indent vaccines as per due list;

maintain cold chain at session site. Power shortage in one block was

solved by arranging for back up generator and funds. Checked for time

of reconstitution written on BCG and measles vials; checked entries in

register for corrections at the spot. Demonstrated injection technique for

DPT, Measles, HepB; how to use hub cutter and dispose off waste at

session site. Informed about new schedule and four key messages for

RI; scheduling for over aged child; contraindication of any vaccine, AEFI

management, motivating community. Helped to tackle families resisting

immunization by visiting their homes and counseling reluctant parents;

assure parents for minor AEFI.

Monitoring and using data for action after training

Analysis of the routine immunization data from the subcentres was done by

health supervisor mainly, followed by MOI/c/MO, BPM/BEE/BPO, PHN,

statistical staff/data operator/ICC investigator cum computer and IO.

Data was analyzed from the routine reports for immunization coverage,

drop-outs, left-outs; vaccine wastage, shortage of vaccines, sessions held

versus planned, target etc.

50

Data was analyzed subcenter wise for immunization coverage; shared

feedback of drop outs/left outs during monthly meetings; conducted reason

analysis for low immunization coverage and took action depending on

reasons e.g. arranged additional sessions in low coverage areas; asked

supervisors, ANM, ASHA and AWW to focus on unimmunized; increased

mobilization by ASHA and influential leaders for low coverage areas,

planned special sessions if drop outs were high; sent MO, HEEO, HA, H/I to

Nomadic and resistant areas for mobilization; arranged for another ANM on

immunization days where ANM work load was very high; used due list and

counter foils to identify drop outs and track them.

Conducting review meetingsReview meetings were held at Block/PHC in all the states. They were not

held in few blocks of MP, MH and WB. Frequency was monthly in majority

(73%) of the blocks. No significant difference was seen between trained and

untrained MOI/C.

Participants during the review meetings were mainly HWs followed by

ASHAs, AWWs, PRIs and others as

BPM, BEE, CHO, PHN, MO and MPW. Records of immunization review

meetings which were available were

mainly for attendance followed by

minutes and agenda.Topics discussed as per MOs were

subcent re wise immunizat ion

coverage, drop-out rates, supervisory

findings, problems faced by HWs, data of MCTS and others as infant and

100

50

43

100

50

83

33

100

50

100100

25

0

10

20

30

40

50

60

70

80

90

100



Maharashtra



4, 2N1, N2= 4, 4 4, 4 4, 2 7, 6 7, 3

(% of PHC where immunization review meetings are held)


Fig. 3.21: Immunization review meetings are held at Block/PHC

91

23

92

38

5

32

0

62

0

10

20

30

40

50

60

70

80

90

100

Health workers ICDS workers ASHA PRI members


Fig. 3.22: Participants attending immunization review meetings

Total review meetings held = 35 (22 trained MOICs & 13 untrained MOICs)Note : N1=Trained MOICs interviewed in PHC excluding missing values & review meetings not held, N2 = Untrained

MOICs interviewed in PH C excluding missing values & review meetings not held

51

maternal death, diarrhoea, FP cases, ANM

Register, new programme of Govt., AEFI and

VPD reporting issues, planning for VHND,

vaccine and logistic problems, subcentre micro

plan; availability of health workers, guidelines

on immunization weeks.

The topics discussed as per HWs were preparation of due list, updating of

MCP cards and FSR (field survey register); introduction of new vaccine like

JE, measles second dose; discard reconstituted BCG/measles after four

hours and JE (two hrs), use conditioned ice packs; new guidelines; cold

chain; AEFIs; communication skills; injection safety; and waste disposal;

session planned and held; resistant families; discussion on immunizations

weeks; fixing extra immunization days if missed.

Reporting of AEFIs and VPDs Majority of the PHCs had not reported any AEFIs or

VPDs during last three months.

Community involvement and communication

activities conducted after training

As per MOs: Held VH sanitation committee meeting, community meeting

with pregnant women and women with small children, convergence

meeting, PRI meeting and meeting with ASHA/AWW.

In village health meetings, MOs addressed about new schemes and

programmes of state/ national govt.; provided health education and talked

on importance of RI. MOs gave health talk during VHND and breast feeding

weeks; distributed pamphlets and organized health camps for tribal areas

once a month in epidemic season.

Mos educated ASHAs and AWWs, sent them to houses of children with drop

outs and asked them to visit each beneficiary home; ANM was asked to

conduct home visits for drop outs and participate in AWW meeting once in a

month to impart knowledge on RI. MOs visited houses of families refusing

routine immunization and involved local influential persons for community

mobilization and conducted community meets.

Fig. 3.25: Reportingof AEFI & VPD cases

Total MOICs interviewed in PHC = 51 (30 trained & 21 untrained)

Note : N1=Trained MOICs interviewed in PHC excluding missing val ues, N2 = Untrained MOICs interviewed in PHC

excluding missing values

20

27

19 19

0

10

20

30

40

50

60

70

80

90

100

AEFI reporting done VPD reporting done


Pe

rce

nt

55

45

69

31

15

2732

14

3131

0

10

20

30

40

50

60

70

80

90

100

SC wise

ImmunizationCoverage

Drop-out rates Supervisory

findings

Problems faced by

HWs

Data of mother &

child trackingsystem


Fig. 3.24: Topics discussed in the review meetings

Pe

rcent

Total review meetings held = 35 (22 trained MOICs & 13 untrainedMOICs)Note : N1=Trained MOICs interviewed in PHC excluding missing values & review meetings not held, N2 = Untrained MOICs interviewed in PHC excluding missing values & review meetings not held

52

As per HWs: MO attended mother's meeting (village level meeting at AWC

for mothers - attended by ANM organized by AWW and ASHA); addressed

VHND meeting and explained about immunization; coordinated with school

health and ICDS; MOs gave health talks and sensitized community during

routine visits; visited houses of left-outs and dropouts to advise mothers for

vaccination; talked to teachers for support; motivated parents of children

who came at session site; involved local community leaders in hard to reach

areas; held SC meeting with ANM, ASHA, Pradhan, AWW pregnant and

lactating mothers; asked ANM to track drop outs; called mothers of drop outs

at session site and counseled them for immunization. The MO organized

block level task force meeting (BTF) on RI (starting last month) participants

were CDPO, ABSA, BDO, MO, IO and MOIC; talked about PRI involvement,

tickler box use, liberal use of untied funds and locally funded typhoid

vaccination.

Methods used for immunization waste management in the PHCHub cutter was used in majority of PHCs

followed by use of disposal pit, red and black

bags and disinfection. Other means were

outsourced to agency, bury syringes in the

pit, sent to CHC for collection by

municipality vehicle and burn it. Waste

management was poorest in UP.

Performance of medical officers as per DIOs All DIOs noted improvement in performance of MOs after training in areas of

supervision/monitoring of the immunization and VHND sessions;

improvement in quality of immunization; community mobilization; AVD;

micro planning and logistics management; improved RI data analysis at

block level; waste disposal; Injection safety; cold chain maintenance. (Temp

chart, placement of vaccines, time and date of reconstitution)

Performance of medical officers as per HWsSixty percent HWs found improvement in performance of MOs after training.

Performance of MOs improved in: immunization schedule, new vaccines

and FAQs; maintenance of cold chain at session sites; route and site of

injectable vaccines; positioning of children; waste management; informing

Fig. 3.26: Methods used for immunization waste management

Total MOICs interviewed in PHC = 51 (30 trained & 21 untrained)

Note : N1=Trained MOICs interviewed in PHC excluding missing val ues, N2 = Untrained MOICs interviewed in PHC

excluding missing values

83

47

76

33

60

47

5252

0

10

20

30

40

50

60

70

80

90

100

Hubcutter used Red & black bag used Disinfection done Disposal pit used


Pe

rce

nt

53

key messages to the beneficiaries; preparation for vaccination session.

coordination with other dept (ICDS); AVD point introduced (through NGO)

for collection of vaccine; checked tally sheet, due list, filling of immunization

cards and, immunization schedule of children; drop outs were monitored

and reasons sought, better tracking of dropouts, preparation of due list.

Additional support from MOs required to improve HW performance: mobility

support like loans for two wheeler; residential accommodation at subcenter;

timely disbursement of rent for subcenter; provide more space at session

sites to properly conduct session; attend community meetings; encourage

and appreciate HWs; guide in preparation of microplans and latest updates

of immunization activities; interact with influential persons of the community;

more supervisory visits in the field to correct mistakes; visit to houses with

drop outs; meet PRI members; it would create confidence in community;

vehicle to be arranged for vaccine delivery to operationalize AVD

mechanism; ensure regular supply of vaccines, logistics and tour

diary/register, ASHA payment; need training from MO, orientation on RI -

particularly HepB vaccine.

iii. Programme support to the MOs Clear guidelines for fund utilization for AVD, ASHA, supervision, untied

funds with ANM etc. were available with majority of respondents (78%).

Some issues were highlighted as delayed or no receipt of funds from district

for mobility for supervision; for AVD and for ASHA. Supervision of medical officers in last three monthsSeventy percent of MOs were

visited by their supervisors in last

three months.

Suggestions of district supervisors

for RI strengthening in the

block/PHC were: to analyze the

sub-centre wise data for dropouts,

follow up and track them; target

migratory areas. Supervisor

checked monthly reports for the

gaps; checked temp. records and guided on maintenance of cold chain;

gave general instructions and new updates; increased number of

Clear guidelines available for fund utilization

Total MOICs interviewed in PHC = 114 (68 trained & 46 untrained)Note : N1=Trained MOICs interviewed in PHC excluding missing values, N2 = Untrained MOICs interviewed in PHC excluding missing values

19, 22%

67, 78%

Supervisor visited the Medical officer in last 3 months

31, 30%

71, 70%

Medical officers feels the need for additional immunization training to improve proficiency of work

12, 12%

89, 88%

Yes No

Fig. 3.27: Program support to the medical officers

54

supervisory visits by MO/sector supervisor; repeated training of HWs;

increased two sessions in two SCs; suggested improvement in the

microplans for the urban area; to follow the plan for VHND, prepare work

plan for field visits; immunization week; ABC categorization of villages; to

update due list of ANMs and immunization register of ANMs; suggested for

holding sessions on time to provide immunization for full working hours;

ANM timings discussion on AVD and its improvement; safe injection

practices; how to prevent AEFI; biomedical waste management - deep burial

pits for every sub-centre; some management issues related to staff

punctuality, visit all subcentres etc. allocation of Gram Panchayats to MOs

specifically.

Role of District Immunization Officers (DIOs) in immunization

programmeImmunization review meetings were held in seven out of eleven districts in

last six months. 8/11 DIOs had access to HMIS data. Coverage monitoring

chart was displayed only in two out of eleven districts. Only two out of eleven

DIOs had made no supervisory visits (Khurda and North 24-Parganas) in

last three months. Others had made more than six visits in last three months.

Methods used were desk monitoring of HMIS reports from divisional and

block level; field monitoring and supervisory visits from district level and

immunization meetings.

Specific issues identified and discussed during last three review meetings

were: HMIS data-immunization coverage and drop-outs; reports of any VPD

and AEFI; sessions not held, shortage of staff at PHCs, shortage/stock outs

of vaccines; weakness in health supervisory link, no funds for RI supervision

/ monitoring, late start of activity etc. capacity building of health workers

especially elderly and overworked ones to increase their motivation level;

Infant deaths; synchronization of ICDS and health area; gaps identified

during supervisory visits; orientation and review on MCTS, ASHA/AWW not

mobilizing all children; community resistance; planning of outreach sessions

in hard to reach areas.

Major issues identified during supervision and actions taken: low community

involvement due to AEFI; health workers not reaching session sites on time;

due list of beneficiaries not available; not giving the key messages; not

55

updating register, tally sheet and counterfoils: shortage of AD syringes,

vaccines and immunization cards, micro-plans not available; mobilization

issues. DIOs supported and motivated supervisors to help them during

quarterly review meetings on immunization and meetings held with ASHA

and AWW at block level.

Mechanism (and frequency) of sharing information with ICDS, Partners and

PRIs: CDPOs were part of monthly and quarterly meeting; convergence

meeting with ICDS was held every month at district, block and sub center

level. Health, ICDS and PRI meetings were held at gram panchayat level

each month.

Role of District Program Manager (DPM) in immunization programNine out of eleven DPMs were involved in HMIS reporting and eight out of

eleven in RI-monitoring. As informed by them, they visited 10-12 VHND

sessions per month with a checklist and looked for cold chain and vaccine

management, waste management, monitored funds for AVD and ASHA

etc.Involvement in other immunization activities: PIP preparation and

disbursement of funds and logistics (monitoring formats, immunization

cards); participated in development of sub-centre and PHC microplan in

meetings; attended monthly review meeting where immunization was

discussed; provided support in arranging district level meeting by ensuring

availability of meeting hall and inviting MOs etc.; involved in planning and

monitoring of Bal Swasthya Poshan Mah (BSPM). DPMs were involved in

monitoring of the immunization program at district level.

iv. Need for additional immunization training by MOs to help improve

proficiency in workEighty-eight percent of MOs felt the need for additional training in

immunization. Untrained MOs asked for complete RI training while majority

of trained MOs asked for refresher training at district level as HWs were to be

trained repeatedly. Areas were specified as microplanning/planning, cold

chain, logistics management, new vaccines, community involvement,

records, reports and using data for action, AEFI, updates and changes in

guidelines, waste disposal and role of AYUSH doctor.

PART-3: handlers training

Results from evaluation of cold chain

56

Factors affecting differential progress between states In CCH TrainingCCH Training progress in 12 states: Before the study, seven states had less than 40% CCH trained.

After phase-1 study only KA had <40% CCH trained; UP, WB, DL and MN had 40-70% CCH trained; rest of the seven states had >70% CCH trained. Non-reporting was the main reason before the study.

Table 3.9: Categorization of states before and after the phase-1 of Training evaluation study

Name of the states

Before the study

After the study

VCCH-Training < 40%UP, Assam, MP, WB,MN, MH, KAKA

VCCH-Training 40 to 70%OD

UP, Delhi, WB, Manipur

VCCH-Training > 70%AP, DL, GJ,HR

AP, MP, GJ, HR, Assam, MH, OD

Fig. 3.28: % CCH trained before and after phase-1 study

22

99

64

150

34

3

104

0

36

154

4

38

100 100 95 90 84 76 71 61 61 6043

27

020406080

100120140160

MA

DH

YA

PR

AD

ES

H

GU

JA

RA

T

OD

ISH

A

HA

RY

AN

A

MA

HA

RA

SH

TR

A

AS

SA

M

AN

DH

RA

PR

AD

ES

H

MA

NIP

UR

WE

ST

BE

NG

AL

DE

LH

I

UT

TA

R

PR

AD

ES

H

KA

RN

AT

AK

A

% CCH trained as of Dec'11 % CCH trained as of Mar'12

SEPIO and SCCO trained as trainers: SEPIO was trained as trainer of CCH in four states of AP, UP, HR and MH. SCCO was trained as trainer of CCH in 10 states except HR and UP. The SCCO of UP who was trained had retired since then and Haryana had a new cold chain officer on contract after the national trainings were conducted. Trained trainers were available in all the states visited. Development partners mainly UNICEF supported TOTs for CCH training in 7 states.

Number and level of training centres involved and the progress of CCH-training: Majority of the states conducted the training of CCH at the district level. The progress of training has been good in all states except UP and KA.

57

Table 3.10: Progress of CCH training based on number and level oftraining centres in the state

Venue of CCHtraining

State level

Regional level

District level

States (no. of Trainingcentres)

DL (1)

MP (17)

GJ, OD, UP, MH, MN, AS, AP, HR, KA and WB in all districts

Progress of Training

On track

•good coord inat ion by officers

• Dedicated district vaccine and logistic managers were made accountable

• Intensive monitoring by dedicated person at state level

Good pool of trainers and

Good

Good/On track in all states except UP and Karnataka.

Table 3.11:to the SEPIO/SCCO

Reasons for variable progress in CCH training according

SLOW ON TRACK FAST

•SEPIO

• District level planning• Good attendance and

one day training

Review by CFW and • Handbooks translation and printing delayed.

• SCCO on leave• CBI, CAG audit• HR shortage

Reporting system is from district to state to national level as and when

required.

Monitoring of CCH training was conducted in seven states. Few issues were

identified as CC equipment not available at training venue; shortening

training duration; not involving original trainers and not following the

methodology.

Suggestions given by SEPIO/SCCO to improve the progress and quality of

CCH training in the state: more funds required to arrange stay of trainees in

hilly / tribal districts in Assam; increase pool of state trainers; intensify state

level tracking and support; support of development partners; develop district

level training infrastructure; residential training to be made mandatory and

mobility support for monitoring.

58

2. Factors affecting the quality of CCH trainingTypes of training centers involved in CCH training were district vaccine

stores, DTCs and HFWTCs.

Duration of CCH training conducted in 2011-12 was for two days in nine

states and for one day in DL, MN and UP. According to 11 district trainers

interviewed, duration of training was two days in five states except UP.

Number of cold chain handlers planned to be trained at each ILR point were

two in six states; three or more in HR and OD and one in DL, MP and GJ; UP

had not done any planning.

Handbook was translated and printed/available in local language in all

states except in AP and Manipur where the participants were comfortable in

English.

Training was residential in all states except GJ. Training was residential

according to 50% of the district trainers. Reasons given for training not being

residential were that either there were no accommodation facility; everyone

had provision of accommodation at district; all were local participants.

Number of trainers involved per batch for both days: four trainers were

involved in six states; three trainers in five states and five trainers in Assam.

Training methods Immunization handbook for VCCH and handouts were given to each

participant; certificate was given in all states except in Assam, Karnataka

and UP. Pre and post test was done and feedback received from the

trainees.

To facilitate demonstration and practice during training, cold chain

equipment of ILR, DF, voltage stabilizers, cold box with ice packs, vaccine

carriers and thermometers were available in all training centres. UP and MN

did not have fridge tag, freeze tag and vaccine cartons. MP did not have

fridge-tag and vaccine cartons.

Even though interactive training methods were used by majority of district

trainers for all sessions, all demonstrations and exercises were not

59

conducted uniformly. More than 80% of the respondents reported that

demonstrations on Day 1 of the training (conditioning of ice packs, correct

placement of vaccines in ILRs and temperature monitoring) were held while

only just more than one-third of the respondents reported that exercises for

practice of distribution of vaccines and vaccine stock management to be

held on Day 2 of the training were conducted. This could be because the

demonstrations on Day 1 were conducted as per training plan while the

exercises on Day 2 were skipped due to mismanagement / shortage of time

(delayed starting of training on Day 1).

Actions were taken after feedback of trainees as classroom seating

arrangement and audio system was changed; DIOs were asked to monitor

trainings; per diem (Rs.200/-) was lower than the expenditure, so

participants were not charged for hostel and dinner/breakfast. More focus

given on demonstration and practice, differential emphasis on topics was

given and lodging and boarding was improved.

Problems faced by the trainer: There were no issues related to release of

guidelines and funds to the training centers except in KA where funds were

not available for CCH training. There were no issues related to distribution of

training materials to the training centers except in MH where the printing was

delayed.

Major observations and suggestions of the trainers and state/district

study teams

Training contents• Clarification needed for calculation of Tetanus Toxoid doses

requirement (why multiplied by 3.5). “Return” column does not exist in

vaccine registers• Update in handbook is needed with following additions - used vial

storage guidelines, open vial policy, CCH related programme errors

(AEFI), procedures for condemnation of CC equipment, EVM/VMAT

assessment components, compendium of GoI memos on immunization

as appendix• Translation and publishing in local language for second CCH in each CC

point (AP)

60

•

Hoshangabad) can be added• Specification standards needed for all cold chain equipment including

WIC / WIF• Different pre and post test pages to be provided• Photo of domestic refrigerator showing storage of vaccines needs to be

modified. Do not keep vaccines in freezer and chillers, door and basket• Film quality not good. Need to change and include standard protocols in

the film• How to calculate target beneficiaries – clarification on wastage

multiplication factor (1.33) and wastage rate (25%)• Hindi powerpoint required for CCH training

Training methods • Include field visit, strengthen hands on training through supportive

supervision in the field• Poster and flip charts should be supplied• Freeze tag could not be demonstrated• Provide calculator to trainees for calculation• Ready reckoner for training (GOI handbook not used in UP)• Demonstration and exercise should be more. Demonstrate reading of

thermometers• Cold chain equipment needed for demonstration and hands-on-practice

In the training should be made available at the training venue

Training duration, venue etc• For refresher one-day training is enough. All health workers and LHVs

should be trained (frequent transfers)• Monitoring of quality of trainings by DIOs need to be strengthened.

District wise monitoring/ evaluation needed• Supervision is needed to follow-up how CCH are actually practicing their

knowledge• Quality of trainers at district level should be improved through retraining.

District should ensure supervisory visits by trained persons. The process

itself will facilitate the trainer to refresh his/her knowledge• Training should be like IMNCI or BEmOC training (WB)• Web portal for updates, follow-up refreshers (WB)

Vaccine wastage register at each cold chain focal point (prototype in

61

•• Improve district training accommodation facilities• DA of participants needs to be increased

Quality of training as perceived by the cold chain handlersOut of 76 CCH interviewed, 54 (71%) were trained. Out of 54 trained CCH,

89% received training within last two years and reported duration of training

for two days while 11% reported one day training (UP, WB, and MP). sixty-

six received certificate during the training; 83% reported that three

or more trainers were available on each day of training and film on cold chain

was shown during the training. Almost all CCH received handbook during

training and used the training handbook as a resource since attending the

training.

Difficulties faced by CCH and suggestions for improving future

training: Majority of CCH faced no problems during training. Very few issues were

about late intimation of training and lack of electric supply. They suggested

refresher training once every year and also before introduction of new

vaccines.

Sufficient funds must be requested by the state for CCH training.

percent

62

Areas of improvement after the training were mentioned as • Correct placement of vaccines in ILR; OPV and measles now kept

in ILR• Correct placement and freezing of icepacks in DF and defrosting

regularly• Conditioning of icepacks• Positioning of ILR / DF away from the ground level and walls;

thermostat setting• Putting up job aids and IEC material in cold chain room• Developing emergency plan for power failure management• Recording temperature twice daily in temp log book• Checking labels of VVM; ensuring reconstituted vaccines to be

used within four hours• Kept diluent 24 hrs before session in ILR• Vaccine and logistics calculation and indent practice• Open vial policy use as per the GOI guidance• Block training programme

Box 3.6: Examples of measures taken by CCH to improve cold chain after training

63

3. Knowledge and skills of vaccine and CCH

KnowledgeTo assess the knowledge level of CCH, 10 questions were asked. The

knowledge of cold chain

handlers was found to be good

as the of correct

answers by trained personnel in

all the states was more than

65%. Difference between

trained and untrained CCH was

marked in UP. All the CCH in AP

were trained.

The highest responses from both trained and untrained CCH were for

questions related to storage of vaccines in PHCs/CHCs and for listing of

freeze –sensitive vaccines. There was not much gap in knowledge levels on

these two questions between trained and untrained handlers.

percentege

Fig. 3.29: Assessing knowledge of CCH –

trained Vs untrained

70 7375

8682

67

37

60

80 80

60

0

10

20

30

40

50

60

70

80

90

100



Maharashtra

% Correct answers by trained CCH % Correct answers by untrained CCH



64

Table 3.12: Question wise comparison: of CCH answered correctly (trained vs untrained)

percentege

Question

W h e r e a l l r o u t i n e immunization vaccines s h o u l d b e k e p t i n PHC/CHC?

UP

T

4

75

100

75

50

50

0

75

50

75

75

WB

U

7

71

71

14

0

14

0

0

0

0

0

MP

U

4

100

75

50

50

25

0

50

50

25

25

U

1

100

100

100

100

100

0

100

100

0

100

OD AP MH

T

8

88

100

88

88

75

38

88

88

63

13

T

11

100

82

73

64

64

36

73

64

36

64

T

11

100

100

73

73

28

73

64

64

55

64

T

14

100

100

86

86

100

71

86

86

71

79

T

6

100

100

100

83

67

17

67

67

33

33

U

3

100

100

100

100

33

100

33

33

0

0

U

0

0

0

0

0

0

0

0

0

0

0

U

7

100

100

57

29

14

43

43

43

29

14

Which vaccines are sensitive to freezing?

How do you prevent vaccines from freezing?

Where are the diluents of BCG and Measles stored before use?

Can anything (such as food items, lab reagents, medicines and injections, etc.) other than routine immunization vaccines be kept in ILRs?

In the stock register, should there be separate pages for entry of stock of different diluents?

When is defrosting done?

Can we take deeply frozen ice packs from d e e p f r e e z e r s a n d immediately use them to store vaccines in vaccine carriers?

V o l t a g e s t a b i l i z e r connecting the ILR to the mains has s topped functioning. Is it okay to connect ILR directly to the m a i n s t i l l v o l t a g e stabilizer gets repaired?

Some of the T-series vaccines were found frozen in the ILR one morning. What will you do?

SN

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

N=

65

The poorest responses from both trained and untrained handlers were for

questions related to entry of diluents details on separate pages in stock

registers. There was also not much gap in knowledge for this question

between trained and untrained handlers.

The maximum gaps (between 39 and 44 percentage points) were for correct

responses to questions related to diluents storage before use, storage of

nonvaccines in ILRs, when to defrost, need for conditioning of ice packs, use

of ILRs without voltage stabilizer and what is to be done when vaccines are

found to be frozen.

Skills To assess the skills of CCH, observation of five skills was made e.g.

demonstration of reading the

thermometer and conditioning of

ice-packs; placement of ice-packs

and frost in DF and recording of

diluents. Skills of trained CCH were

found to be better than the untrained

ones, though gaps were identified in

their practices also.There were

gaps of more than 30 percentage

points in 4/5 skills except frost in DF.

It was suggested by the study teams to expedite the training of CCH to train

all the untrained ones at the earliest.

Fig. 3.30: Assessing skills of CCH –

Trained vs Untrained

40

55

64

82

73

37

23

40 40

80

23

0

10

20

30

40

50

60

70

80

90

100


Pradesh

Odisha Andhra

Pradesh

Maharashtra

% Correct answers by trained CCH % Correct answers by untrained CCH

Total questions : 5


66

Table 3.13: Cold chain handlers observed correctly demonstrating skills(trained vs. untrained)

percentege

Skill observed

Correct reading of thermometer from the ILR by Cold chain handler

UP

T

4

100

0

25

100

50

WB

U

7

57

0

0

57

29

MP

U

4

25

0

75

50

50

U

1

100

0

100

100

0

OD AP MH

T

8

88

0

100

100

88

T

11

100

36

91

82

73

T

11

100

100

100

73

10

T

14

100

79

86

79

79

T

6

67

0

67

100

50

U

3

100

100

100

67

67

U

0

0

0

0

0

0

U

7

14

14

57

100

29

Correct recording of details of diluents (quantity, batch no and expiry date) s e p a r a t e l y ( o n different pages) in s t o c k r e g i s t e r verified

C o r r e c t demonstration of condit ioning and packing of ice-packs in vaccine carrier

Frost more than 5 mm thick in the DF or ILR not observed

Observe if ice packs are placed in correct manner in the DF for freezing

SN

1.

2.

3.

4.

5.

N=

PART-4: Results from evaluation of cold chain technicians training

67

Profile of respondent cold chain techniciansQualifications: Out of the eight cold chain technicians, six were ITI trained

and two cold chain technicians from Maharashtra were diploma holders in

engineering.

Job experience: Six had more than 10 years of experience as a cold chain

technician while two had 6-10 years of experience.

Type of service: Seven were permanent employees while one in Khurda,

Odisha with 6-10 years experience was on contract.

Responsibilities: All had charge of only one district and only ILRs and DFs.

Only one from Ganjam, Odisha reported that he had charge of a WIC. Three

of the cold chain technicians (from Odisha, Madhya Pradesh and

Maharashtra) have been involved in vaccine management as part of their

duties in the past three years.

The two technicians from MH had received training in repair of other hospital

equipment such as BP apparatus, autoclaves, blood storage units, ACs,

suction machines and fumigation machines and were repairing and

maintaining these additionally.

Training status of cold chain techniciansAll had received training in repair and maintenance of ILRs and DFs at

SHTO Pune while seven received training in repair of 1 kVA voltage

stabilizers (used with ILRs and DFs).

The lone cold chain technician from Ganjam, OD with WIC under his charge

has been trained in both repair and maintenance of WIC/WIF and in repair of

10kVA Servo stabilizers used with WIC/WIF.

Three others from OD, UP and MH had received training in repair and

maintenance of WIC/WIF but had not been given training in repair of 10kVA

servo stabilizers. Of these three, two have been involved in repair and

maintenance of WIC/WIF over the past three years (Washim, Maharshtra

68

and Ganjam, OD). The third person has been trained on WIC and WIF and

had been incharge of district with WIC/WIF for seven years but is now posted

in district without WIC/WIF.

Only one cold chain technician (from Khurda, OD) has been trained to install

and maintain solar refrigeration equipment.

The cold chain technicians reported that the training received by them at

SHTO, Pune was helpful in improving their performance specifically in areas

of gas charging, testing and repair of compressors, control panel of

WIC/WIF and training in repair of stabilizers.

Assessing knowledgeAll eight cold chain techniques knew about correct placement of vaccines at

PHCs and cold chain handelers and that the cabinet temperature of inside of

ILRs and DFs should be recorded in the log book twice daily. However,

seven could answer which refrigerants (CFC or non-CFC) are being used

currently in ILRs /DFs and six could correctly answer the question about

sickness rate of cold chain equipment of the district. Knowledge level was

good.

Suggestions for improving trainings given to cold chain technicians Three of the cold chain technicians were satisfied with training that they had

received. Trainings were requested for voltage stabilizers of different makes

and types as well for repair and maintenance of new three-phase gensets.

Some of them wanted the training period for WIC/WIF to be increased to a

few more days for more practical experience on the machines with the

trainers at SHTO, Pune. Training on Haier equipment and Chintz voltage

stabilizers was needed urgently due to high breakdown instances.

Other issuesOnly one of the eight (Jaunpur, UP) cold chain technicians reported that he

did not have a tool kit (uses his own tools). All others had tool kits which they

were using for repairs and maintenance of cold chain equipment.

Two of the eight cold chain technicians reported problems with TA/DA which

prevent them from visiting cold chain points for conducting preventive

maintenance and repair of cold chain equipment.

69

The respondents reported that the following commonly required spare parts

needed to undertake minor repairs of ILR/DF, but are not available are

relays, capacitors, thermostats, overload protectors, compressors, fan

motors, copper rods, micro circuit breakers, hinges, three pin tops and three

core wires.

Cold chain technicians complained about the poor quality and high

breakdown rate of ILRs, DFs and voltage stabilizers of Haier resulting in

higher workload.

In addition to guidance and motivation, cold chain technicians requested for

funds or arrangement of transport for spare parts and equipment, space for a

workshop cum office, a helper and an official closed user group mobile

connection to boost their performance.

Chapter-4Conclusions and recommendations

70

Medical officers Training

1. Factors affecting progress in immunization training

of MOs in the states I. Enabling factorsFour states Andhhra Pradesh, Assam, Karnataka and Haryana had trained

more than 70% MOs. Major factors responsible for good progress in training

in these states were identified as follows:

• Review of progress in training Top priority was given to tracking and completion of immunization

training during review by MD-NRHM/Director FW in Andhra Pradesh and

Haryana. There was proactive involvement of Director FW, MD-NRHM,

and SEPIO in Karataka and Assam to facilitate the progress of training.

• Monitoring the quality of trainingGood monitoring was done by the state and district officials e.g. use of

'SKYPE' for online monitoring of training in Karnataka and monitoring of

training in districts by SIHFW in Andhra Pradesh.

• Decentralization of training Decentralization of MO-training to district level expedited the progress of

training in Andhra Pradesh, Assam, Karnataka and Haryana. (West

Bengal is exception).

Salient findings of the study

71

• Large pool of trainers helped to improve the training progress.

ii. Barriers and Issues in the progress of training •

Priority was not given to training in the states with weak progress; there

was no accountability for not attending the training. Database of trained

personnel was not maintained. Trainings were cancelled due to poor

attendance of MOs. Lack of coordination was found between SIHFW and

state/district offices to followup on the training nominations and

progress.

• Training infrastructure and facilitiesThere were less number of training centres and lack of training

infrastructure with no stay facility in majority of districts and in three states

of Delhi, Gujarat and Manipur. There was shortage of trainers with

vacancies at SIHFW; too many training courses in HFWTC/SIHFW. Lack

of trainers was noticed as they ware posted in NRHM and not available

for actual training.

• Implementation and monitoring of trainingInadequate attendance of MOs in training was due to shortage of doctors

in some states. MOs were not relieved for three days due to other

priorities as outbreaks, floods, school health programme and pressure to

utilize PIP funds. CMOs were reluctant to spare MOs frequently as

service delivery in PHC suffered, especially in last quarter of the financial

year. No system of regular reporting and no mechanism for regular

monitoring of training were in place.

• Release of funds and financial normsDelay in release of funds from NRHM office was reported as the reason

for slow progress. RCH training norms were not followed and participants

were not given TA/DA and trainers honorarium as per RCH norms. No

trainings were conducted in April to June because funds were released

from GoI in June. In-house trainers were not given honorarium leading to

reluctance to train.

Pool of trained trainers

Planning and coordination of training

72

2. Factors affecting the quality of MO trainingOverall quality of training was found to be good as gathered from the trainers

and the trainees.

I. Enabling factors•

Right types of officers were trained as trainers for MOs. They were faculty

of training centres; medical colleges; SEPIO / programme officers; CMO

/DIO/DTO; pediatrician; senior medical officers; divisional coordinators;

NPSP SMOs; retired senior health officer etc.

The MOs who were involved in the immunization programme were trained

as MO (PHC/CHC); contractual doctors; AYUSH doctors and MOs of

hospitals.

• Involvement of trainersAdequate numbers of trainers were involved on all three days during last

three batches in all states except MH where only one trainer was

involved.

• Training methodologyInteractive training methods as per facilitators guide and training kits

were used in all states. Transport was provided for the field visits to

practice supervision. Immunization handbook and handouts were given

as a part of training. Training kit and CD with films was used. Pre and post

test was done and feedback received from the trainees. Certificate was

given to each participant.

• Follow-up on feedback of traineesCorrective actions were taken after feedback from the participants.

Training days were arranged such that third day was Immunization day.

Quality of lunch and organization improved. More emphasis was given to

supervision. Training was made more participatory. Disturbance due to

noise was reduced.

Profile of trainers and MOs

73

•SIHFWs in Andhra Pradesh, Assam, Delhi and Gujarat proactively

coordinated the immunization training for MO in the state.

ii. Barriers and Issues in the quality of training • Training facilities

Lack of training, hostel and mess facilities observed in the states of Delhi,

Manipur and Gujarat was a barrier.

• Lack of involvement of SIHFWsSIHFWs in five states of Uttar Pradesh, West Bengal, Haryana,

Karnataka and Manipur were not at all involved in coordinating and

monitoring the immunization training.

• Availability of trainersShortage of trainers was reported by Delhi, Gujarat, West Bengal,

Odisha, Uttar Pradesh and Andhra Pradesh. Trainers were not present in

full strength in MP and MH. Reasons given were mainly transfer of

trained trainers to other positions leading to shortage.

• Inclusion of immunization training in induction training of MOsThough all states except Delhi, Manipur and Assam had policy for

induction training of medical officers varying from two to six weeks, only

half to one day sessions were allocated to immunization which was

inadequate.

3. Knowledge and practices of medical officers in

immunizationi. Knowledge level of trained and untrained MOs To assess their knowledge level, all the MOs were asked 10 open ended

questions from the immunization handbook. They were scored based on the

correct responses. Comparison was made between the trained and

untrained medical officers. Trained medical officers performed better than

the untrained MOs Performance of medical officers in Uttar Pradesh,

Maharashtra and Odisha was lowest compared to rest of the states.

Involvement of SIHFW

74

ii. Practices of trained versus untrained MOs in PHCsGood practices•

Performance of trained MOs in data analysis from the routine reports on

immunization coverage, drop-outs and left-outs was better when

compared to untrained MOs. The difference in their performance was

statistically significant.

• Conducting review meetingsReview meetings were held at Block/PHC levels in all the states. The

frequency was monthly in majority of the blocks and the participants were

mainly HWs and ASHAs/AWWs. The feedback from data analysis was

shared by the trained MOs with health workers during monthly

meetings, to improve coverage.

• Conducting supervision and on the job trainingMOs who conducted supervisory visits gave good examples of problem

solving and provided on the job training during supervision.

• Community involvement and communication activitiesAfter training, medical officers supported various communities'

involvement activities e.g. addressed various meetings in the community

to educate the caregivers and the frontline workers. The MOs visited

resistant families with local influential persons to counsel and motivate

them.

• Supervisors' opinionsAll DIOs noted improvement in performance of MOs after training in

areas of cold chain maintenance, monitoring and supervision,

community mobilization and injection safety.

• Health workers' opinions Health workers were able to appreciate change in the attitude of MOs

following training. They came up with examples of on-the-job training

provided, various topics discussed during the review meetings and

activities conducted by the MOs for improving community involvement.

Monitoring and using data for action after training

75

Gaps in immunization practices after training• Inadequate involvement in RI-Microplans

Majority of MOs had no role in micro-planning; it was prepared by PHN,

LHV, MHS, MPHS (M), BEE, BPM and Community Health Officer. ANM

roster and AVD plans were available in all the states. WB performed

poorest in availability of maps, estimation of beneficiaries and plans for

supervisory visits.

• Lack of supervisory visitsThough plans for supervisory visits were available in all the states except

WB, no records to support supervisory visits were available in majority of

the PHCs.

• In adequate monitoring and using data for action after trainingAll trained MOs were not analyzing the routine reports to calculate the

immunization coverage (%), drop-outs and left-outs. Coverage

monitoring chart was not available in majority of the PHCs.

• AEFIs and VPDs Majority of the PHCs had not reported any AEFIs or VPDs during last

three months.

• Immunization waste management in the PHCWaste disposal was poor in all the states, though little better in PHCs with

trained MOs. Waste disposal pits were not used properly. There were

reports of burning the waste and discarding syringes in to the pit.

iii. Programme support to the MOs• Guidelines for fund utilization

Clear guidelines for fund utilization for immunization activities were

available with majority of the MOs. Some issues were highlighted as

delayed or no receipt of funds from district for mobility for supervision; for

AVD and for ASHA.

76

Supervision of medical officersMajority of the MOs were visited by the district immunization officers in

last three months. Supervisors guided the MOs on micro-planning, cold

chain, using data for action, injection safety and waste management

issues etc.

• Role of the DIOs in immunization program managementMajority of DIOs were conducting supervisory visits, organizing review

meetings and analyzing the data from monthly reports. But the coverage

monitoring chart was displayed by only two out of eleven district

immunization officers.

iv. Need for additional immunization trainingMajority of MOs felt the need for additional training in immunization.

Untrained MOs asked for complete RI training while majority of trained MOs

asked for refresher training at district level as HWs were to be trained

repeatedly. Areas were specified as microplanning/planning, cold chain,

logistics management, new vaccines, community involvement, records,

reports and using data for action, AEFI, updates and changes in guidelines,

waste disposal and role of AYUSH doctor.

Key recommendations for improving training of MO• Establish state/district training cell with one officer designated as training

coordinator to coordinate for all programmes; improve coordination

among SIHFW, NRHM and directorate and ensure that overlapping with

other trainings is avoided

• Review the progress of training as part of regular programme reviews at

state and district level. Devise mechanisms to ensure adequacy of batch

size and mandatory attendance of nominated participants

• Strengthen and involve SIHFWs to coordinate and monitor the

immunization training. Integrate immunization training in the induction

training program for MO

• Training database should be maintained by the state and district training

centres. Regular reporting of training should be ensured through HMIS

•

77

•

transport facilities in Delhi, Gujarat and Manipur. Districts with trained

MOs, good training and residential facilities should be made training

centers for MO training e.g. Hoshangabad in Madhya Pradesh

• Address shortage of faculty and staff at the training centers by hiring on

contract basis under NRHM. Training cadre/faculty should be full time,

regular and if required, transfer to other training centers only

• Conduct state TOT to increase the pool of trainers at the state and in all

regional training centers. Provide regular refresher training to master

trainers/ faculty members of SIHFW. Involve medical college faculty in all

training courses on immunization

• Training monitoring should be institutionalized. Use of technology e.g.

SKYPE should be encouraged. Involve the state trainers to monitor

trainings at regional and district level. District trainers should follow-up

the trainees on the job

• Revise financial guidelines for immunization trainings in line with RCH

training norms. The budget of MOs training to be included in the state PIP

of 2013-14 so that all MOs are trained by end of 2013

• Train the untrained MOs including AYUSH MOs and organize refresher

course at the district level. Encourage all MO in addition to the MO-I/Cs to

be actively involved in micro-planning, monitoring and supervision

activities• Address non-training factors affecting the immunization services as

release of funds, supply of logistics and conduct of supervision at all

levels to enable the medical officers to translate the training into good

practices

Cold chain handlers training1. Factors affecting progress in CCH trainingThe progress of training was good in all states except Uttar Pradesh and

Karnataka. Major reasons for good progress were:

Develop training infrastructure in all districts. Provide hostel and

78

•

dedicated person at state level• Trained trainers in adequate numbers were available in all the states

visited• Training was decentralized to district level• Development partners mainly UNICEF supported ToTs for CCH training

in seven states

Reasons for slow progress were cited as delay in translation and printing of

handbooks; HR shortage and SCCO on leave.

2. Factors affecting the quality of cold chain handlers trainingQuality of training was found to be good as gathered from the trainers and

the trainees. • Duration of training was two days in nine states and one day in Delhi,

Manipur and Uttar Pradesh• No of cold chain handlers per cold chain point were two or more in eight

states• Handbook was translated and printed/available in local language in all

states except in Andhra Pradesh and Manipur where the participants

were comfortable in English• Training was residential in all states except Gujarat• Three or more trainers were involved per batch for both days in all states

3. Knowledge and practices of CCH after training• The trained cold chain handlers had better knowledge and skills in all

areas (storage of vaccines and diluents, maintenance of equipment,

recording of temperatures and stock registers etc.) as compared to

untrained handlers• Knowledge and skill levels remained poor for both trained and untrained

handlers in recording of diluents details in stock register and contingency

actions, conditioning of ice packs and freezing of ice packs in deep

freezers

Cold chain technicians trainingi. Positive observations • All cold chain technicians had minimum required qualifications and were

in-charge of only one district

Regular reviews by CFW and SEPIO and intensive monitoring by

79

•• MH technicians were also repairing and maintaining hospital

equipment• A few of the cold chain technicians were also involved in vaccine

management duties• The technician with a WIC under his charge had received trainings for

repair and maintenance of WIC/WIF and also for the servo stabilizers (for

use with WIC/WIF)• All technicians except one had tool kits• All were satisfied with the quality of trainings received at SHTO, Pune

ii. Areas of concern• One technician was not trained to repair 1 kVA voltage stabilizers used

with ILRs / DFs• Three cold chain technicians trained for WIC/WIF were currently posted

in districts without WIC/WIF. They were also not trained in repair and

maintenance of servo stabilizers• Training has not been provided for all the different types and brands of

voltage stabilizers available in the field• A technician each gave incorrect answers to two questions directly

related to his job responsibilities. This indicates nonapplication in actual

work of knowledge gained during training or the requirement of short

refresher trainings to update knowledge after every few years• TA/DA receipt / reimbursement issues have been reported by two of the

eight technicians• Most of the technicians did not have dedicated rooms to be used as

workshops/offices. They also did not have easy access to transportation

for travelling to repair broken down machines/ compressors and other

spare parts• High breakdown instances / rates for Haier equipment and Chintz

stabilizers reported by at least two of the eight cold chain technicians• Many spare parts used commonly for minor repairs were neither

available with technicians nor at state level

All had received trainings for repair and maintenance of ILRs/DFs

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Key recommendations for improving training of CCH

and technicians

Cold chain handlers•

two days provided proper data base of trained cold chain handlers is

available• The CCH training should be followed by intensive supportive

supervision and on job training to ensure that knowledge and skills

acquired are used in the actual settings

Cold chain technicians• For optimum utilization of resources, states may post technicians trained

in repair and maintenance of WICs/WIFs to districts with WIC/WIF. They

should receive training on Servo stabilizers before or immediately after

getting posted to these districts• Trainings on different types/brands of 1kVA voltage stabilizers need to

be organized for technicians who have not received the training• Training to be urgently organized for repair and maintenance of Haier

equipment and Chintz stabilizers• Refresher trainings need to be organized for technicians regularly as per

training needs assessment• Supply of spare parts for minor repairs should be made regular• TA/DA reimbursement issues of cold chain technicians should be taken

up by states and districts regularly. States and districts should ensure

dedicated room as workshop for the technician along with priority

allocation of four wheeler vehicle for transportation of ILRs/DFs and

heavy spare parts

Way forwardNational level• Revise and update the training materials for medical officers based on

feedback received• Streamline the reporting of RI training, may include under HMIS

A oneday refresher course may be recommended for CCH trained for

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State level • Establish state training cell to coordinate with all the programme officers

and SIHFW• Develop / improve training infrastructure in SIHFW and all the districts• Training database of health service providers should be maintained by

district training centres and SIHFW• Give priority and ensure mandatory attendance of MOs through some

orders from state• Include RI training as a part of induction training of MOs• Conduct state ToT to increase the pool of trainers at training centres and

conduct refresher training for the master trainers at SIHFW • Develop systematic monitoring plan by state officials to facilitate training

process and ensure quality of training

District level• Invite more nominations for better participation• After training, ensure follow-up and on-the-job training by the district level

officers• Ensure that quarterly RI review meetings are held and are used to review

the training issues identified through supervision visits• Provide mobility support to the MOs and other supervisors at block/PHC

level to ensure supervision• Encourage all MOs in addition to the MO-I/Cs to be actively involved in

micro-planning, monitoring and supervision activities• Organize refresher course at the district level for all MOs in RI including

new vaccine being introduced and capacity building of HWs to utilize

VHND for increasing awareness

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State specific observations from evaluation of immunizationtraining of MOs, CCH and technicians (2012)

Andhra Pradesh

State level

Positive observations:• Good progress in training of MOs (94%) and CCH (71%)• Proactive involvement of commissioner FW, MD-NRHM, SEPIO and

director SIHFW to review the progress of training and monitor the quality

of training in the districts• Good planning and coordination with WHO-NPSP and UNICEF for

training and monitoring• Attendance of participants is 95% of those nominated• IIHFW conducted the ToTs for MO and CCH training using participatory

training methods• Monitoring of the district level trainings was done by IIHFW faculty, SEPIO

and master trainers including SMOs and feedback was provided to the

SEPIO and CFW• Regular monitoring of immunization programme including training was

done at state level by Commissioner FW and SEPIO• Newly recruited doctors (742) need to be trained by the end of 2012• All CCH were pharmacists and trained in English module

Issues Recommendations

• Accommodation for MO training

was not available at the district HQ• Training fund was available for

one day training of CCH but two

day training was held• Venue of CCH training was a

problem in two districts as the

CC equipment could not be

shown at the same place• HW refresher training with

updated handbook had not

started

•

be upgraded to prov ide

accommodation• HW-handbook (2011) needs to

be printed in Telugu to start the refresher training

• CCH assisting the pharmacists need to be trained in CCH module in local language (Telugu)

• Include RI training as a part of induction training for MOs

District training facilities may

83

District level

Positive observations: • DIOs were actively involved as trainers of MOs and CCH• Community Health and Nutrition Clusters (CHNCs) had been created in

the district. Each cluster was headed by Senior Public Health Officer

(SPHO) of the rank of Dy. DMHO and was responsible for all health

programmes in 8-9 PHCs• Supervisory visits were regularly conducted and quarterly immunization

review meetings were also held• Agenda, minutes and list of participants of all meetings with documents

were available at each PHC• Monthly convergence meetings were held at each PHC to synchronize the

records and reports of ICDS and health workers• Smooth conduct of both MO and CCH trainings- no problems faced by the

participants.• Knowledge of trained MOs was better than the untrained MOs• District cold chain technicians participated actively in the CCH trainings• All CCH were trained, knowledgeable and practiced the skills• Krishna district took initiative to regularly train the new and untrained MOs.

It maintained an updated database of trained MOs• Proper vaccine storage and distribution as per guidelines


• Large pool of untrained doctors in Medak and CCH in Krishna

• Shortage of trainers in Medak district

• Micro-plans were incomplete• Data from the HMIS reports or

other sources was not analyzed• Monitoring checklists were not

filled• Coverage monitoring charts

were not used

•

more trainers to provide training

of MOs• Disseminate standard micro-

planning formats and guidelines from the state level

• HMIS reports should be analyzed for drop outs and left outs

• Use GoI monitoring formats for superv is ion ; ana lyze the monitoring data and share feedback

Conduct one state TOT to train

84

•visits

• AEFI and VPDs were not reported

• AVD system was not functioning• Open vial policy was used for T

series vaccines and OPV• MOs and CCH were not clear

a b o u t t i m e r e q u i r e d f o r conditioning of ice-packs

• Poor recall by the MOs on the knowledge acquired during the training

• Sub optimal involvement of MOs in the RI services

• Immunization waste disposal not as per guidelines

CCT did not get TA/DA for field • for tracking of the drop-outs and left-outs

• Provide mobility support to CCT and MO for field visits

• MOs to use monthly review meetings to update and refresh the knowledge. Any one topic from immunization handbook for MOs could be discussed

• Promote use of tally sheets at session sites

• Make available red and black bags for use at session site

• Ensure proper maintenance of safety pits and disposal of waste as per protocol

Use coverage monitoring charts

85

Madhya Pradesh

State level

Positive observations:• SIHFW Gwalior has good infrastructure and facilities• Interactive training methodologies were used as per the facilitators' guide

and training kits


• Slow progress as only 42% MOs trained in three years

• Only three training centres were involved for MO training

• Faculty of medical colleges and SIHMC were not involved in MO training

• Weak coordination between training centres and trainers available in SIHMC and medical colleges

• Major issue was low (50-80%) attendance of nominated MOs due to poor fol low-up of nominated participants

• Honorarium of internal faculty had been suspended

• HW training started without orientation of the trainers at the state level

• No monitoring was done from the state level

• Include RI training as a part of induction training of MOs

• Invite more nominations for

better participation• Ensure mandatory attendance of

MOs through some orders from

the state level• Need for better coordination

between SIHMC, Gwalior and

RHFWTC, Gwalior• Consider involving more training

centres for MO training e.g.

medical colleges, SIHMC district

training centres• Utilize RCH training norms for RI

training• Monitor the progress and quality

of training

District level

Positive observations:• Fully functional district training and resource centre was available in

Hoshangabad• Quality of training as recalled by MOs was found to be satisfactory• CCHs had improved knowledge and practices after training• Regular supportive supervision provided to CCHs by the district refrigerator mechanic and block child health managers in Hoshangabad

86


• MOI/C of the Block/PHC responsible for immunization programme was not nominated for RI training

• Trained medical officers were not practicing the knowledge gained during training

• Acute shortage of medical officers in Satna district

• AYUSH MOs were not included in the RI training

• Utilize functional district training centres to train MOs and HWs

• Train AYUSH MOs and involve them in RI monitoring

• Involve all MOs in immunization review meetings and supportive supervision

87


• Low priority was given to RI training• Existing trainers for medical

officers training were not trained at state level

• Monitoring of trainings was not conducted from state level

• Trainings not conducted as per t h e g u i d e l i n e s e . g . n o demonstration done for safe injection and waste disposal, no e x e r c i s e f o r c o m m u n i t y participation

• Turn out for the training was low as many contractual MOs were reluctant to undergo training

• Cold chain handbooks were not available in local language resulting in delay in training the second CCH

• In most of the districts, CCH training was given by LHVs and Health Assistants

• Knowledge of trainers at district level was far below satisfactory level

• All trainers are not present for complete duration. Many trainers w e r e n o t a w a r e o f t h e methodology

• Health workers training based on new handbook-2011 did not start

• Plan state TOT for MO trainers in consultation with Partners

• Ensure monitoring of MO and CCH trainings from the state level

• Consider up-gradation of training centers at Thane and Akola

• Develop a pool of trainers in all districts by conducting TOTs at state and regional level

• All new DIOs should be trained both on routine immunization and cold chain

• Print cold chain handbooks in local language as translation is already done

• Conduct health workers training on the basis of new handbook in 2012-13

State level

Positive observations:•• Excellent facilities were available for training in the state• Records and reports were well maintained• State had completed one round of training for first line CCH except one

district (Parbhani) (83.5% trained)

State was on track to complete the training before 2012-2013

Maharashtra

88


• DIO Raigad was not trained and not involved in any training being conducted at district training centre

• DIOs not monitoring RI and review meetings not held

• DPM was involved in HMIS reporting and preparing PIP part C but not trained in RI

• Trained MOs didn't use the knowledge acquired during the training for RI improvement

• Micro-plans were not available at any PHC

• Regular review meetings were not held at PHCs

• MOs were not monitoring the sessions with standard GoI formats

• As supervisory cadre worked as AVD; conditioning of icepacks was dependant on them. CCH did not take part in morning vaccine distribution

• Knowledge of thermometer reading, defrosting and stock register management was not satisfactory. Entry of diluents was missing at most of the PHCs.Waste disposal pits were not u s e d a p p r o p r i a t e l y a n d disinfection was not done

• All DIOs should be trained in RI and monitor the quality of CCH and health worker training at district training centre

• D IOs shou ld rev iew the immunization data and conduct regular review meetings

• DPM should be trained and involved in RI monitoring

• Standard microplanning formats should be used to prepare micro-plans

• MOs should conduct regular RI r e v i e w m e e t i n g s , s h a r e monitoring feedback and update the staff

• Each MO to fill PHC and session site supervisory checklist for RI. This check list could be filed at PHC for verification by DIO

• District should plan training for untrained CCH

• Standard stock register and issue register should be made available at all the PHCs

• CCH should be available at the vaccine distribution points and supply vaccine in conditioned ice packs

• More frequent field visit by MOs and use of supervisory check lists would help health workers to perform much better

• Improve waste management practices

District level

Positive observations:• The quality assurance team (DIO as one of the members) also monitors the

performance of routine immunization• There was monthly couriers meeting (Supervisory staffs carrying the

monthly report for monthly meeting) which is reviewed by the DIO• Districts had Marathi version of CCH module• Trained CCH had better knowledge than the untrained ones

89


• State had trained only 50 % of the MOs in >two years

• Forty percent shortage of doctors in the state lead to poor attendance in trainings

• Doctors were not relieved from duty to attend training by their CDMOs

• Prolonged flood and epidemic duty of MOs disrupted the training schedule in the state

• No state plan for monitoring the MO and CCH trainings (lack of fund for the same)

• Shortage of trainers in the state due to transfer, retirement of trainers etc

• At the district level CC equipment were not available at the training venue rather the trainees were asked to go the cold room for the demonstrat ion which was against guidelines

• A state ToT is needed to increase trainers pool in the state

• Redistribution of districts among the seven regional training centres is essential to expedite training

• More clarity on fund flow and guidelines is essential for the regional training centres

• A systematic monitoring plan by state and fund support through PIP is needed to facilitate training and ensure quality

• State can incorporate RI training for MOs in the Induction training for MOs to enhance training %

• State needs to follow-up with CDMOS directly for relieving MO for training instead of training centre without any administrative power

State level

Positive observations:• State had recorded excellent progress with > 90% CCHs trained• Enough ToT trained trainers were available at the state and district level• District and block programme officers coordinated the process of training• Dedicated vaccine logistics manager as nodal person at the district level

helped the training process accelerate• UNICEF Support for the ToTs at state level had been very critical• Medical colleges were involved in the MO trainings and seven regional

training centres were allocated districts for MO training

Odisha

90


•in RI and lacked knowledge on v a r i o u s t e c h n i c a l a n d programmatic aspects of RI

• AYUSH doctors, trained in RI, had suboptimal understanding of programme

• AYUSH doctors were given responsibility for RI activities at PHC level but they had no supervisory power over staff

• Suboptimal data analysis /use at PHC /CHC level

• RI micro plans did not have any HR /high priority areas identified fo r coverage improvement plans/special micro plans in the district

• Both MOs as well as CCH had huge turnover, leading to attrition of trained manpower

• Hub cutters were not available at all the places leading to poor waste management practices

Majority of the MO were not trained • Conduct training of MO I/c on the priority basis and train other MOs also

• Provide training for longer duration to AYUSH MOs and involve them in monitoring and supervision of RI in PHCs

• Better coordination amongst MO I/c and AYUSH doctors and higher involvement of MO I/c may help

• Trained MOs to guide the BEE/HS/BPOs for RI data analysis and use in their monthly meeting of HWs

• Advise MOs to identify high priority areas based on coverage data/hard to reach areas/ measles outbreaks/migratory population for special RI plan to improve coverage

• Refresher training for both trained and untrained (MOs /HWs/CCHs) should be a continuous process for better RI programme in the districts

• Ensure availability of hub-cutters at session sites

District level

Positive observations:• A large proportion of AYUSH MOs had been trained • All CCH posted in the district were trained• District had trained two to three cold chain handlers per ILR point (good back-

up plan)• Urban area was using outsourced agency 'Saniclean' for immunization

waste disposal • DIO and CMO reviewed block wise RI issues in monthly and quarterly

review meetings• Standardized vaccine stock registers were well maintained in most ILR points• Vaccine pass book concept was in practice at HSC and ILR points for indenting• A vaccine logistics manager at the Regional Vaccine Store had improved

and streamlined vaccine indenting, distribution and pipe line management• Use of locally improvised twin buckets and disinfection with hypochlorite

solution before waste disposal in safety-pits was an excellent practice• Complete out-sourcing of AVD to locally available NGOs was a very good

demonstration of public-private partnership that was working in all the blocks

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• V e r y s l o w p r o g r e s s o f immunization training of MOs

• MO training was not conducted from July 2011 due to state orders

• Release of funds and guidelines from state to the training centres were delayed/not sent

• N o a c c o u n t a b i l i t y f o r coordinating the immunization training at state level

• Coordination issues between the state directorate and NRHM dept

• Coordination issues between AD and principal of RHFWTC as funds were released to ADs at divisional level and not to the training centres

• CCH training not started with new modules due to lack of trainers and lack of motivation of SCCO

• There was no monitoring of training from the state level

• TOT trained trainers were not utilized for MO training as not placed at the training centres

• SIHFW was not involved for immunization trainings

• Shortage of trainers and facilities in training centres

• Need to restart MO training, may be by refresher training of a pool of trainers from SIHFW and RHFWTCs

• Conduct ToTs and training of CCH with new GoI handbooks with support of partners

• Involve SIHFW for ToTs and MO-training

• Assign a state level officer for coordinating the immunization training in the state

• Regular monitoring of al l immunization training should be done to maintain quality of training

• Trainers should be utilized for training

• Improve coordination between JD training and director SIHFW

• Improve the number of trainers and facilities in training centres

State level

Uttar Pradesh

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•and immunization practices

• MOs involvement in RI was restricted to monitoring

• DPM's role was restricted to assisting CMO in field visits and organizing meetings

• Only ANM rosters were observed as Microplan for 2012-13

• District had acute shortage of immunization cards

• Coverage monitoring charts or any tracking mechanism was not available

• The district had less cold chain points

• A good system of Alternate Vaccine Delivery (AVD) was established one year back but it has been stopped due to lack of funding from state/NRHM

Trained MOs had poor knowledge • Trained MOs should be followed up to improve immunization service delivery

• Orientation of DPMs on RI will aid in improving the immunization status in the district

• CCH training to be undertaken as per GoI guidelines

• Increase Number of cold chain points for effective services to the beneficiaries

• Establish AVD system which was functional one year back and was very well accepted by the field staffs

• Expedite the condemnation process in the district to reduce space wastage in the cold chain rooms

• GoI/Government of UP to supply vaccine carriers, ice packs and voltage stabilizers to facilitate cold chain management in the district

District level

Positive observations:• Adequate availability of human resource, buildings and equipment at the

facilities• RI monitoring formats were collected, collated and analyzed at district NPSP

office and shared with the district. Copies of the same were shared by the DIO with all MOI/c for corrective action

• Weekly review meetings on RI had been initiated every Monday with involvement of CMO, Deputy CMOs, MOI/c, NPSP and UNICEF (suggested involving ICDS as well and sharing copies of minutes with CDO and DM). This feedback was shared with the HWs at the blocks in weekly meetings on Tuesdays

• Few dedicated staff contributed effectively to the immunization programme in Jaunpur district: MOIC at Jalalpur PHC, District Cold Chain Technician and Immunization Officer (IO) at CHC Kerakat

• The programme was mostly managed by a proactive cold chain technician, partly with the DPM's involvement in Jaunpur

• Initiatives were taken to strengthen RI in urban Ferozabad by deploying trained MOs from additional PHCs. The city was divided into four sectors for polio SIAs, each being managed by one MO. These MO managed both SIA and RI activity in their area, including microplanning, cold chain maintenance and monitoring

93

• Cold chain sickness rate of the district was 29% due to lack of spare parts and tool kit and inadequate funds

• There was shortage of vaccine carriers, ice packs and voltage stabilizers in the district

• Absence of standard stock and issue register, indent and receipt form

• Diluents were not documented in any of the available registers

• Ad hoc vaccine distribution resulted in vaccine stock out (JE, HepB, DPT, BCG) at several of the sites in spite of adequate amount of vaccine at the district store

• Vaccine storage practices were poor at three of the five facilities visited

• At the district PPC, ILR had thick layer of ice and food items were stored inside

• At one session sites ice was used in the vaccine carrier along with two ice packs. Melting of the ice resulted in open vials floating inside the vaccine carrier

• Two children due for measles and BCG vaccination each were refused vaccination for fear of wastage in spite of availability of vaccines at the session site

• Waste was found thrown in open, or even sold for recycling

• Functional hub-cutters, red and black bags were not available at most of the places

• Ensure adequate spare parts, standardized tool kit and mobility support to the cold chain technician

• Establish a second line of cold chain handlers as IOs get phased out

• All available monitoring data to be analyzed for action

• Introduction of coverage monitoring chart to aid in self monitoring of immunization coverage by H facilities

• Use of standard vaccine and syringe stock registers and indenting mechanism

• Ensure availability of hub cutters and waste disposal bags at session sites

• Ensure availability of adequate quantity of immunization cards in the district

• Minimize missed opportunities: daily immunization sessions at fixed points and vials to be opened for even single beneficiary

• All MOs besides MOI/c should be involved in all facets of RI, and not just restrict to monitoring

• The districts need to take initiatives in waste management on urgent basis

• Funding issue needs to be sorted out to keep up the morale of MO and health workers involved in routine immunization

94


• MO training progressed slowly due to state level emphasis on training of ANMs and CCH and too m a n y v e r t i c a l programmes

• S I H F W r e m a i n e d inadequately supported and sub op t ima l l y utilized

• Acute shortage of MOs made it difficult to depute them for training

• Immed ia te se r v i ce providers (paramedical) were given more priority

• Remote locations and lack of transport affect training attendance in UDJ, DDJ and Jalpaiguri

• Lack of district level training centres

• T r a i n e e p e r d i e m needed to be enhanced

• SIHFW should be the nodal agency for all training programme

• Kalyani and Jalpaiguri Centres should be developed and linked with SIHFW

• Fixed facility training infrastructure needs to be developed in each district with a dedicated pool of trainers under SIHFW as a “hub and spoke” model

• Stronger coordination is needed among ADHS (training), EPI cell, state training hub (UNICEF-supported) and SIHFW

• Medical colleges (pediatrics + comm. medicine) need to be involved

• Monitoring of training and post training performance may be conducted by SIHFW as they are doing in the form of “prescription audit” following diarrheal training

• District-wise Training load to be calculated with availability of trainers

• State to communicate a roster of training to be completed within a defined time-line

• Fund allocation for immunization should be like IMNCI/ BEMOC model

• MOs of one district need to be shifted to other districts to make them compulsorily residential

• Administratively stringent action to be ensured by DHS, if attendance and other feedback are given in time

State level

Positive observations:• The new state team was composed of very experienced and committed

people taking things forward• CCH training progress was faster than the MO training

• Attendance of CCH had been better than that of MOs• State trainers' participation and monitoring had been more stringent in

case of CCH training

West Bengal

95


• Long gap between ToTs at state level and actual trainings resulting in

• very few batches of MO and CCH t ra in ing conducted in the districts

• Shortage of trainers due to transfer• District level training for MOs

concluded in two days. Field visits were l imited to PHC/CHC. Sessions were not visited

• Trained MOs (assistant MOs) were not used for monitoring of RI sessions and cold chain points while many of the Block MOs who were ac tua l l y invo lved in microplanning and monitoring of sessions were not trained and lacked updated knowledge on RI

• Complete microplan with all components was not available

• Start planned trainings for MO and CCH after reorientation of master trainers immediately

• Priority for nominations should be all BMOHs who are yet untrained

• Trained Mos should be involved in RI microplanning and monitoring. Th i s w i l l a l so r educe t he workload on BMOHs

• Review of microplans with increase in immunization session days to two/week or eight / month. Ensure all components of microplans are prepared and available in all cold chain points

• Exclusive RI review meetings at block and district should be conducted as per GoI guidelines

District level

Positive observations:• Very good rapport between district programme officers and partner agencies

such as UNICEF, WHO-NPSP and Rotary involved in RI and polio activities• One of the two training batches for Mos was conducted at Jangipura at

subdistrict level in Murshidabad. Training was as per guidelines with field visits• Young MOs had good knowledge of RI, were very enthusiastic and wanted to

be involved in RI• MO handbook for immunization was distributed in the trainings and used by

MOs as reference material after training• Improvement in quality of microplanning and monitoring was seen when MOs

trained in immunization were involved in immunization activities• Some MOs had given one day training to HWs and CCHs on their own initiative

using MO handbook on immunization after their own training. MOs guided HWs on vaccinating defaulters at delayed age; to counsel reluctant parents and to manage and report AEFIs

• CCHs that were trained and supervised by trained MOs had good knowledge, skills and practices in maintaining cold chain

96

• Exclusive RI review meetings at PHC/CHC and block level were not held. When RI is discussed in meetings, drop-outs figures and means of reducing dropouts were rarely discussed

• District level supervision was inadequate

• Diluents were not being recorded in stock registers

• There was severe in-coordination between urban local bodies and district authorities. Only four out of 28 health officers were trained

• DPMU was not much involved - did not even maintain updated database

• Meetings at all levels should include discussions on feedback of RI sessions monitoring and also activities related to tracking and reducing dropouts

• Increase district level supervision in blocks

• Improve documentation of diluents in stock registers

• Improve immunization activities in urban municipal areas to increase coverage levels

• SUDA needs to be involved as an intermediate coordinating agency. They should be given charge of training urban health personnel

• Alternate vaccinator needs to be hired for regular sessions

• PHNs posted at SG hospitals should be at municipality and coordinate entire coldchain and vaccine distribution

• AVD funds need to be utilized for urban bodies tooUrban ANM cadre should be raised, while UHIP HHWs should be treated as urban ASHAs

• DPM training and state directive may help in optimal utilization of this humanresource

•

97


• There was a gap in the sharing of progress of training between the SIHFW and Directorate

• There was lack of coordination between the Directorate of FW and SIHFW. While SIHFW coordinated the MO-RI training, SCCO and SEPIO coordinated the CCH and HW training

• T h e r e w a s n o e s t a b l i s h e d mechanism for monitoring of training

• No trainer at SIHFW was trained at national level for the RI training

• Budget calculation for immunization training programme often deviated from RCH training norms

• The major concern expressed by the director (FW) was the sub optimal coordination between the NRHM contractual staff and the regular staff at the SIHFW. The contractual staff reported to MD-NRHM, while the regular staff reported to him

• Status of the progress of RI training should be shared regularly between the Directorate and SIHFW

• As the state is following a cascade mechanism for RI trainings, it is all the more necessary that all trainings at district level must be monitored and the monitoring findings recorded and feedback shared with all concerned

• There is a need to train a pool of trainers at SIHFW and also refresher training for the other master trainers

• Printing of CCH handbook in local language needs to be expedited

• Revised budget based on RCH training norms should be prepared and incorporated in State PIP

• The re i s need f o r be t t e r coordination between SIHFW, directorate and NRHM staff

Positive observations:• There was good progress in immunization training of MOs (99%) and

CCH (75%)• A large number of trainers were trained for MOs and CCH at state level• Proactive SEPIO ensured that a large pool of district trainers were trained

by director SIHFW• The state had taken initiatives to translate the CCHs and HW handbook in the

local languages• The SIHFW was well equipped to conduct trainings• Trainers used interactive training methods as per the facilitators' guide

and the training kits

Assam

Following 6 states were visited only during the first phase of the study

98


• Low performance of MO training, mainly due to low attendance in training (54%)

• SIHFW cancelled 26 batches in last year due to poor attendance of MOs

• MOs were not relieved for the training by district development officers due to other priorities as epidemic management, FP drive, school health programme etc

• Funding was much less than the RCH training norms TA/DA was not given, less honorarium to trainers and less incidental charges

• No building with SIHFW for >two yrs, land to be earmarked, funds are available

• Training was conducted in Infocity club, Cambay resort or Jal Sewa Trg Centre af ter get t ing specia l permission

• Director SIHFW earl ier held additional charge of epidemic control till five months back

• Additional responsibility given to SIHFW for admission of FHWs for private sector ANMTCs twice a year

• Mandatory training policy is required• Need for SIHFW building and

facilities• Training cadre Training faculty

should not be transferred frequently to other programmes. If required, transfer to other training centres

• State nursing cell should take charge of recruiting FHWs for private sector ANMTCs

• RCH training norms should be followed

• Trg Database should be available with all DTTs

• Training reporting should be made regular as part of HMIS

• Need for one state level TOT to train trainers from SIHFW, DTCs and RCHOs

• Involve medical college faculty in all training courses on immunization

• Need to train 80+ MOs from municipal corporation

• RI monitoring data needs to be compiled, analyzed and feedback shared

Positive observations:• Good performance of CCH and HW training (100%) as it was done directly

through the programme officers. HW training was done at block level. CCH training was funded by UNICEF

• Trainers used interactive training methods as per the facilitators' guide and the training kits

• Good coordination and support of WHO and UNICEF• eighteen days induction training of MOs included one day on immunization• DTC Vadodara started 17 days induction training of FHWs in January 2012 • SIHFW Director followed up with CDHOs for relieving the MOs and took a

decision to conduct training even with smaller batch size of 10-11 participants• State RI cell conducted regular review meetings, RI monitors and DTT MOs

went to monitor MAMTA sessions and provided supportive supervision

Gujarat

99


Immunization programme related• Lack of dedicated SEPIO (Principal

HFWTC had additional charge)• Lack of dedicated SCCO (Faculty

HFWTC had additional charge)• Lack of dedicated DIOs (MO I/C of

dispensary in CMO office had additional charge)

• No mobility support was available.• Shortage of cold chain technicians, only

two at state level• Lack of designated CCH in the state

• State immunization cell should be formed at the state level

• Dedicated posit ions of SEPIO, SCCO and DIO are urgently required

• Des igna te co l d cha in handlers at cold chain points

• Institute regular monitoring a n d r e v i e w o f t h e immunization programme at state and district levels

Positive observations:• Faculty of HFWTC was experienced, dedicated and committed. Inspite of

shortage of faculty and facilities, it was performing to the best of its capacity.

Delhi

Training related• Training was not a priority and there was

no mandated training policy for induction or refresher training in the state

• Inadequate deputation of MOs for training. There was no accountability of the MOs for not attending the training

• Only one training centre (HFWTC) in the state to cater to all the organizations of Delhi Govt, MCD, NDMC, CGHS, ESI, Delhi cantonment, NGOs etc

• HFWTC had only one training hall, no residential facility and shortage of trainers

• No district training centre in the districts. DTCs were formed in few districts but as their rent was not reimbursed by GoI, they were not functional

• No follow up of trained personnel was done

• Priority should be given to training of health service providers

• State training cell with one state training coordinator to coordinate with multiple agencies in Delhi

• State institute of health and FW with adequate facilities needs to be developed

• DTCs should be developed in each district

• Mandatory attendance of p a r t i c i p a n t s t h r o u g h incentives/disincentives.

• Database of health service providers with training status

• Follow-up and OJT by the district level officers

100


• State norms for DA fixed at Rs 200/- per participant which was less than RCH training norms. Hostel accommodation, breakfast and lunch cost was more than Rs.200/-

• Average attendance post nomination was around 90% but only 60% of the participants were appropriately nominated for the trainings

• Civil surgeons were reluctant to spare MOs frequently for small duration mostly in December – March of financial year

• As there were multiple, vertical trainings to be attended by the same MOs, service delivery in PHC suffered

• Increase pool of trainers at state level (Panchkula) for training

• Use state trainers for monitoring of training in the districts

• DA for participants may be increased as per the RCH training norms to motivate participants

• Comprehensive integrated trainings should be held throughout the year.

• Regular full-time faculty is needed in training centres

Positive observations:• Training was progressing well due to excellent leadership by the SEPIO• There was a support system at state level for tracking trainings • Training was monitored and monitoring reports were submitted to MD (NRHM)

for use in monthly review meetings CS and DIO were also given copies for local and immediate action

• Top priority was given to completion of training during CMO review meetings with MD (NRHM)

• Support of MD (NRHM) was taken for expediting training in the districts • A draft training policy had been prepared

Haryana

101


• SIHFW was not involved for the MO-RI training plans and not involved in MO training

• No funds were available in PIP for CCH trainings as it was not planned, but still training was held in few districts

• Involve the SIHFW faculty as trainers even if someone else is holding the training

• SIHFW to have database for all trainings in health sector

Positive observations:• Good progress of training in a short period through 'hand picked' young and

motivated trainers.• Exemplary process of training: five teams with five trainers each and seven

spare trainers were trained at State ToT at Bangalore. These were young motivated medical officers hand picked by the SEPIO. One team captain was identified per team who was responsible for conducting and reporting of training by that team. MD NRHM letter was issued to all districts for MO trainings at their district training centers with training schedule

• The state trainers went to each district (except their parent district) and conducted the trainings there in two to four batches. All trainings were done in 3 phases. No TA/DA was given to the trainee MOs but the trainers were given amount for stay and other expenses (approved from MD NRHM)

• Participatory methods were followed by the trainers for training the MOs• Full support from MD-NRHM for immunization• Good use of 'Skype' for online monitoring by the SEPIO Dr Ramesh Babu,

DPMs and RCHOs• Mostly pharmacists were trained as CCH. CCH trainers were 3 per district:

RCHO-MO, vaccine store manager at district (Pharmacist) and Ref. mechanic/maintenance person

• Two persons per ILR point were called for training

Karnataka

102


• There was no state policy regarding induction or refresher training of MOs and CCHs

• State training centre was not conducting any training as facilities and space at its disposal had been gradually depleted

• Training was done at Directorate conference hall except few batches at one Medical College (JNIMS). However, two faculty members of state training centre were state level trainers

• CCH Trg was also coordinated by SEPIO. SCCO was on sick leave for three months and would remain absent for unknown duration. In his absence responsibilities were being carried out by a refrigerator mechanic

• CCHs training was being done without TOT. It was predominantly one day training (out of six batches only one batch was two day) due to shortage of funds

• There were some issues around communication and release of funds from NRHM to directorate

• State training institute should be developed and made functional

• System should be developed for continuous provision of induction and refresher training for all health staff

• The Mission Director, NRHM was also Joint Secretary (Home) and Sericulture. When the team shared feedback of shortfall in funds for MO training, MD asked his office to increase the budget in PIP (2012-13) for 200 MOs instead of 100 MOs

• Improve coordination between the directorate and NRHM office

Positive observations:• Good momentum for MO training has been maintained through personal

involvement and initiative of the SEPIO• Training sessions were conducted a per the protocol with use of proper teaching-learning methods, like demonstration, role play, use of flip charts etc• Trainers were knowledgeable about course contents and methods• All trainers interviewed, praised the MO training module for medical officers.

They considered it as “one of the best” that they have used

Manipur

ANNEXURE

103

Annex-1: Study tools for Phase-1 study:Study tool-1: for State Immunization Officer and State Cold Chain OfficerStudy tool-2 for State level Trainers of CCHStudy tool-3 for Trainers of State Training Centre for MO trainingStudy tool-4 for the Director of State Training Centre for MO trainingStudy tool-5: for Director FW and MD-NRHM

Annex-2: Study tools for Phase-2 study:Study tool-1A for District Immunization Officer (DIO)Study tool-1B for District Programme Manager (DPM)Study tool-2A for Trainer of MOStudy tool-2B for Trainer of CCHsStudy tool-3 for District CCTsStudy tool-4 for MOs (Block/PHC)Study tool-5 for CCH (Block/PHC)Study tool-6 for ANM/LHV being supervised by the interviewed MO.

Annex-3: List of study team members

104

Study tool-1: For State Immunization Officer and State Cold Chain Officer (Talk to the SEPIO and review the relevant records)

A. General Information

State:

Name/s of the evaluators:

Name, designation and contactdetails of SEPIO:

Academic qualifications

Total years in service as SEPIO:

Designation in previous 2 postings

Mention if SEPIO has any additional charge also

Name, designation and contact details of the officer performing role of SEPIO (If other than SEPIO)

Name, designation and contact details of SCCO

Date(s) of visit:

o <1 o 1 to <2 2 to <3 o 3 or more o

1.2.

B. Information regarding Immunization Training of Medical Officers (During 2009 – 2012)

Were you trained as trainer for MO-training (attended TOT)

If yes, mention the name of training center

If no, state the reason

Have you attended MO-training batch as observer?If yes, where did you observe MO training?

Who is coordinating the MO-training in the state (write name, designation and contact details)

Give names, designations and contact details of three state level trainers

1.2.3.

Is there any support of development partners in MO training?

If yes, specify the support and name of the organizations (e.g. technical, administrative, financial etc.)

oYes oNo

oYes oNo

Explain the process followed for operationalizing MO training - Levels of cascade (state/divisional/regional/ district levels)

1.

2.

3.

4.

5.

6.

7.

8.

9.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Annex-1: Study tools for phase-1 study

105

Number of training centers involved for MO training

Types of training centers involved in MO training

According to you, what is the current status of progress of MO-training in the state?

What are the reasons for current status of progress in MO training?

If no, what are the barriers? Related to (Other priorities, Human resources, flow of funds, training material, venue and other arrangements etc.)

What are your suggestions to improve the progress and quality of MO training in the state?

1.2.3.

1.2.3.

1.2.3.

Any issues related to release of funds to the training centers? o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

If yes, give details

Any issues related to release ofguidelines to the training centers?

Any issues related to distribution of training materials (Handbooks, Training Kits) to the training centers?


What is the system of reporting the progress of training to state and national level?

Has the state conducted any monitoring of MO training?

If yes, is there a system to compile the information and provide feedback?

Will you be able to complete MO training by March-2013?

Any other RI related training of MOs held in last two years.

If yes, specify the areas as AEFI, Measles Catch-up Campaigns and HepB introduction etc.

If yes, describe the system

Major issues identified and actions taken?

If no, what are the reasons?


o Slow oOn Track oFast

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

o Yes o No

o Yes o No

106

No of trainers of MOs in immunization training trained since 2009

Profile of trainers involved in MO training

Number and dates of TOTs conducted (month and year)

When did MO-Training start in the state (month and year)

Profile of medical officers trained in RIe.g. MO (PHC/CHC), Contractual doctors, AYUSH Doctors, Others (specify)

Training load of Medical officers (MOs, AYUSH and others ) in the state

No of MOs trained in 2009-2010

No of MOs trained in 2010-2011

No of MOstrained in 2011-2012

Handbooks available in local language (Translation and printing done, if required)

Trainers oriented/trained on the new handbooks

Hws (ANM, LHV, SN, Cold chain/data handlers) training started

If yes, since when (specify month and year of initiation)

If yes, % trained

If no, reasons

If no, reasons

If no, reasons

C. Information regarding Training of Health Workers with Immunization Handbook (2011)

1 .National level _________________2. State level ___________________3. Regional level _________________4. District level ___________________

1 .2.

1 .2.

1 .2.3.

32.

33.

34.

35.

36.

37.

38.

39.

40.

1.

3.

5.

6.

7.

8.

4.

2.

REVIEW RELEVANT RECORDS TO COLLECT THE FOLLOWING INFORMATION:

o Yes o No

o Yes o No

o Yes o No

107

SEPIO: Were you trained as trainer for CCH (Attended TOT)

If yes, mention the name of training center

If no, give reasons

If there is no SCCO in the state, then who is coordinating the CCH-training in the state (write Name, designation and contact details)

Give names, designations and contact details of three state level trainers.I

Is there any support of Development Partners in CCH training?

Number of training centers involved for CCH training

Types of training centers involved in CCH training

According to you, what is the current status of progress of CCH-training in the state?

What are the reasons for current status of progress in CCH training?

Any issues related to release of funds to the training centers?


Any issues related to release of guidelines to the training centers?

If yes, specify the support and name of the organizations.

SCCO: Were you trained as trainer for CCH (Attended TOT)

D. Information regarding Training of Cold Chain Handlers (talk to SEPIO and SCCO)

1.

3.

4.

5.

6.

7.

10.

11.

12.

13. 1.2.3.

14.

15.

16.

8.

9.

2.

o Yes o No

SEPIO

SEPIO

SCCO

SCCO

If SEPIO is unable to answer following questions, then ask State Cold Chain Officer/Coordinator of CCH trainings.

1.2.

1.2.3.

Explain the process followed for operationalizing CCH training - Levels of cascade (state/divisional/regional/ district levels)

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

108


Any issues related to distribution of training materials to the training centers?

What is the system of reporting the progress of training to state and national level?

Has the state conducted any monitoring of CCH training?

Will you be able to complete CCH training by March-2013?

If no, what are the barriers?

What are your suggestions to improve the progress and quality of CCH training in the state?

Numbers of trainers trained since 2010

Profile of trainers involved in CCH training

Profile of trained CCH (e.g. HW (M), HW (F)/ANM, Pharmacist, Others (specify)

Number of days of CCH training conducted in 2011-12

Number and dates of TOTs conducted (month and year)

When did CCH training start in the state (month and year)

Major issues identified and actions taken?


17.

18.

20.

21.

23.

24.

25.

26.

27.

30.

31.

28.

29.

1.2.3.

1.2.3.

1. National level_________2. State level ____________3. Regional level_________4. District level__________

1.2.3.

1.2.3.

o 1 day o 2 days

1.2.3.

22.

19.

REVIEW RELEVANT RECORDS TO COLLECT THE FOLLOWING INFORMATION:

o Yes o No

o Yes o No

o Yes o No

109

Number of CCH planned to be trained at each ILR point?

Was the handbook translated and printed/available in local language

If yes, mention the language in which translated and get a copy.

If no, mention the reason

Training load of CCH in the state

Number of CCHs trained in 2010-11

No of CChs trained in 2011-12

32.

33.

34.

35.

36.

37.

38.

o 1 o 2 o 3 or more

E. Major observations and suggestions of the study team:

o Yes o No

110

State (name ):

What was the duration of state level trainings since April 2011

If two days training, were the trainings residential

If no, give reasons

Numberof trainers per batch for both days? Check reports, if available.

To whom are you reporting the training status?

Training and other materials given to all participants (First ask open ended question. Prompt only if unable to answer) Cross check some samples.

Was the certificate given to each participant during training

If no, reasons

To facilitate demonstration and practice during training which items were used at the training venue?

(First ask open ended question. Prompt only if unable to answer)

Pre and post test done

If yes, verified from filled in Handout number 1

Feedback received from trainees at the end of training

If yes, verified from filled in Handout number 14

Mention any specific action taken to improve training based on feedback

o 1 day o 2 days

Venue of state level TOTs for CCH

Date of interview

Name/s of evaluators

Name and designation of the interviewee

1.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

2.

3.

4.

5.

Study tool-2: For state level trainers of Cold Chain Handlers


1. 2.

B. Information regarding training of Cold Chain Handlers

o 1 o 2 o 3 o 4

o GoI Handbook for Vaccine and CCHs (2010/2011)o Handouts o Other (specify)

o ILR o DF o Voltage Stabilizerso Cold box with icepacks o Vaccine Carriers

o Thermometerso Fridge-tago Freeze-tago Vaccine cartons o Vaccine vialso Other (specify)

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

111

TopicS1

What methods were used while training on “Conditioning of ice-packs”?

What methods were used while training on “Correct placement of vaccinesin ILR”?

What methods were used while training on “Temperature monitoring”?

What methods were used while training on “Preventive maintenance of cold chain equipment”?

What methods were used while training on “Distribution of vaccines from PHC to sessions”?

What methods were used while training on “Diluents management”?

What methods were used while training on “Stock management”?

Problems faced in cold chain handlers training related to:• Human Resources (trainers, trainees)• Flow of funds• Training material (translation, printing)• Venue, accommodation for participants, other logistics (please specify)

1.

2.

3.

4.

5.

6.

7.

1.

2.

2a.

2b.

2c.

C. Information regarding training methods used during the training. Ask open ended question for each of the topics below and tick the responses given: (multiple responses are applicable)

Methods used

oLectureoPPT oReadingHandbook







o Demonstrationo Practice o Exercise







D. Information regarding problems faced and suggestions:

Suggestions for future training courses related to:

Course Contents

Training methodology

Training, hostel and transport facilities at the training center

2d.

2e.

2f.

3a

3b

3c

Number. of trainers

Flow of funds

Any other support required

Areas to be added

Areas to be deleted

Areas to be modified

3. Suggestions for changes in the CCH Handbook:

112

E. Major observations and suggestions of the study team:(Write the major gaps identified and observed )

113

State (name ):

o Yes o NoIs a training centre available at the state level?

If no, then what was the venue of MO-Immunization training at state level?

If yes, state training centre (name and address)

Date of interview


Name of the Director of the State Traning Centre (write name, designation and contact details)

Name of the immunization training coordinator at the training centre

Name and des igna t ion o f the interviewees

1.

1.

2.

2.

3.

4.

5.

6.

7.

8.

9.

3.

4.

5.

6.

7.

8.

9.

Study tool-3: For MO-trainers at the State Training Institute


1. 2.

1.2.

B. Information regarding training of medical officers (Ask Immunization Training Coordinator at SIHFW)

(Tick the responses where required)

Is the training for whole of the state coordinated by this training center?

If no, this training center is responsible for training of MOs from how many districts?

To whom are you reporting the training status?

What was the source of funds for training?

Number. of TOT trained trainers available in the training center

Training was residential (trainees stayed overnight)

If no, give reasons

If no, give reasons?

Field visit organized for the trainees to practice supervision at cold chain point and immunization. Session site in last three batches.

o NRHM o Others (specify)

o 1 o 2 o 3 o 4 o >4

o Yes o No

o Yes o No

o Yes o No

114

o Yes o NoWas transport provided for field visits?

Training and other materials given to all participants (First ask open ended question. Prompt only if unable to answer)


If no, reasons

Number. of training batches conducted since April 2009

Number of MOs trained since 2009 till date?

Number of training batches with > 25 participants

When was last training batch conducted

Number. of trainers involved in MO training course on all three days during last three batches

o Immunization Handbooko Handouts from Facilitators Guideo Other (specify) ___________

o Yes o No

C. RECORDS REVIEW

o Within 6 mths o >6mths-1 yr o> 1yr-2 yrs o>2 yrs back

Last batcho 1 o 2 o 3 o 4 or more

2nd last batcho 1 o 2 o 3 o 4 or more

3rd last batcho 1 o 2 o 3 o 4 or more

D. TRAINER-1D1. Ask the following questions

Training kit including the games was used during the training

CD with films in training kit was used during training

If no, what was the reason?

Pre and post test done.

If yes, verified from filled in Handout no. 1




Which unit was most difficult for you to teach and why?

In your opinion, which unit the participants found most challenging and why?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

10.

11.

12.

13.

14.

15.

16.

17.

18.

2d.

2e.

2f.

3a

3b

3c

Number. of trainers

Flow of funds


Topics to be added

Topics to be deleted

Topics to be modified

3. Suggestions for changes in the Immunization Handbook

115

Topic


What methods were used while training on “use of ADS and Hub-cutter and safe waste disposal”?

What methods were used while training on “AEFIs”?

What methods were used while training on “Community Involvement and Communication”?

What methods were used while training on “Supportive Supervision”?

What methods were used while training on “Records, Reports and Using data for action”?

What methods were used while training on “VPDs and VPD surveillance”?

Problems faced in immunization training related to:• Human resources (Trainers, trainees)• Flow of funds• Training material • Venue, accommodation for participants, other logistics (please specify)

1.

Sl

2.

3.

4.

5.

6.

7.

1.

2.

2a.

2b.

2c.

D2. Training methods used during the training. Ask open ended question to the trainer for each of the topics below and tick the responses given:(multiple responses are applicable)

Methods used















D3. Information regarding problems faced and suggestions:


Course contents


Training, hostel and transportfacilities at the training center

116

E. TRAINER-2E1. Ask the following questions:


CD with films in training kit was used during training









1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

117

Topic


What methods were used while training on “Use of ADS and hub-cutter and safe waste disposal”?






Problems faced in immunization training related to:• Human resources (Trainers, Trainees)• Flow of funds• Training material • Venue, accommodation for participants, other logistics (please specify)

1.

Sl

2.

3.

4.

5.

6.

7.

1.

2.

2a.

2b.

2c.

E2. Training methods used during the training. Ask open ended question to the trainers for each of the topics below and tick the responses given: (multiple responses are applicable)

Methods used















E3. Information regarding problems faced and suggestions:


Course contents



2d.

2e.

2f.

Number. of trainers

Flow of funds


3a

3b

3c

Topics to be added




118

G. Major observations and suggestions of the study team:

F. Facilities at the training centre (Tick appropriate response only if available at the training center by visiting the venue of training)

o Classroom

o Black /white board

o Flip charts/marker pens

o LCD player

o Hostelrooms

o Mess

o Water facilities

o Electricity backup

119

State (name ):

Date of interview


Name, qualification and designation of the Director of state Traning Centre

Charge as Director is

Years of service as Director

Are you responsible for all regional and district training centres in the state?

If no, then you are responsible for which training centres?

How is the t ra in ing budget for immunization training allocated to the state training center?

Do you have the authority to spend funds for immunization training at your own discretion?


Is there a mandated policy for training of MOs in the state?

If yes, what is the training policy for induction training of MOs in the state? (Govt. order/DO, duration of training etc.) Collect policy document if available.

What i s a l loca ted dura t ion fo r immunization training?

What is the training policy for refresher training of MOs including immunization in the state?

What is average attendance of MOs (%) after nominations?

Any issues faced in immunization/RCH training of the health service providers?

Your suggestions for improving the quality of training by the state training centre

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Study tool-4: For Director/Principal of the State Training Centre for MOs

1.2.

o Yes o No

o Full time o Additional charge

o <1 o1 to <2 o 2 to <3 o 3 or more

o Yes o No

o Yes o No

120

Study tool-5: For MD-NRHM and Director-FW


State (name ):

Date of interview


Name and designation of the interviewee

1.

2.

3.

4.

1.

2.

B. Discussion guide to interview MD-NRHM and Director-FW regarding immunization

training of MOs and CCHs• Ask their opinion about the progress of immunization training in the state.• Provide feedback on your observations from the state level interviews and desk reviews. • Start with positive feedback and then ask specific questions on the issues which emerged

during the study and require interventions at higher level. • The issues could be regarding training policy of induction/refresher training; availability of

training centres and residential arrangements; availability of funds under PIPs; availability

of trainers/ training skills; coordination of training; release of funds for training; attendance

of trainees etc.

C. Record the results of discussion with the MD-NRHM

D. Record the results of the Director FW

121

Annex-2: Study tools .......phase-2 study Study tool-1A: For District Immunization Officer (DIO) (Talk to the DIO and ask to see the relevant records)


State:

District


Date(s) of visit:

Name and contact details of the DIO:

Total years in service as DIO: o <1 o 1 to <2 r 2 to <3 o 3 or more

B. Immunization training status

Are you a trainer for MOs

If not a trainer were you trained as a medical officer for immunization training?


If yes, when was the MO-Training attendedAre you a trainer for CCHs

oYes oNo

oYes oNo

1.

2.

3.

4.

5.

6.

1.

2.

3.

4.

5. oYes oNo

o<6m 6-<12m o1-<2 yr o2 or more yrs


Have you noted any change in the performance of MOs after training as compared to their previous performance?

What is the percebted of fully immunized infants in the district per DLHS-3?

What is the coverage of fully immunized infants based on HMIS report for 2011-12 financial year?

What is the drop-out rate (DPT1-DPT3) in your district?

How do you monitor the performance of immunization programme in the district?

6.

7.

1.

2.

3.

4.

oYes oNo

C. Monitoring and Supervision

8. If yes, specify the areas where their performance in respect toimmunization has improved.

122

Any specific issues identified? (Related to human resources, supplies, Cold chain equipment, microplanning, supervision, mobilization of beneficiaries etc.)

Do you have access to HMIS data?

Coverage monitoring chart is displayed and updated monthly (Check to see the chart and updating)

Are the immunization quarterly review meetings held at district level?

If yes, how many immunization review meetings were held in last six months? (Check for the Minutes, Agenda and list of participants of last three meetings

Number. of supervisory visits made to the blocks and Subcentres in last three months. (look for the plan and the reports of the visits)

Major issues identified during supervision and actions taken

What is the mechanism (and frequency) of sharing information with ICDS, Partners and PRIs?

5.

6.

7.

8.

9.

oYes oNo

oYes oNo

oYes oNo

o 1 o2 o 3 o 4 or more

Specify three major issues discussed during last three review meetings 10.

11.

12.

13.

o 0 o 1-3 o 4-6 o 7-9 o 10 or more

D. Progress in immunization training of MO, CCH and HWs (Record study)

Training load of MOs in the district

Number trained

Training load of CCH in the district

Number trained

Training load of health workers in the district

Number trained

If there are any issues, please specify

1.

2.

3.

4.

5.

6.

7.

E. Major observations and suggestions of the study team: (Write the major gaps identified and observed)

123

State (name ):

Immunization activity

Training of MOs

Training of CCHs

Training of health workers

Any other immunization related training, specify

Quarterly review meetings

Any others (pl. specify)

Are you involved in reporting under HMIS?

Are you conducting any monitoring of Immunization programme?

If yes, provide details

Specify and provide details about your involvement in other immunization activities

District


Date(s) of visit:

Name and contact details of the DPM:

Total years in service as DPM:

1.

N

2.

3.

4.

5.

6.


B. Immunization training status in the district during the financial year 2011-12

Talk to the DPM and ask to see the relevant records

o <1 o1-<2 o 2-<3 o3 or more

Study tool-1B: For District Program Manager (DPM)

Numbers based on funds utilized

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

oYes oNo

oYes oNo

124

Study tool-2A: For MO-trainer at the District


District (name ):

Date of interview:

Name/s of evaluator/s:

Name and designation of the interviewee:

Is a Training Centre available in the district?

Training was residential (trainees stayed overnight)

Field visit organized for the trainees to practice supervision at cold chain point and immunization. session site in last three batches.


Was transport provided for field visits?

Training and other materials given to all participants (first ask open ended question. Prompt only if unable to answer)

Was the certificate given to each participant during training ?

If no, reasons


CD with films in training kit was used during training?






1.

1.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

2.

2.

3.

4.

5. oYes oNo

B. Information regarding training of medical officers

(Tick the responses where required)

oYes oNo

oYes oNo

oYes oNo

o Immunization Handbooko Handouts from Facilitators Guideo Other (specify)

oYes oNo

oYes oNo

oYes oNo

oYes oNo

oYes oNo

oYes oNo





15. oYes oNo

16.

17.

18.

125

Topic


What methods were used while training on “use of ADS and Hub-cutter and safe waste disposal”?






Problems faced in immunization training related to:• Human resources (trainers, trainees)• Flow of funds• Training material • Venue, accommodation for participants, other logistics (please specify)

1.

Sl

2.

3.

4.

5.

6.

7.

1.

2.

2a.

2b.

2c.

C. Training methods used during the training. Ask open ended question to the trainer for each of the topics below and tick the responses given:(multiple responses are applicable)

Methods used

















Course contents



126

E. Major observations and suggestions of the study team:

2d.

2e.

2f.

3a

3b

Number. of Trainers

Flow of funds


Topics to be added




127

Study tool-2B: For CCH Trainer at the district


District (name ):

Date of interview

Name/s of evaluator/s:

Name and designation of the interviewee:

What was the venue of CCH training in the district?

B. Information regarding training of Cold Chain Handlers

What was the duration of district level trainings since April 2011

If two days training, were the trainings residential

If no, give reasons

Number. of trainers per batch for both days? Check reports, if available

Training and other materials given to all participants (first ask open ended question. Prompt only if unable to answer) Cross check some samples.


If no, reasons

To facilitate demonstration and practice during training which items were used at the training venue?

(first ask open ended question. Prompt only if unable to answer)

o 1 day o 2 days

o Yes o No

1.

2.

3.

4.

5.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

o 1 o2 o 3 o 4

o GoI Handbook for Vaccine and CCH (2010/2011)o Handouts o Other (specify) ___________

o Yes o No

o ILR o DF o Voltage Stabilizers o Cold box with ice packs o Vaccine Carriers

oThermometersoFridge-tagoFreeze-tagoVaccine cartons o Vaccine vialsoOther (specify)

o Yes o No

o Yes o No

o Yes o No

o Yes o No

Pre and post test done




Mention any specific action taken to improve training based on feedback13.

128

Topic


What methods were used while training on “Correct placement of vaccines in ILR”?

What methods were used while training on “Temperature monitoring”?

What methods were used while training on “Preventive maintenance of cold chain equipment” ?

What methods were used while training on “Distribution of vaccines from PHC to sessions”?

What methods were used while training on “Stock management”?

Problems faced in immunization training related to:• Human resources (trainers, trainees)• Flow of funds• Training material • Venue, accommodation for participants, other logistics (please specify)

1.

Sl

2.

3.

4.

5.

6.

1.

2.

2a.

2b.

2c.

C. Information regarding training methods used during the training. Ask open ended question for each of the topics below and tick the responses given: (multiple responses are applicable)

Methods used















Course contents


Training facilities (including accommodation)

E. Major observations and suggestions of the Study Team: (Write the major gaps identified and observed)

2d.

2e.

2f.

3a

3b

Number. of trainers

Flow of funds


Topics to be added



Suggestions for changes in the CCH Handbook:3.

3c.

129

Study tool-3: For District Cold Chain Technician


District:

Date(s) of visit:


Name of cold chain technician interviewed:

Total years in service

Type of service

Technical education

Number. of districts responsible for

Type of equipment available in districts he is responsible for

Types of training received under immunization

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Talk to the Cold Chain Technician

o<2 o2-5 o6-10 o>10 yrs

oPermanent oOn contract

oITI o B. Engg. oothers (specify) -

o1 o2 o3 o4 and more

oWIC o WIF oSolar refrigerators oNone

No.

1)

2)

3)

4)

5)

6)

Training type

Repair and maintenance of ILR and DF

Repair and maintenance of Voltage Stabilizers: 1kVa for ILR/DFSpecify which company-

Repair and maintenance of WIC/WIF

Repair and maintenance of Voltage stabilizers: 10kVa for WIC/WIFSpecify which company-

Installation, maintenance and repair of solar refrigerators

Any other (specify)

Where

oSHTO, PuneoState capitaloOther (specify)-






Which year

oNot trainedo2012 to 2009o2008 to 2006o2005 and earlieroNot trainedo2012 to 2009o2008 to 2006o2005 and earlier

oNAoNot trainedo2012 to 2009o2008 to 2006o2005 and earlier

oNAoNot trainedo2012 to 2009o2008 to 2006o2005 and earlier

oNAoNot trainedo2012 to 2009

oNAoNot trainedo2012 to 2009o2005 and earlier

130

L i s t v a r i o u s t a s k s undertaken by you in past three years

Duration of training attendedRepair and maintenance of ILR/DFRepair and maintenance of WIC/WIF

Name three specific areas in which the training

helped you in improving your performance

(mention specifically for which machine)

Name three specific areas in which the training

was lacking in improving your performance

(mention specifically for which machine)

Where should all vaccines be kept at PHC/CHC level? (Correct if answer is ILR only)

In the temperature log book, the temperature reading to be noted is

that of the thermometer placed inside the ILR/DF or of the display

on the outer lower part of the ILR/DF?(Correct if answer is- of the thermometer placed inside the ILR/DF)

Below what percentage should the sickness rate of cold chain

equipment of the district be at all times? (Correct answer is – less than two percent)

Currently, which refrigerants are being used in ILRs and DFs ?

CFC or non-CFCCorrect answer is non-CFC

Did you face any difficulties during training? If yes, mention them. Please specify for

which training

Any suggestions for improving the contents of the training? Please specify for which

training

11.

1.

2.

3.

1.

2.

3.

4.

4.

5.

o installation and preventive maintenance of ILRs/DFso minor repairs of ILRs/DFso major repairs of ILRs/DFso installation and preventive maintenance of WIC/WIFominor and major repairs of WIC/WIFo repair of voltage stabilizerso vaccine management at district levelo Others (specify)

If not trained in repair and maintenance of ILRs/DFs/WICs/WIFs, then skip section B and move to section C

B. About the Training courses

o4 days o5 days o6 dayso4 days o5 days o6 days oNA

C. Assessing knowledge

oCorrectoNooDo not know




131

Do you have a tool kit in your district for use to repair and maintain equipment?

Is there any problem related to TA/ DA which

restricts you from visiting health centres for

preventive maintenance and repair? If yes,

please specify

Name three most commonly required spare

parts needed to undertake minor repairs of

ILR/DF, but are not available

Name three most commonly required spare

parts needed to undertake major repairs of

ILR/DF, but are not available

What more could your supervisor do to

support your efforts to improve your

performance?

What additional trainings do you need to help

you to improve proficiency in your work?

1.

2.

3.

4.

5.

6.

D. Other issues

oYes o No oNo tool kit but use own tools oCannot answer

oYes o No oCannot answer

132

Study tool-4: For Medical Officer (Block/PHC)


District:

Block/PHC:

Date(s) of visit:


Name and designation of MO interviewed (Tick if o In-charge of PHC/Block

Qualification of MO

When was the training workshop attended?

Training center where trained

How many days did the training last?

How many trainers were available on all three days?

Was film on immunization shown during the training?

Was field visit organized during training for supervision

Did you receive certificate during training?

Did you receive copy of Handbook during training?

immunization

Is the MO-Handbook available at the PHC?

Which unit did you find most useful and why?

Which unit did you find most difficult to understand and why?

How have you used the training handbook as a resource since attending the training? (Specify three most common units you referred to)

Give two examples of measures taken by you to improve immunization after training.(Specify any improvement in Micro-planning)

Did you face any difficulties during training? If yes, mention them

Place of posting

Type of posting


Were you trained in RI with immunization Handbook for MOs

1.

2.

3.

4.

5.

6.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

7.

8.

9.

10.

Talk to the MO and ask to see the relevant records

oMBBS oAYUSH

o<6m o6-12m o1-2 yr o>2 yrs

oState oRegional oDistrict level

o1 day o2 days o3 days

o2 o3 o4 o >4

oUrban o Rural

o Regular oContractual

o<2 o 2-5 o 6-10 o >10 yrs

oYes oNo

If not trained in routine immunization, skip Section-B and move to Section C

B. About the Training course

oYes oNO

oYes oNO

oYes oNO

oYes oNO

oYes oNO

Give suggestions for improving future immunization training

• Training venue

• Boarding and lodging

• Training handbook --

• Training methods------

• Any other----------------

15.

133

C. Assessing knowledge (Ask open ended questions and write/tick the answersgiven in next column)

1.

2.

3.

4.

5.

6.

7.

8.

What vaccines can be given to a child who comes for the first time at 16 mths? (Correct if all 3 answers are given)

How many minimum sessions are required per year to fully immunize all infants in a hard to reach village with population of less than 1000? (Correct if answer is 4)

What is most important criterion to prioritize sub-centers for action?(Correct if based on the number of unimmunized children or drop-out rate)

Which vaccines are sensitive to freezing? (Correct if DPT, TT, and HepB)

How will you prevent freezing of freeze sensitive vaccines in PHC and during vaccine distribution?

0(Correct: By storing vaccines in ILR at +2to+8 C and by keeping conditioned ice-packs in Cold box/vaccine carrier )

How are the diluents of BCG and Measles stored before use?(Correct if: they are stored in ILR at 2 to 8 °C along with the vaccine, at least 24 hours before use)

What is minimum stock level to place an order?(Correct if buffer stock + Lead time stock)

What are serious AEFIs?(Correct if at least 3 out of 4 answers are right)

o Correcto No

o Correcto No

o Correcto No

o Correcto No

o Correcto No

o Correcto No

o Correcto No

o Correcto No

oDPT-1o OPV-1o Measleso-----

o1-3 o 4o 5-7 o 8 or >

oNo. of unimmunized children oDrop-outso ---

o DPTo TTo HepBo ----

0o 2-8 C in ILR oConditioned ice-packs in VC o In cold box ------

0o 2-8 C in ILR oConditioned ice-packs in VC o In cold box ------

o DeathoDisabilityoHospitalizationo Cluster of events

9. How do you calculate drop-out rate between DPT1 & DPT3?(correct if cumulative DPT1-cumulative DPT3) X 100

o Correcto No

10. What tools are used to track drop-outs?(Correct if answer at-least 3 out of 4)

o Correcto No

oCounterfoilsin tracking bagoMonitoring chart Imm. oRegisteroDue list

134

D. Routine Immunization services at the PHC as provided by the MO(Talk to the MO and observe. Tick the appropriate response, multiple responses is applicable)

1. Is RI microplan with the components available at the PHC? (Ask for the current micro-plan and check for the following:)

a. Map of catchment area (indicating sub-centers and distances from vaccine storage point)

2. How many total supervisory visits have you conducted to SC/Session site during last three months?If less than four visits, specify the reasons

3. Which records are available at the PHC to support the supervisory visits

b. Estimation of beneficiaries and logistics (village/ area wise) for 2011-12

c. ANM work-plan / roster

d. AVD plan to supply the vaccines and logistics to session sites.

e. Day-wise plan for supervisor field visits

f. Special plan for high risk and Hard to reach areas available

o Yes o No

0 1-4 4-7 8-12 12 or more, specify number

supervisory reports filled in checklists/monitoring format movement registers Any other, specify No records

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

If complete RI microplan is not available at the PHC, ask the MO why and record the reasons

Specify the role of medical officer in micro-planning:

4. Give an example of a) problem-solving and b) On-the-job training you provided during supervision of HW?

5. Who analyzes the routine immunization data from the sub-centres?

6. What analysis is done from the routine reports?

8. Coverage monitoring chart (check to see)

9. Immunization review meetings are held at Block/PHC

10. Who all participate during the review meetings?

11.What topics are discussed review meetings? (Check for report)

7. How do you use data for action? give examples

o Imm. coverage o Left-outs

o Available o Updated

o Not held o Monthly o Once in two mths o Quarterly

o HWs o ICDS o PRI o

o ASHA

o Sub-centre wise Imm. Coverage

o Drop-outs

o Displayed

o Drop-out rates

o Supervisory findingso Problems faced by HWso Data of mother and child tracking system

135

12. Check for records of immunization review meetings to see which ones are available?

14. Any AEFI reported or Zero Report in last three months? (Check monthly reports of the last three months)

15. Any VPD reported or Zero Report in last three months? (check reports)

15. Mention the methods used for immunization waste management in your PHC (Ask and observe if possible)

16. Any activities supported by you to improve community involvement and communication during last one year? (e.g. Community meetings, visits to houses of dropouts etc.) Please specify

13. What is discussed about immunization meeting during monthly review meeting?

o Agenda

o Yes

o Yes

o Yes

o Yes

o Yes

o Attendance

o Hub-cutter used

o Minutes

o NO

o NO

o NO

o NO

o NO

o Red and black bags usedo Disinfection doneo Disposal pit used for sharps

o Other means (specify)

E. Other issues

F. Availability of equipment and supplies at the PHC/CHC

1. Clear guidelines available for fund utilization for AVD, ASHA, supervision, untied funds with ANM etc.

2. Specify if there are any issues related to financial management/funds released for immunization activities?

3. Has your supervisor visited you in last three months?

5. Do you need any additional immunization training to help you to improve proficiency in your work?

6. If yes, please specify the areas

4. What suggestions were given by your supervisor for RI strengthening in your PHC / Block?

Equipment and supplies Available (Y/N) Functional(Y/N)

Remarks (Mention any shortage of

specific equipment)Cold chain and logistics• DFs• ILRs• Voltage stabilizers• Cold boxes• Vaccine carriers• Ice packs• Thermometers• Temperature log books• Vaccine and logistics indent

forms, supply vouchers • stock register and • vaccine and logistic issue

register

136

Equipment and Supplies Available (Y/N) Functional(Y/N)

Remarks (Mention any shortage of

specific equipment)

Injection safety equipment• ADS, disposable syringes• Functional hub cutters• Bleaching solution/powder • Red and black bags• Waste disposal pit

Records reports and using data for action• Immunization/MCP cards• Tally sheets• HMIS formats• Tracking bags• Immunization register• Stock register• Coverage monitoring charts

Study tool-5: For Vaccine and Cold Chain Handler (Block/PHC)


District:

Block/PHC:

Date(s) of visit:


Name of Vaccine and CCH

Designation/ Post:

Overall total years in service

In charge of cold chain since

Have you received CCHtraining in past three years?

If yes, when was the training held

Name of the training center (where trained)

How many days did the training last?

Did you receive certificate during training?

Did you receive copy of Handbook for vaccine and CCHduring training?

What was the language of the handbook?

How many trainers were available on each day?

Was film on cold chain shown during the training?

Which of the following were available during the training at the venue?

Have you used the training handbook as a resource since attending the training?

Give two concrete examples of measures taken to improve cold chain in your health centre after your training

Did you face any difficulties during training? If yes, mention them

Give suggestions for improving future cold chain training• Training venue• Training handbook• Training methods• Any other

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Talk to theCCH, inspect cold chain room and give exercise of conditioning ice-packs (D3) at the beginning.

oPharmacist ANM LHV Male MPW Others. Specify:o o o o

o2 2-5 6-10 >10 yrso o o

o2 2-5 6-10 >10 yrso o o

oYes

o<6m 6m-2 yrs 2-3 yrs o o

o<6m 6m-2 yrs 2-3 yrs o o

o 1 day 2 days o

o Yes Noo

o Yes Noo

o Yes Noo

o English Hindi oLocal Language oNA

o

o 1 2 3 4 >4o o o o

137

oNo

If Not trained, then skip section B and move to section C

B. About the Training course

o o DF o Voltage Stabilizers o Cold box with ice packs o Vaccine Carriers

ILR oThermometers oFridge-tag oFreeze-tag oVaccine cartons oVaccine vials oOther (specify)

o Yes No o o Na

C. Assessing knowledge

Where should all routine immunization vaccines be kept in PHC/CHC? (Mark correct if answer given is – in the ILR only)

Which vaccines are sensitive to freezing? (Correct if DPT, TT and HepB )

How do you prevent vaccines from freezing?(Correct: Store all vaccines in ILR at +2 to+80 C and keep conditioned ice-packs in Vaccine carrier )

Where are the diluents of BCG and Measles stored before use?(Correct if: stored in ILR at 2 to 8 °C, at least 24 hours before use)

Can anything (such as food items, lab reagents, medicines and injections, etc.) other than routine immunization vaccines be kept in ILRs?

In the stock register, should there be separate pages for entry of stock of different diluents? (Mark Correct if answer is Yes)

When is defrosting done? (Mark correct if the answer is – at least once a month or when frost on the wall of the DF/ILR is more than 5 mm thick)

Can we take deeply frozen ice packs from deep freezers and immediately use them to store vaccines in vaccine carriers? (Correct if answer is No)

Voltage stabilizer connecting the ILR to the mains has stopped functioning. Is it OK to connect ILR directly to the mains till voltage stabilizer gets repaired? (Correct if answer is No)

Some of the T-series vaccines were found frozen in the ILR one morning. What will you do? (Correct if all three points or Point no. 1 is stated along with either of point no. 2 or 3) – 1. Remove the frozen vaccines from the ILR for disposal and record in stock register after informing the MO – in charge,2. Regulate thermostat to decrease the cooling and increase the temperature, 3. Inform the cold chain technician to find if there is problem with the ILR)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

o Correct

o Correct

o Correct

o Correct

o Correct

o Correct

o Correct

o Correct

o Correct

o Correct

138

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

o Incorrect

Take a thermometer from the ILR and ask the Cold chain handler (CCH) to read the temperature. Tick on 'correct' if CCH is able to read correctly. Otherwise, tick 'No.

Observe if there is frost more than 5 mm thick in the DF or ILR?

Observe if the ice packs are placed in correct manner in the DF for freezing?

Are the diluents (quantity, batch no and expiry date) recorded separately (on different pages) in the stock register? Check stock register.

Ask the CCH to demonstrate conditioning of ice-packs using ice packs from DF and a vaccine carrier. (Mark correct if ice packs are taken out from deep freezer and laid out on flat surface in a row with at least 5 cm gap between two ice packs; CCH keeps checking for sound of slightly melted water on the ice packs' surface by shaking it every five minutes; keeps the four ice packs in the vaccine carrier after demonstrating the sound of water on shaking the ice packs and the movement of layer of water just beneath the ice pack surface).

1.

4.

5.

2.

3.

o Correct

o Yes Noo

o Yes

o Correct

o No

o No

o No

D. Assessing skill

139

o Yes Noo


District:

Block/PHC:

Date(s) of visit:


Name of interviewee:

Designation:


Do you find change in performance of MO after immunization training?If yes, specify in which areas:

Give an example of either problem-solving or on-the-job training provided by the MO during a supervisory visit?

What topics related to immunization are discussed during the review meetings at PHC?

Any activities supported by MO to improve community involvement andcommunication? (e.g. Community meetings, visits to houses of dropouts etc.)Please specify

What more could your supervisor do to support your efforts to improve your performance?

1.

2.

3.

4.

5.

6.

7.

1.

2.

3.

4.

5.

6.

o2 2-5 6-10 >10 yrso o o

o Yes Noo

140

B. About the trained MO PHC

Study tool-6: For Health Worker/Health Supervisor being supervised by the trained Medical Offices

oSub-centre wise . coverageoDrop-out ratesoSupervisory findingsoProblems faced by HwsoData of mother and child tracking systemo

immunization

141

Annex-3: List of study team members

Organization

NIHFW

WHO Country Officefor India

UNICEF

MCHIP

NIPI-UNOPS

State Govt

Study team members

Prof J K Das, M Bhattacharya, profeser Utsuk Datta, Dr Sanjay Gupta, Dr Renu Shahrawat, Dr Gyan Singh, Dr Nanthini Subbiah and Dr P Deepak

profeser

Dr Anindya Bose, Dr Satyabrata Routray, Dr Sujeet Jain, Dr Arindam Ray, Dr Chandrakant Lahariya, Dr Rahul Kapse, Dr Arun Kumar, Dr Nilanjan Mitra, Dr Arup Debroy and Dr Renu Paruthi

Dr Satish Gupta, Dr Srihari Dutta, Dr Bhupendra Tripathi and Dr S H Ali

Dr Vijaya Kiran and Dr. Gunjan Taneja

Dr Narottam Pradhan

Dr Yangchan Dolma

evaluation of immunization training of medical … · collaborative study by nihfw, who country...

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